Zero Suicide in Health Care: Not Another Life to Lose

DAVID COVINGTON, LPC, MBA—CRISIS ACCESS, LLC

crisisaccess.com

“Over the decades, individual [mental health]

clinicians have made heroic efforts to save lives… but systems of care have done very

little.”

Richard McKeon, SAMHSA

Largest Data Set to Date: UTAH

Learning Collaborative, Julie Goldstein-Grumet

Learning Collaborative, Meena Dayak

ZS Advisory Board (Mike Hogan & David Covington Co-leads)

3,802

2,507

1,123

6,2921,562

6,816

771

6588,344

National Survey of 30,000 MH Professionals Across Nine States

“I never know what to say.”

“I have attempted suicide seriously once in my life.”

“

“If people are serious about it, they will complete it, no matter what is done

for them.”“We need more

education on this issue. No one wants to

talk about it!”“My sister killed herself

just yesterday”

“I think suicide is in our communities, but I do NOT

think we should be spending tax dollars to do ANYTHING

about it.”

“Love the Columbia scale”

“Why no mention of firearms?”

“Many can be prevented, some

can't.”

“I think about suicide everyday.”

“I don't know how to handle this topic,

honestly.”

“This survey is somewhat naive.”

“ALL health care providers should have training in

suicide prevention.”

“The terminally depressed will

succeed in suicide.”

”

“The terminally depressed will

succeed in suicide.”

Question 16 of 16. (Behavioral Health)

6

Question 13. TRAINING (Behavioral Health)

7

Question 14. SKILLS (Behavioral Health)

8

Question 15. SUPPORT (Behavioral Health)

9

Question 16 of 16. (Educators)

10

Question 13. TRAINING (Educators)

11

Question 14. SKILLS (Educators)

12

Question 15. SUPPORT (Educators)

13

Looking at Suicide Differently

Polling Question #1Someone who died by hanging with their hands bound behind their back and feet tied together was probably a murder, not a suicide.

A. TrueB. False

572,000Hospitalizations**

752,000 AttemptsRequiring Medical Attention**

1,100,000Suicide Attempts**

8,700,000 Seriously Considered Suicide**

38,364 Suicides*

Source: * National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. (2009). Web-based Injury Statistics Query and Reporting System (WISQARS). Available from: www.cdc.gov/injury/wisqars/index.html.**Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-42, HHS Publication No. (SMA) 11-4667. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

Pyramid of Suicidal Behaviors

6.8 to 10.5

10.6 to 13.9

14 to 16.9

17 to 23

23.2

17.1

14.0

14.5

10.6

13.9

16.9

10.5 6.8

Suicide Rates (2010 National Average Rate 12.4)

0

5

10

15

20

25

30

35

40

45

50

5-9 10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

Rat

e/10

0,00

0

Age Group (Years)

White Male AI/AN Male Black Male

White Female AI/AN Female Black Female

Source: National Center for Health Statistics. Note: Non-Hispanic Ethnicity

Suicide Rates by Age, Race, & Gender

What Have We Learned Over the Past Decade

Polling Question #2Suicide Can Be Prevented.

A. Never in Those Truly Intent on Suicide

B. Sometimes, but Only in Advance of Acute Risk

C. Always, but Only in Advance of Acute Risk

D. Always, Even Up to the Last Moment

1978

1990

2003200520062010

1975

1978

1990

2003200520062010

1975

1978

1990

2003200520062010

1975

1978

1990

2003200520062010

1975

1978

1990

2003200520062010

1975

1978

1990

2003200520062010

1975

Suicide Attempts: • Female>>male• Rates peak in adolescence• Concern: Latina youth and LGBT

Suicide Deaths: • Male : female = 4:1• Elderly white males • Working aged males (60%)

Group A Group B

Diagnosis is Not Destiny: Survivors Survive!

Ambivalence is Universal

Polling Question #3Suicide is (mark all that apply):

A. A ChoiceB. A Sign of Psychological WeaknessC. Akin to Murder (Only of the Self)D. Akin to CancerE. All of the Above

Suicide is Not a Choice

Rabbi Kushner’s Reference to Ice Endurance

Experiments

Survival is In Our Cells & Souls

Death by suicide fearsome and daunting prospect.

What are the Implications for Health Systems?

The Forgotten Patient

Polling Question #4The risk of death by suicide for those with Serious Mental Illness is how much greater than the general population?

A. The Same RateB. Two Times GreaterC. Four Times GreaterD. Six to Twelve Times Greater

“Suicide represents a worst case failure in mental

health care. We must work to make it a ‘never event’

in our programs and systems of care.”

Mike Hogan, Former State MH

Commissioner

Saving Lives Saves Money: Case Examples

Reduction in Suicide Rates

What Inspired Zero Suicide?

The Air Force Did It

Henry Ford Also Did It

What Does It Look Like to Make Suicide Care Core Business?

From: To:Training and tools Systems & culture changeIndividual provider actions; suicide care as “specialty”

Suicide prevention woven into all aspects of care; everyone’s job

Episodes of crisis Continuity of care

Suicide Care in System Framework

• Joint Commission National Patient Safety Goal

• Veteran’s Administration Training, Surveillance and Enhanced Care

• NSPL Standards and Guidelines

Lots of Groups Are Making Progress

alternatives to hospitalization based

on trusting therapeutic relationships

alternatives to ER such as same-day scheduling for MH services and in-

home crisis care

immediate and continuous follow-up after ER or Inpatient

discharge

Educate family members and

significant others

What Can You Do to Help Implement the National Strategy?

Case Study Phoenix: TERROS

One of a dozen founding organizations of the AZ programmatic suicide

deterrent system in 2009.

TERROS, Phoenix, Arizona

Clinicians/Social Workers

35%

Case Managers

30%

Physicians/ Nurses

3%

Admin &Non-clinical

26%

Certified Peer Staff

6%

PC

Workforce Composition

11% of Agency Staff Report Specific Suicide Care Training (ASIST)

57%

18%

25%

None One Two or More

Suicide deaths

reported by clinicians

PC

2009 Survey

81% of Agency Staff Report Specific Suicide Care Training (ASIST)

PC

2012 Survey

Agree or Greater x3 Don't Know/ Mixed Disagree or Greater x3

36% 37%

27%

86%

12%

2%

2009 - Non-ASIST 2012 - ASIST

1) Training 2) Skills 3) Supervision/Support

Comparing Two Cultures

How to Become Suicide Safer Care Center

Role #Counselor 2,421Social Worker 2,361Physician 416Nurse 1,371Case Manager 3,312Para-professionals 826Certified Peer Staff 479Administrator 2,640Support Staff 3,409

Skills

39%

Trai

ni

ng

44%

Supports

30%

One/Three

53%

Endorsed Don’t Know, Disagree, or Completely Disagree

I have the _________ to engage and assist those who are suicidal.

•3,314 / 15%Once

•2,792 / 13%More than once

Over 6,000 report a patient has died by suicide (27%).

1x2x3x4x6x

4%24%

38%23%

12%

SMI Suicide Rate vs. General Population

The Survey Results

Skills

57%

Trai

ni

ng

48%

Supports

31%

One/Three

63%

Endorsed Don’t Know, Disagree, or Completely Disagree

I have the _________ to engage and assist those who are suicidal.

Without Specific Suicide Training

1,407

Skills

8%

Trai

ni

ng

6%

Supports

10%

One/Three

15%

Endorsed Don’t Know, Disagree, or Completely Disagree

I have the _________ to engage and assist those who are suicidal.

ASIST Trained

1,324

ClinicianPhysician/Nurse

Certified Peer StaffAdministrator

Case ManagerSupport Staff

Overall

33%

37%

62%

66%

70%

80%

63%

15%

10%

9%

12%

17%

18%

15%

ASIST TrainedNo Suicide TrainingO

ne/T

hree

Two Day ASIST Training

zerosuicide.com

“Suicide prevention has not been informed by peers who have experienced the agony and decision-making. They

can provide support that can be magic”

Eduardo Vega, MHA of San Francisco

“I have long felt that the word of survivors/sufferers is

considered somehow suspect by many medical professionals.

So long as that is so, or perceived to be so, there will be a silencing fear -- much like the fear that can silence a victim of

rape.”

Forest Rogers

Contact Us Zero Suicide Advisory Group Co-Leads david.covington@crisisaccess-co.com dr.m.hogan@gmail.com

Social Networking http://www.linkedin.com/in/davidwcovington https://twitter.com/davidwcovington https://www.facebook.com/david.covington http://www.youtube.com/davidcovington

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