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The New York State Office of Mental Health is launching several Zero Suicide initiatives across the state, utilizing the AIM for Zero approach. While the overarching approach is the same, adaptations have been made to accommodate unique challenges of different treatment settings.
Long considered the highest level of care available to suicidal individuals, inpatient psychiatric units face a range of challenges in treating suicidality. Today’s inpatient units remain geared toward stabilization of acute symptoms, primarily with psychotropic medication. Even though as high as 60-80% of admissions may be due to suicide risk, adoption of suicide specific treatments is low.¹ Health systems are faced with bridging this services gap while also improving transition care and engagement. National data suggests that individuals are at highest risk for a suicide attempt the week after discharge from a hospital, even for those admitted for reasons other than suicide risk, and the 3 months after hospitalization remain an extremely high-risk period.² Despite this vulnerability, engagement rates for this population remain alarmingly low. Approximately 50-75% of patients do not attend their post hospitalization therapy appointments.³ Reducing suicide risk among those receiving inpatient psychiatric care calls for a systemic approach.
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In an Office of Mental Health 2016 internal analysis of New York Incident Management Reporting System (NIMRS) and Medicaid claims data,¹ among the 1,643 individuals receiving care within the New York State mental health system who attempted or died by suicide, there were 1,527 visits to psychiatric hospitals and emergency departments less than 6 months prior to suicidal behavior. More than half (53%) of these visits occurred less than 30 days prior to the suicidal behavior, consistent with nationwide trends. A similar trend occurs within the general New York State population: a significant proportion of individuals who die by suicide are seen in inpatient or ED settings not long before their deaths. In another internal analysis crosswalking the state’s all payer hospital dataset, Statewide Planning and Research Cooperative System (SPARCS), and Vital Statistics (2013-14), there were a total of 3,564 suicides; 452 (13%) had an inpatient discharge and 415 (12%) had an ED discharge within seven days of their suicide. It is estimated that up to 8% of patients presenting to medical EDs have active suicidal ideation, most of which goes undetected.2,3 Like inpatient units, CPEPs and EDs see high volumes of suicidal patients but inconsistently deliver suicide specific assessment and intervention, missing opportunities to triage or treat those at greatest risk.
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New York State survey data demonstrate that many mental health clinicians are poorly equipped to identify and treat suicidal patients. In a survey administered to 1,585 New York State outpatient mental health providers in 2014,¹ 64% reported little or no specialized training in suicide-specific interventions and 20% reported they were not comfortable asking direct and open-ended questions about suicide with their patients. Furthermore, about 33% did not feel they had sufficient training to assist suicidal patients, and 43% did not feel confident in their ability to manage suicidal ideation and behavior with an evidence-based approach. Nearly 50% reported a need for greater training in risk assessment and suicide-specific treatments. Coupled with the fact that almost 49% of outpatient mental health patients who died by suicide saw their provider in the month before their deaths, training in and implementation of suicide-specific protocols remains urgently needed in outpatient facilities.
For patients receiving outpatient mental health care where suicidality is part of the clinical picture, suicide-specific treatments are recommended as part of an evidenced-based psychotherapy. Those include Dialectical Behavior Therapy (DBT), Cognitive Therapy for Suicide Prevention (CT-SP), and Collaborative Assessment and Management of Suicide (CAMS).
It is critical that outpatient mental health providers monitor patients between appointments and follow up when patients miss appointments.
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Substance use is the second most common risk factor for suicide. Click here for more information. Substance users who present with suicidal thoughts or behaviors in an outpatient substance use department are likely to be referred to a mental health facility for treatment. Given that rates of follow-up in suicidal populations remains so low, New York State’s implementation of the Zero Suicide model includes a protocol for inpatient and outpatient substance use disorder treatment providers. Organizational protocols will vary by type of facility and staffing. Adaptations should be made based on the clinical discretion of agency leadership.
It is well-established that nearly one half of individuals who die by suicide had a primary care contact in the month prior to their death. The comparable figure for mental health visits within a month of suicide deaths is 15-20%.¹ As a result, primary care visits offer a crucial opportunity to detect and triage for suicide risk among individuals who may not have direct contact with the mental health system.
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