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Suicide Prevention

Overview of Suicide Prevention

Every 12 minutes, someone in the U.S. completes suicide. For every one suicide, there are 25 attempts. The widespread tragedy of suicide and suicidal ideation has caused an increase in the number of people intimately familiar with its effects and associated trauma. Knowing the warning signs of suicide, and how to help a person contemplating suicide, are essential skills for health care providers, especially those who work in integrated health settings.

The SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) has gathered a list of resources and tools for provider organizations looking to implement a suicide prevention strategy or enhance a current one.

  • The Adverse Childhood Experience Survey (ACE) measures 10 types of childhood trauma; five are personal — physical abuse, verbal abuse, sexual abuse, physical neglect and emotional neglect; five are related to other family members: a parent engaged in substance misuse, a mother who’s a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness and the disappearance of a parent through divorce, death or abandonment.
  • The Columbia-Suicide Severity Rating Scale (C-SSRS) is an instrument used for suicide assessment. It is available in 114 country-specific languages, and mental health training is not required to administer the C-SSRS. Various professionals can administer this scale, including physicians, nurses, psychologists, social workers, peer counselors, coordinators, research assistants, high school students, teachers and clergy. Learn more about the C-SSRS and how it can be used.
  • The MacArthur Depression Toolkit assists primary care clinicians with recognizing and managing depression. This toolkit includes user-friendly instruments to assist with recognizing, diagnosing, treating and monitoring depression.
  • This edition of the Center for Integrated Health Solutions (CIHS) eSolutions focuses on Suicide Prevention in Primary Care and contains a profile of a New York FQHC, common suicide warning signs and featured resources.
  • A Discussion Guide for Primary Health Care Providers is an online guide to equip primary health care providers with questions to begin discussions with their patients about alcohol, illicit drug, and mental health issues, as well as co-occurring disorders. This brief guide also includes resources for patients who need an evaluation based on positive screening results.
  • Stories of Hope and Recovery is a video guide for suicide attempt survivors and features inspiring stories from three people who survived an attempted suicide. Told through their voices and those of their families, the stories recount their journeys from the suicide attempt to a life of hope and recovery. You can find additional resources in A Journey Toward Health and Hope: Your Handbook for Recovery After a Suicide Attempt, which guides survivors through the first steps toward recovery and a hopeful future after a suicide attempt.
  • Suicide Prevention Toolkit for Rural Primary Care, developed by the Western Interstate Commission for Higher Education (WICHE) Mental Health Program, in collaboration with the Suicide Prevention Resource Center, assists rural primary care providers in effectively identifying and intervening with individuals who are suicidal.
  • Suicide Safe is a suicide prevention, mobile-learning tool to help providers integrate suicide prevention strategies into their practice and reduce suicide risk among their patients. SAMHSA'S free app is available for Android and iOS operating systems.
  • The Suicide Resource Prevention Center (SPRC), funded by SAMHSA, provides technical assistance, training and materials to increase the knowledge of professionals serving people at risk for suicide. The SPRC Training Institute has a variety of trainings that focus on suicide prevention among specific populations, including for LGBT youth and youth in juvenile justice facilities. The institute also offers a one-day curriculum for mental health professionals on assessing and managing suicide risk. SPRC’s Zero Suicide program offers toolkits designed to help assess an organization’s readiness and ability to impact suicide, and specific training and development strategies to provide safer prevention-informed care.
  • The California Mental Health Services Authority developed the Training Resource Guide for Suicide Prevention in Primary Care Settings to help guide county efforts to engage primary care in suicide prevention. It includes training materials and implementation tools, a suicide prevention toolkit for rural primary care practices, and sample handouts and resources.
  • Mental Health First Aid is a public education program that helps the public identify, understand and respond to signs of mental illnesses and substance use disorders. 

Find local suicide prevention resources in your community and state.

Quick Tips for Population-Specific Suicide Prevention Care

Racial and Ethnic Minority Populations

The Suicide Prevention Resource Center’s American Indian/Alaska Natives website helps individuals who work with Native populations to support suicide prevention and mental health promotion. 

Veterans 

The Safety Plan Treatment Manual to Reduce Suicide Risk: Veterans Version is a manual describing brief clinical intervention and safety planning, that can serve as a valuable adjunct to risk assessment and may be used with veterans who have made a suicide attempt, have suicide ideation, have psychiatric disorders that increase suicide risk, or who are otherwise determined to be at high risk for suicide.

Rural Populations

The Rural Health Information Hub (Formerly the Rural Assistance Center) provides tools and resources to address suicide in rural and frontier areas of the U.S., where suicide is the second leading cause of death.

Looking for more information?

Take a closer look at these resources.

Case Study: Institute for Family Health

New York Health Center Saves Lives Through EHRs

Neil Calman, MD, President and CEO, and Virna Little, PsyD, LCSW-r, Senior Vice President, Psychosocial Services and Community Affairs — SAP Institute for Family Health, New York, NY

Traditionally, the responsibility of assessing suicide risk has mainly fallen to primary care professionals, as they often actively treat people who are suicidal but not engaged in mental health treatment. Past research shows that up to 64% of people contemplating suicide seek attention for a medical problem in the month before an attempt, and over half that amount in just week preceding an attempt. Such evidence speaks to the need for systems to help identify and monitor individuals at risk for suicide in primary care settings.

Electronic health records facilitate immediate feedback to healthcare providers and offer ways to identify and track potentially suicidal patients. Using EHRs, with the involvement of primary care providers, in suicide assessment and prevention may significantly help identify suicidal patients who are not actively seeking mental health treatment and ultimately reduce overall suicide rates. Understanding the major effect that training and EHR decision support can have on suicidality, the Institute for Family Health, a not-for-profit community health center network located in New York, launched a two-prong approach striving for a zero suicide rate in the populations it serves.

The Institute’s senior leadership understood that training staff on suicide prevention and awareness is crucial to eliminating completed suicides in its patient population. Partnering with the Mental Health Association of Ulster County and Dr. Max Banilivy, the Institute set upon a mission to train its entire staff using the evidence-based models SAFETALK and ASIST. In 2008, the Institute implemented a policy mandating suicide prevention training for every employee. All staff, regardless of discipline or position, must participate in at least one of the trainings: behavioral health staff participate in the two-day ASIST training and all other staff attend the 3-hour SAFETALK training. The Institute has trained over 700 of its 900 staff members, making this initiative one of the largest employer suicide prevention initiatives in New York. As a training center for family practice and mental health clinicians, the Institute’s mandate ensures that over 50 mental health interns and family practice residents are trained each year.

The Institute's second initiative was implementation of the EHR system Epic (Epic Systems, Verona, Wisconsin) 10 years ago for the identification and assessment of patients at risk for suicide. While the Institute implemented Epic, it simultaneously launched a depression identification and treatment program, making it the first organization to build the PHQ9 depression screening tool into their EHR, scoring it as a lab value. When the PHQ-9 score is a 10 or above, it is added as an abnormal lab value in the EHR, which then alerts providers to the patient’s potential risk. Many organizations only flag scores over 10 as an alert; the Institute took it one step further, adding the additional indicator of using a decimal point score for how a patient answers on question 9 (Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself?), which better alerts staff to the patient’s thoughts of suicide. While electronic health technology and the use of the PHQ-9 has advanced since that time, the Institute maintains one of the country's highest screening rates at almost 90%.

Now, the Institute requires that all patients who respond positively to the PHQ-9 suicide screening question have “suicide risk” put on their problem list, which means it is visible to all providers who see the patient regardless of discipline, and it is “blown in” to each provider’s note, automatically bringing immediate attention to the patient's risk for suicide. Staff are required to ask the patient if they are at risk. Then, they must develop and review the safety plan and, if necessary, seek mental health support if they are not a mental health provider.

A safety plan has been built into the EHR that is designed to be completed concurrently with the patient and can be printed individually or as part of an after-visit summary for the patient. As part of a comprehensive suicide prevention program, the Institute developed policies that require direct care staff of any discipline to address suicidality during all interactions.

The Institute also pioneered several decision support tools to alert providers of a patient at risk of suicide. An “FYI” alert is placed in the patient’s chart that pops up to notify all providers that the patient needs to be assessed for risk as they open the encounter. The ability to view the FYI alert gives providers immediate information on how to access the patient’s safety plan and information regarding the patient’s suicidality in order to review it with the patient and further assess risk.

The Institute can run reports for patients with “suicide risk” on their problem lists that have not accessed the organization in 30, 60, or 90 days, prompting staff to review the patients’ records and conduct outreach calls or visits. The Institute also utilizes two electronic portals?a physician portal and patient care portal. The patient care portal, or “MyChart,” allows patients to view their health records, obtain accurate health related information, and communicate with their providers. The Institute has recently built the PHQ-9 into the MyChart portal so patients can complete the tool electronically while in the community. In addition, the ability to communicate with their provider through secure electronic mail helps patients because they can reach out to someone with whom they have a relationship for help and support. The physician portal, “InstituteLink,” provides access to patients’ records. The community providers' ability to see a patient’s problem list alerts them to a patient’s potential suicide risk and gives them access to the safety plan, allowing them to review and update the plan with the patient thereby reducing the patient's risk. This increases the opportunities for assessment, risk reduction, and care coordination as community organizations can communicate with the patients’ health and mental health providers at the Institute, creating a true care network for the patient.

The EHRs can play a significant role in identifying patients in community health settings, a common difficulty. Including risk in problem lists, in addition to decision support tools, can dramatically improve the likelihood of assessment for an at-risk patient. However, without proper training, providers in community health settings will feel unprepared to ask patients about suicidality ? and we will continue to see the high rates of completed suicides for patients known to primary care. Community health organizations can significantly impact suicide rates by adopting a model that incorporates both the systematic training of providers and the identification and monitoring of at-risk patients through their electronic health records.

For more information on the Institute for Family Health, visit https://www.institute2000.org/. For more information on how CIHS supports FQHCs’ integrated health efforts, visit https://www.integration.samhsa.gov/about-us/about-cihs.

Call Our Helpline: 202.684.7457

Overview of Suicide Prevention

Every 12 minutes, someone in the U.S. completes suicide. For every one suicide, there are 25 attempts. The widespread tragedy of suicide and suicidal ideation has caused an increase in the number of people intimately familiar with its effects and associated trauma. Knowing the warning signs of suicide, and how to help a person contemplating suicide, are essential skills for health care providers, especially those who work in integrated health settings.

The SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) has gathered a list of resources and tools for provider organizations looking to implement a suicide prevention strategy or enhance a current one.

  • The Adverse Childhood Experience Survey (ACE) measures 10 types of childhood trauma; five are personal — physical abuse, verbal abuse, sexual abuse, physical neglect and emotional neglect; five are related to other family members: a parent engaged in substance misuse, a mother who’s a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness and the disappearance of a parent through divorce, death or abandonment.
  • The Columbia-Suicide Severity Rating Scale (C-SSRS) is an instrument used for suicide assessment. It is available in 114 country-specific languages, and mental health training is not required to administer the C-SSRS. Various professionals can administer this scale, including physicians, nurses, psychologists, social workers, peer counselors, coordinators, research assistants, high school students, teachers and clergy. Learn more about the C-SSRS and how it can be used.
  • The MacArthur Depression Toolkit assists primary care clinicians with recognizing and managing depression. This toolkit includes user-friendly instruments to assist with recognizing, diagnosing, treating and monitoring depression.
  • This edition of the Center for Integrated Health Solutions (CIHS) eSolutions focuses on Suicide Prevention in Primary Care and contains a profile of a New York FQHC, common suicide warning signs and featured resources.
  • A Discussion Guide for Primary Health Care Providers is an online guide to equip primary health care providers with questions to begin discussions with their patients about alcohol, illicit drug, and mental health issues, as well as co-occurring disorders. This brief guide also includes resources for patients who need an evaluation based on positive screening results.
  • Stories of Hope and Recovery is a video guide for suicide attempt survivors and features inspiring stories from three people who survived an attempted suicide. Told through their voices and those of their families, the stories recount their journeys from the suicide attempt to a life of hope and recovery. You can find additional resources in A Journey Toward Health and Hope: Your Handbook for Recovery After a Suicide Attempt, which guides survivors through the first steps toward recovery and a hopeful future after a suicide attempt.
  • Suicide Prevention Toolkit for Rural Primary Care, developed by the Western Interstate Commission for Higher Education (WICHE) Mental Health Program, in collaboration with the Suicide Prevention Resource Center, assists rural primary care providers in effectively identifying and intervening with individuals who are suicidal.
  • Suicide Safe is a suicide prevention, mobile-learning tool to help providers integrate suicide prevention strategies into their practice and reduce suicide risk among their patients. SAMHSA'S free app is available for Android and iOS operating systems.
  • The Suicide Resource Prevention Center (SPRC), funded by SAMHSA, provides technical assistance, training and materials to increase the knowledge of professionals serving people at risk for suicide. The SPRC Training Institute has a variety of trainings that focus on suicide prevention among specific populations, including for LGBT youth and youth in juvenile justice facilities. The institute also offers a one-day curriculum for mental health professionals on assessing and managing suicide risk. SPRC’s Zero Suicide program offers toolkits designed to help assess an organization’s readiness and ability to impact suicide, and specific training and development strategies to provide safer prevention-informed care.
  • The California Mental Health Services Authority developed the Training Resource Guide for Suicide Prevention in Primary Care Settings to help guide county efforts to engage primary care in suicide prevention. It includes training materials and implementation tools, a suicide prevention toolkit for rural primary care practices, and sample handouts and resources.
  • Mental Health First Aid is a public education program that helps the public identify, understand and respond to signs of mental illnesses and substance use disorders. 

Find local suicide prevention resources in your community and state.

Quick Tips for Population-Specific Suicide Prevention Care

Racial and Ethnic Minority Populations

The Suicide Prevention Resource Center’s American Indian/Alaska Natives website helps individuals who work with Native populations to support suicide prevention and mental health promotion. 

Veterans 

The Safety Plan Treatment Manual to Reduce Suicide Risk: Veterans Version is a manual describing brief clinical intervention and safety planning, that can serve as a valuable adjunct to risk assessment and may be used with veterans who have made a suicide attempt, have suicide ideation, have psychiatric disorders that increase suicide risk, or who are otherwise determined to be at high risk for suicide.

Rural Populations

The Rural Health Information Hub (Formerly the Rural Assistance Center) provides tools and resources to address suicide in rural and frontier areas of the U.S., where suicide is the second leading cause of death.

Looking for more information?

Take a closer look at these resources.

Case Study: Institute for Family Health

New York Health Center Saves Lives Through EHRs

Neil Calman, MD, President and CEO, and Virna Little, PsyD, LCSW-r, Senior Vice President, Psychosocial Services and Community Affairs — SAP Institute for Family Health, New York, NY

Traditionally, the responsibility of assessing suicide risk has mainly fallen to primary care professionals, as they often actively treat people who are suicidal but not engaged in mental health treatment. Past research shows that up to 64% of people contemplating suicide seek attention for a medical problem in the month before an attempt, and over half that amount in just week preceding an attempt. Such evidence speaks to the need for systems to help identify and monitor individuals at risk for suicide in primary care settings.

Electronic health records facilitate immediate feedback to healthcare providers and offer ways to identify and track potentially suicidal patients. Using EHRs, with the involvement of primary care providers, in suicide assessment and prevention may significantly help identify suicidal patients who are not actively seeking mental health treatment and ultimately reduce overall suicide rates. Understanding the major effect that training and EHR decision support can have on suicidality, the Institute for Family Health, a not-for-profit community health center network located in New York, launched a two-prong approach striving for a zero suicide rate in the populations it serves.

The Institute’s senior leadership understood that training staff on suicide prevention and awareness is crucial to eliminating completed suicides in its patient population. Partnering with the Mental Health Association of Ulster County and Dr. Max Banilivy, the Institute set upon a mission to train its entire staff using the evidence-based models SAFETALK and ASIST. In 2008, the Institute implemented a policy mandating suicide prevention training for every employee. All staff, regardless of discipline or position, must participate in at least one of the trainings: behavioral health staff participate in the two-day ASIST training and all other staff attend the 3-hour SAFETALK training. The Institute has trained over 700 of its 900 staff members, making this initiative one of the largest employer suicide prevention initiatives in New York. As a training center for family practice and mental health clinicians, the Institute’s mandate ensures that over 50 mental health interns and family practice residents are trained each year.

The Institute's second initiative was implementation of the EHR system Epic (Epic Systems, Verona, Wisconsin) 10 years ago for the identification and assessment of patients at risk for suicide. While the Institute implemented Epic, it simultaneously launched a depression identification and treatment program, making it the first organization to build the PHQ9 depression screening tool into their EHR, scoring it as a lab value. When the PHQ-9 score is a 10 or above, it is added as an abnormal lab value in the EHR, which then alerts providers to the patient’s potential risk. Many organizations only flag scores over 10 as an alert; the Institute took it one step further, adding the additional indicator of using a decimal point score for how a patient answers on question 9 (Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself?), which better alerts staff to the patient’s thoughts of suicide. While electronic health technology and the use of the PHQ-9 has advanced since that time, the Institute maintains one of the country's highest screening rates at almost 90%.

Now, the Institute requires that all patients who respond positively to the PHQ-9 suicide screening question have “suicide risk” put on their problem list, which means it is visible to all providers who see the patient regardless of discipline, and it is “blown in” to each provider’s note, automatically bringing immediate attention to the patient's risk for suicide. Staff are required to ask the patient if they are at risk. Then, they must develop and review the safety plan and, if necessary, seek mental health support if they are not a mental health provider.

A safety plan has been built into the EHR that is designed to be completed concurrently with the patient and can be printed individually or as part of an after-visit summary for the patient. As part of a comprehensive suicide prevention program, the Institute developed policies that require direct care staff of any discipline to address suicidality during all interactions.

The Institute also pioneered several decision support tools to alert providers of a patient at risk of suicide. An “FYI” alert is placed in the patient’s chart that pops up to notify all providers that the patient needs to be assessed for risk as they open the encounter. The ability to view the FYI alert gives providers immediate information on how to access the patient’s safety plan and information regarding the patient’s suicidality in order to review it with the patient and further assess risk.

The Institute can run reports for patients with “suicide risk” on their problem lists that have not accessed the organization in 30, 60, or 90 days, prompting staff to review the patients’ records and conduct outreach calls or visits. The Institute also utilizes two electronic portals?a physician portal and patient care portal. The patient care portal, or “MyChart,” allows patients to view their health records, obtain accurate health related information, and communicate with their providers. The Institute has recently built the PHQ-9 into the MyChart portal so patients can complete the tool electronically while in the community. In addition, the ability to communicate with their provider through secure electronic mail helps patients because they can reach out to someone with whom they have a relationship for help and support. The physician portal, “InstituteLink,” provides access to patients’ records. The community providers' ability to see a patient’s problem list alerts them to a patient’s potential suicide risk and gives them access to the safety plan, allowing them to review and update the plan with the patient thereby reducing the patient's risk. This increases the opportunities for assessment, risk reduction, and care coordination as community organizations can communicate with the patients’ health and mental health providers at the Institute, creating a true care network for the patient.

The EHRs can play a significant role in identifying patients in community health settings, a common difficulty. Including risk in problem lists, in addition to decision support tools, can dramatically improve the likelihood of assessment for an at-risk patient. However, without proper training, providers in community health settings will feel unprepared to ask patients about suicidality ? and we will continue to see the high rates of completed suicides for patients known to primary care. Community health organizations can significantly impact suicide rates by adopting a model that incorporates both the systematic training of providers and the identification and monitoring of at-risk patients through their electronic health records.

For more information on the Institute for Family Health, visit https://www.institute2000.org/. For more information on how CIHS supports FQHCs’ integrated health efforts, visit https://www.integration.samhsa.gov/about-us/about-cihs.

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