Health Systems Making Suicide Prevention a Priority
AFSP’s Christine Moutier and Maggie Mortali discuss programs and tools that support health care workers
By Sue Ellen Wagner
Health care professionals who are proactive about their own health — both physical and mental — protect their ability to maintain optimal, safe patient care. So untreated mental health issues in health care professionals affect not only themselves but also the health care organizations where they work and the patients they treat.
A number of health care professionals experience burnout, depression and other forms of distress, and are at increased risk for suicide as compared to the general population.
Sue Ellen Wagner, vice president, trustee engagement and strategy at the AHA, sat down with leaders from the American Foundation for Suicide Prevention (ASFP) — Christine Moutier, M.D., chief medical officer, and Maggie Mortali, vice president, programs and workplace initiatives, — to discuss some of the steps hospitals and health systems can take to increase care for the mental health of front-line health professionals.
Sue Ellen Wagner: Christine, as the chief medical officer of AFSP, can you educate us about what the foundation is seeing regarding suicides, particularly in the health care setting?
Christine Moutier: It’s wonderful to be with the AHA Team today. We at AFSP are so grateful for your leadership and that of the many health system leaders you work with. The American Foundation for Suicide Prevention has been working in the national arena of suicide prevention for the last three and a half decades.
What we’ve been seeing is a two-decade period of increasing national suicide rate from 1999 through 2018, when the rate increased by a total of 35%. Fortunately, in 2019 and 2020, we saw the first decreases that we’d seen in a couple of decades. And so that takes us right into the early pandemic period when, in 2020, we saw a 3% decrease in the national rate of suicide for the second consecutive year, perhaps a surprise to some during a period as stressful as the start of a global pandemic.
We know that suicide, while complex, is a health outcome and therefore many factors are always important when considering an individual, let alone a population’s suicide rate. Even in the face of distress and external challenges, suicide risk is dynamic and so protective factors, support and evidence-based treatment can change an individual’s course toward greater resilience and reduce suicide risk.
To answer your question, we’re seeing that health systems around the United States are making suicide prevention a priority, and this is truly a sea change. I think it’s a result of societal trends showing decreases in stigma related to mental health and suicide, and a growing scientific field that is discovering not only answers to the questions about what drives suicide risk up, but interventions and treatments that can reduce suicide risk — something we didn’t have even a decade ago.
Since the science demonstrates clearly that suicide, while complex, is a health outcome, clinical settings can take action toward suicide as a clinical priority, by collecting data, training staff on the best practices to implement suicide screening and evidence-based risk reducing care steps.
The last thing I’ll say about health systems is that some systems and large payers are making suicide prevention a priority and starting to scale up their efforts and are tracking the results with some very positive findings such as reductions in suicidal behavior.
Wagner: That’s great to hear about the tracking piece. I think that’ll be critical as we move forward. Maggie, can you inform us about your work related to health care workplace suicide? And can you mention some implementation strategies you see that are effective?
Maggie Mortali: One key aspect of our work related to health care workplace suicide prevention is through the American Foundation for Suicide Prevention’s Interactive Screening Program. The Interactive Screening Program is an online program utilized by hospitals or health systems and in collaboration with their employee assistance program or other employee health provider. Through a customized web-based platform, the Interactive Screening Program provides a safe and anonymous way for employees to take a brief screening for stress, depression, burnout and other mental health concerns and receive a personal response from a health professional that’s affiliated with the health system’s employee health services over the program platform. Those responses provide employees with a personal connection to a caring health professional and the opportunity to exchange messages and learn about what resources and services are available. The program provides a unique opportunity for a personal connection to be made all while the employee remains anonymous, mitigating barriers to help-seeking and increase service engagement, particularly for those that that need it.
The American Foundation for Suicide Prevention has been implementing this program for over a decade and seen great success within our medical schools, hospitals, health systems and physician health programs in connecting individuals to the help and support they need.
AFSP takes a comprehensive approach to suicide prevention, supporting upstream, midstream and downstream strategies that are built into the system’s culture. In addition to implementing the Interactive Screening Program, we work with hospitals and health systems on upstream approaches such as mental health promotion and suicide prevention education, including the American Foundation for Suicide Prevention’s Talk Saves Lives: Suicide Prevention Education for Workplace Settings that health systems are using to educate their staff as a primer on suicide prevention.
AFSP’s downstream strategies provide loss and healing programs and resources, including postvention toolkits that are designed to support health care professionals and organizations after a suicide loss. These toolkits contain strategies for helping the organization and community to grieve, mitigate the risk of contagion, and attend to the main details of crisis response, communication and next steps for prevention. In addition to the toolkits, AFSP’s Healing Conversations gives those who have lost someone to suicide the opportunity to talk with an experienced AFSP volunteer. These volunteers, who are themselves survivors of suicide loss, offer understanding and guidance in the weeks and months following a suicide death. We recommend hospitals and health systems include Healing Conversations as part of their postvention protocols.
We work with organizations at every stage of the suicide prevention implementation process, and work collaboratively to support culture change and risk reduction for not just the organization and their employees and providers, but also for the people that they serve.
Wagner: Christine, Can you describe AFSP’s Project 2025?
Moutier: Project 2025 is AFSP’s signature initiative aiming to reduce the national suicide rate 20% by the year 2025. It is an innovative initiative that utilizes scientific evidence—based strategies and looks to partner with industry leaders that can implement those strategies and interventions at a level of scale that can actually reduce the population suicide rate.
The initiative began in 2015 by reaching consensus among top suicide prevention experts regarding what constitutes the most effective and rapid ways to reduce suicide risk. And then we worked with a group that uses systems dynamic modeling methods to model out for us what it would look like if those interventions rolled out at a particular pace around the country and how many lives we could see saved through these interventions. All of that is captured on the Project 2025 website.
Lastly, with our expert group, we found there are four key areas where these interventions are best implemented. The first is in health systems. Large health systems are ideal because they include primary care, behavioral health and emergency departments, where there is data to show that particular interventions work. And actually, in any clinical setting, there are now things that can be done from screening to particular care steps that can reduce suicide risk.
Additionally, Project 2025 has engaged the firearm-owning community to implement a public health strategy to educate the population and engage them in suicide prevention. That, as you can imagine, was very innovative at the time we embarked on Project 2025 in about 2015. However, it has proven effective and our suicide prevention education programs and resources are now throughout firearm owning communities in more than 40 states. And the last key area of Project 2025 is in the corrections system where we know that while the absolute number of lives being lost to suicide is lower in terms of the total burden of suicide in our nation, suicide is a leading cause of death in jails and there are opportunities to identify those at risk and provide potentially life-saving care.
Project 2025 capitalizes on scaling up specific actions in the places where a higher proportion of people at risk for suicide are passing through and where those settings have been demonstrated to feasibly be able to employ suicide preventive interventions.
Wagner: Can you provide some action steps that hospital and health system boards can take to develop a strategy to reduce suicides for both staff and people in communities?
Moutier: Health systems are in different stages of engagement with suicide prevention. And so depending on where they are, the approach may look a little different. For a health system that’s fairly new in approaching suicide prevention as a program or priority, a hospital board could discuss with the leadership about the community’s interest and readiness to. Oftentimes leadership is hearing concerns from employees, patients and the larger community about their sense of need to prioritize mental health and suicide prevention. Suicide prevention can be implemented for patient care, incorporating steps into patient care workflows; and suicide prevention can also be implemented for an employee base. Those are two different strategies, but they very much can dovetail together because both signal a change in culture that is ready to take stigma out of suicide prevention and postvention. There are two excellent resources that outline clear patient care steps to prevent suicide: AFSP and the National Action Alliance for Suicide Prevention collaborated on a document which summarizes standard care steps for reducing suicide risk in primary care, emergency departments and in behavioral health. See this site for additional information. Another resource is the national Blueprint for Youth Suicide Prevention, which we at AFSP collaborated with the American Academy of Pediatrics and experts from the National Institute of Mental Health to produce and was just released in March. View this site for the information within the Blueprint.
To give people a little preview, what you’re going to find in both of those resources is a set of steps that starts with screening for suicide risk, followed by suicide risk assessment, and then a series of brief interventions that include Safety Planning, Lethal Means Counseling, providing support and education to the patient and family when possible, and then appropriate referrals and crisis resources like the national Suicide Prevention Lifeline, which is 988; and then the last step would be the provision of caring communications.
We are living in a new era where science is providing new solutions and interventions to reduce suicide risk, and so it’s exactly the right time to start implementing suicide prevention strategies in health care settings. We at AFSP would love to work with any health care systems in this effort.
Sue Ellen Wagner (firstname.lastname@example.org) is vice president, trustee engagement and strategy, at the American Hospital Association.
Please note that the views of interviewees do not always reflect the views of the AHA.