- Claims are spreading across social media that a goal of zero suicides can be achieved by radically re-organizing resources in health systems and communities. Extraordinary claims require extraordinary evidence.
- I thoroughly searched for evidence backing claims of “zero suicides” being achieved.
- The claims came up short, after expectations were initially raised by some statistics and a provocative graph. But any persuasiveness to these details quickly dissipated when they were scrutinized. Lesson: Abstract numbers and graphs are not necessarily quality evidence and dazzling ones can obscure a lack of evidence.
- The goal of “zero suicides” has attracted support of Pharma and generated programs around the world, with little fidelity to the original concept developed in the Henry Ford Health System in Detroit. In many contexts in which it is now being invoked, “zero suicides” is a vacuous buzz term, not a coherent, organizational strategy
- Preventing suicide is a noble goal to which a lot of emotion gets attached. It also creates lucrative financial opportunities and attracts vested interests which often simply repackage existing programs for resale.
- How can anyone oppose the idea that we should eliminate suicide? Clever sloganeering can stifle criticism and suppress embarrassing evidence to the contrary
- Yet, we should not be bullied, nor distracted by slogans from our usual, skeptical insistence on those who make strong claims having the burden to provide strong evidence.
- Deaths by suicide are statistically infrequent, poorly predicted events that occur in troubled contexts of interpersonal and institutional breakdown. These aspects can frustrate efforts to eliminate suicide entirely – or even accurately track these deaths.
- Eliminating deaths by suicide is only very loosely analogous to wiping out polio and lots of pitfalls await those who get confused by a false equivalence.
- Pursuit of the goal of “zero suicides,” particularly in under-resourced and not well-organized community settings can have unintended, negative consequences.
- “Zero suicides” is likely a fad, to be replaced by next year’s fashion or maybe a few years after.
- We need to step back and learn from the rise and fall of slogans and the unintended impact on distribution of scarce resources and the costs to human well-being.
- My take away message is that increasingly sophisticated and even coercive communications about clinical and public health policies often harness the branding of prestigious medical journals. Interpreting these claims require a matching skepticism, critical thinking skills, and renewed demands for evidence.
Beginning the search for evidence for the slogan “Zero Sucide.”
Numerous gushy tweets about achieving “zero suicides” drew me into a search for more information. I easily traced the origins of the campaign to a program at the Henry Ford Health System, a Detroit-based HMO, but the concept has now gone thoroughly international. My first Google Scholar search did not yield quality evidence from any program evaluations, but a subsequent Google search produced exceptionally laudatory and often self-congratulatory statements.
I briefly diverted my efforts to contacting authorities whom I expected might comment about “zero suicides.” Some indicated a lack of familiarity prevented them from commenting, but others were as evasive as establishment Republicans asked about Donald Trump. One expert, however, was forthcoming with an interesting article, which proved to have just right tone. I recommend:
Kutcher S, Wei Y, Behzadi P. School-and Community-Based Youth Suicide Prevention Interventions Hot Idea, Hot Air, or Sham?. The Canadian Journal of Psychiatry. 2016 Jul 12:0706743716659245.
Continuing my search, I found numerous links to other articles, including a laudatory, Medical News and Perspectives opinion piece in JAMA behind a readily circumvented pay wall. There was also a more accessible source with a branding by New England Journal of Medicine.
Clicking on these links, I found editorial and even blatantly promotional material, not randomized trials or other quality evidence.
This kind of non-evidence-based publicity in highly visible medical journals is extraordinary in itself, although not unprecedented. Increasingly, the brand of particular medical journals is sold and harnessed to bestow special credibility on political and financial interests, has seen in 1 and 2.
NEJM Catalyst is described as bringing
Health care executives, clinician leaders, and clinicians together to share innovative ideas and practical applications for enhancing the value of health care delivery.
The claim of “zero suicides” originated in the Perfect Care for Depression in a division of the Henry Ford Health System.
The audacious goal of zero suicides was part of the Behavioral Health Services division’s larger goal to develop a system of perfect care for depression. Our roadmap for transformation was the Quality Chasm report, which defined six dimensions of perfect care: safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness. We set perfection goals and metrics for each dimension, with zero suicides being the perfection goal for effectiveness. Very quickly, however, our team seized on zero suicides as the overarching goal for our entire transformation.
We used three key strategies to achieve this goal. The first two — improving access to care and restricting access to lethal means of suicide — are evidence-based interventions to reduce suicide risk. While we had pursued these strategies in the past, setting the target at zero suicides injected our team with gumption. To improve access to care, we developed, implemented, and tested new models of care, such as drop-in group visits, same-day evaluations by a psychiatrist, and department-wide certification in cognitive behavior therapy. This work, once messy and arduous for the PDC team, became creative, fun, and focused. To reduce access to lethal means of suicide, we partnered with patients and families to develop new protocols for weapons removal. We also redesigned the structure and content of patient encounters to reflect the assumption that every patient with a mental illness, even if that illness is in remission, is at increased risk of suicide. Therefore, we eliminated suicide screens and risk stratification tools that yielded non-actionable results, freeing up valuable time. Eventually, each of these approaches was incorporated into the electronic health record as decision support.
The third strategy:
…The pursuit of perfection was not possible without a just culture for our internal team. Ultimately, we found this the most important strategy in achieving zero suicides. Since our goal was to achieve radical transformation, not just to tweak the margins, PDC staff couldn’t justly be punished if they came up short on these lofty goals. We adopted a root cause analysis process that treated suicide events equally as tragedies and learning opportunities.
Process of patient care described in JAMA
What happens to a patient being treated in the context of Perfect Depression Care is described in the JAMA piece:
Each patient seen through the BHS is first assessed and stratified on the basis of suicide risk: acute, moderate, or low. “Everyone is at risk. It’s just a matter of whether it’s acute or whether it requires attention but isn’t emergent,” said Coffey. A patient considered to be at high risk undergoes a psychiatric evaluation the same day. A patient at low risk is evaluated within 7 days. Group sessions for patients also allow individuals to connect and offer support to one another, not unlike the supportive relationships between sponsors and “sponsees” in 12-step programs
The claim of Zero Suicides, in numbers and a graph
…A dramatic and statistically significant 80% reduction in suicide that has been maintained for over a decade, including one year (2009) when we actually achieved the perfection goal of zero suicides (see the figure below). During the PDC initiative, the annual HMO network membership ranged from 182,183 to 293,228, of which approximately 60% received care through Behavioral Health Services. From 1999 to 2010, there were 160 suicides among HMO members. In 1999, as we launched PDC, the mean annual suicide rate for these mental health patients was 110.3 per 100,000. During the 11 years of the initiative, the mean annual suicide rate dropped to 36.21 per 100,000. This decrease is statistically significant and, moreover, took place while the suicide rate actually increased among non–mental health patients and among the general population of the state of Michigan.
[This graph conflicts a bit with a graph in NEJM Catalyst that indicates suicides in the health care system were 0 suicides for 2008 and this continued through the first quarter of 2010]
It is clear that rates of suicide fluctuate greatly from year-to-year in the health system. It also appears from the graph that for most years during the program, rates of suicide among patients in the Henry Ford Health System were substantially greater than those of the general population in Michigan, which were relatively flat. Any comparisons between the program and the general statistics for the state of Michigan are not particularly informative. Michigan is a state of enormous health care disparities. During this period, there was a large insured population. Demographics differ greatly, but patients receiving care within an HMO were a substantially more privileged group than the general population of Michigan. During this time, there were many uninsured and a lot of annual movement in and out of the Henry Ford Health System. At any one time, only 60% of the patients within the health system were enrolled in the behavioral health system in which the depression program occurred.
A substantial proportion of suicides occur with individuals who are not previously known to health systems. Such persons are more represented in the statistics for the state of Michigan. Another substantial proportion of suicides occur in individuals with weakened or recently broken contact with health systems. We don’t know how the statistics reported for the health system accommodated biased departures from the health system or simply missing data. We don’t know whether behavior related to risk of suicide affected migration into the health care system or to the small group receiving behavioral healthcare through the health system. For instance, what became of patients with a psychiatric disorder in a comorbid substance use disorder? Those who were incarcerated?
Basically, the success of the program is not obvious within the noisy fluctuation of suicides within the Henry Ford Health System or the smaller behavioral health program. We cannot control for basic confounding factors or selective enrollment and disenrollment in the health care system, or even expelling from the behavioral health system of persons at risk.
“Zero suicides” as a literal and serious goal?
The NEJM Catalyst article gave the originator of the program free reign for self-praise.
The most unexpected hurdles were skepticism that perfection goals like zero suicides were reasonable or feasible (some objected that it was “setting us up for failure”), and disbelief in the dramatic improvements obtained (we heard comments like “results from quality improvement projects aren’t scientifically rigorous”). We addressed these concerns by ensuring the transparency of our results and lessons, by collaborating with others to continually improve our methodological issues, and by supporting teams across the world who wish to pursue similar initiatives.
Our team challenged this assumption and asked, If zero is not the right goal for suicide occurrence, then what number is? Two? Twelve? Which twelve? In spite of its radicalism — indeed because of it — the goal of zero suicides became the galvanizing force behind an effort that achieved one of the most dramatic and sustained reductions in suicide in the clinical literature.
Will the Henry Ford program prove sustainable?
Edward Coffey moved to President, CEO, and Chief of Staff at the Menninger Clinic 18 months before his article in the NEJM Catalyst. I am curious to what aspects of his Zero Suicides/Perfect Depression Care Program are still maintained at Henry Ford. As it is described, the program was designed with admirably short waiting times for referral to behavioral healthcare. If the program persists as originally described, many professionals are kept vigilant and engaged in activities to reduce suicide without any statistical likelihood of having the opportunity to actually prevent one.
In decades of work within health systems, I have found that once demonstration projects have run their initial course, their goals are replaced by new organizational ones and resources are redistributed. Sooner or later, competing demands for scarce resources are promoted by new slogans.
What if Perfect Depression Care has to compete for scarce resources with Perfect Diabetes Care or alleviation of gross ethnic disparities in cardiovascular outcomes?
A lot of well-meant slogans ultimately have unintended, negative consequences. “Make pain the 5th vital sign” led to more attention being paid to previously ignored and poorly managed pain. This was followed by mandated routine assessment and intervention, which led to unnecessary procedures and unprecedented epidemic of addiction and death from prescribed opioids. “Stamp out distress” has led to mandated screening and intervention programs for psychological distress in cancer care, with high rates of antidepressant prescription without proper diagnosis or follow-up.
If taken literally and seriously, a lofty, but abstract goal like Zero Suicide becomes a threat to any “just culture” in healthcare organization. If the slogan is taken seriously as resources are inevitably withdrawn, a culture of blame will emerge and pressures to distort easily manipulated statistics. Patients posing threats to the goal of zero suicide will be excluded from the system with an unknown, but negative consequences for their morbidity and mortality.
Bottom line – we can’t have slogan-driven healthcare policies that will likely have negative implications and conflict with evidence.
Enter Big Pharma
Not unexpectedly, Big Pharma is getting involved in promoting Zero Suicides:
Eli Lilly and Company Foundation donates $250,000 to expand Community Health Network’s Zero Suicides prevention initiative,
Major gift will save Hoosier lives through a suicide prevention network that responds to a critical Indiana healthcare issue.
According to press coverage, the funds will go to:
The Lilly Foundation donation also provides resources needed to build a Central Indiana crisis network that will include Indiana’s schools, foster care system, juvenile justice program, primary and specialty healthcare providers, policy makers and suicide survivors. These partners will be trained to identify people at risk of attempting suicide, provide timely intervention and quickly connect them with Community’s crisis providers. Indiana’s state government is a key partner in building the statewide crisis network.
I’m sure this effort is good for the profits of Pharma. Dissemination of screening programs into settings that are not directly connected to quality depression care is inevitably ineffective. The main healthcare consequences are an increase in antidepressant prescriptions without appropriate diagnoses, patient education, and follow-up. Substantial overtreatment results from people being identified without proper diagnosis who otherwise would not be seeking treatment. Care for depression in the community is hardly Perfect Depression Care.
It is great publicity for Eli Lilly and the community receiving the gift will surely be grateful.
Launching Zero Suicides in English communities and elsewhere
My academic colleagues in the UK assure me that we can simply dismiss an official UK government press release about the goal of zero suicides from Nick Clegg. It has been rendered obsolete by subsequent political events. A number commented that they never took it seriously, regardless.
The claims in the press release stand in stark contrast to long waiting times for mental health services and important gaps in responses to serious mental health crises, including lethal suicide attempts. However, another web link is to an announcement:
Centre for Mental Health was commissioned by the East of England Strategic Clinical Networks to evaluate activity taking place in four local areas in the region through a pilot programme to extend suicide prevention into communities.
The ‘zero suicide’ initiative is based on an approach developed by Dr Ed Coffey in Detroit, Michigan. The approach aims to prevent suicides by creating a more open environment for people to talk about suicidal thoughts and enabling others to help them. It particularly aims to reach people who have not been reached through previous initiatives and to address gaps in existing provision.
Four local areas in the East of England (Bedfordshire, Cambridgeshire & Peterborough, Essex and Hertfordshire) were selected in 2013 as pathfinder sites to develop new approaches to suicide prevention. Centre for Mental Health evaluated the work of the sites during 2015.
The evaluation found an impressive range of activities that had taken suicide prevention activities out into local communities. They included:
• Training key public service staff such as GPs, police officers, teachers and housing officers
• Training others who may encounter someone at risk of taking their own life, such as pub landlords, coroners, private security staff, faith groups and gym workers
• Creating ‘community champions’ to put local people in control of activities
• Putting in place practical suicide prevention measures in ‘hot spots’ such as bridges and railways
• Working with local newspapers, radio and social media to raise awareness in the wider community
• Supporting safety planning for people at risk of suicide, involving families and carers throughout the process
• Linking with local crisis services to ensure people get speedy access to evidence-based treatments.
The report noted that some of the people who received the training had already saved lives:
“I saved a man’s life using the skills you taught us on the course. I cannot find words to properly express the gratitude I have for that. Without the training I would have been in bits. It was a very public place, packed with people – but, to onlookers, we just looked like two blokes sitting on a bench talking.”
“Déjà vu all over again”, as Yogi Berra would say. This effort also recalls Bill Murray in the movie Groundhog Day, where he is trapped into repeating the same day over and over again.
A few years ago I was a scientific advisor for European Union funded project to disseminate multilevel suicide prevention programs across Europe. One UK site was among those targeted in this report. Implementation of the EU program had already failed before the plate of snacks was being removed from a poorly attended event. The effort quickly failed because it failed to attract the support of local GPs.
Years later, I recognize many of the elements of what we tried to implement, described in language almost identical to ours. There is no mention of the training materials we left behind or of the quick failure of our attempt at implementation.
Many of the proposed measures in the UK plan serve to generate publicity and do not any evidence that they reduce suicides. For instance, training people in the community who might conceivably come in contact with a suicidal person accomplishes little other than producing good publicity. Uptake of such training is abysmally low and is not likely to affect the probability that a person in a suicidal crisis will encounter anyone who can make a difference
Broad efforts to increase uptake of mental health services in the UK strain a system already suffer from unacceptably long waiting times for services. People with any likelihood of attempting suicide, however poorly predicted, are likely to be lost among persons seeking services with less serious or pressing needs.
Thoughts I have accumulated from years of evaluating depression screening programs and suicide intervention efforts
Staying mobilized around preventing suicide is difficult because it is an infrequent event and most activations of resources will prove to false positives.
It can be tedious and annoying for both staff and patients to keep focused on an infrequent event, particularly for the vast majority of patients who rightfully believe they are not at risk for suicide.
Resources can be drained off from less frequent, but more high risk situations that require sustained intensity of response, pragmatic innovation, and flexibility of rules.
Heightened efforts to detect mental health problems increase access for people already successfully accessing services and decrease resources for those needing special efforts. The net result can be an increase in disparities.
Suicide data are easily manipulated by ignoring selective loss to follow-up. Many suicides occur at breaks in the system, where getting follow-up data is also problematic.
Finally, death by suicide is a health outcomes that is multiply determined. It does not lend itself to targeted public health approaches like eliminating polio, tempting though invoking the analogy may be.
It is likely that I exposed anyone reaching this postscript to a new and disconcerting perspective. What I have been saying is discrepant with the publicity about “zero suicides” available in the media. The portrayal of “zero suicides” is quite persuasive because it is sophisticated and well-crafted. Its dissemination is well resourced and often financed by individuals and institutions with barely discernible – if at all – conflicts of financial and political interests. Just try to find any dissenters or skeptical assessments.
My takeaway message: It’s best to process claims about suicide prevention with a high level of skepticism, an insistent demand for evidence, and a preparedness for discovering that seemingly well trusted sources are not without agendas. They are usually providing propaganda rather than evidence-based arguments.