ITHACA, N.Y. — A large effort focused on suicide prevention is underway in Tompkins County. Dozens of local officials across the county have teamed up to create a coalition that sees suicide as a public health concern and wants to take a comprehensive public health approach to address it.
As part of this effort, Dr. Michael Hogan, former New York State Commissioner of Mental Health and a developer of the “Zero Suicide” movement stopped in Ithaca early this week to meet with local officials who work at the colleges, and in services that deal with mental health and health care in the county.
Zero Suicide is what it sounds like — a belief that “suicide deaths for individuals under care within health and behavioral health systems are preventable.” Many people who commit suicide often fall through the cracks of the health care system.
In 2014, more than 42,000 Americans died by suicide, and on average there are about 117 suicide deaths per day. Around 11 people die by suicide each year in Tompkins County.
This summer, a Tompkins County Suicide Prevention Coalition was formed with more than 40 local mental health organizations to address the issue of suicide. The coalition was formed after The Watershed Declaration was adopted in April by mental health stakeholders who declared suicide to be a serious public health concern. With the declaration, members pledged to “intensify efforts toward saving lives and bringing hope to those struggling with suicide thoughts or affected by suicide loss.”
The conference Monday was brought together by Scott MacLeod, a donor adviser of The Sophie Fund. The fund was established in 2016 in memory of Sophie Hack MacLeod to support mental health initiatives helping young people in Ithaca.
As MacLeod began learning about Zero Suicide, he said “What can we do at The Sophie Fund to start people in Ithaca talking about this and actually implementing Zero Suicide, or at least introducing it to them to discuss it and decide whether they would like to do it or not?” The conference Monday was a chance to introduce local leadership in Tompkins County to the concept of Zero Suicide.
Hogan worked as the New York Commissioner of Mental Health from 2007 to 2012 and has served similar roles prior in Ohio and Connecticut. He commended the efforts of Tompkins County so far and said conversations on the topic of suicide prevention are “further along here than I’ve seen almost any place else.”
Ithaca Voice Reporter Kelsey O’Connor spoke with Hogan while he was at Cornell University to discuss Zero Suicide and what he thinks of Tompkins County’s efforts in suicide prevention.
What brings you here to Ithaca?
Scott. Scott hosted an unusual community conversation here involving, around preventing suicide and including some community leaders, leaders from most of the major health care organizations and people involved in campus mental health and suicide prevention in Cornell and Ithaca and TC3. It was the opportunity to have that conversation that brought me here.
And why do you say unusual?
Because suicide prevention is underpowered and underappreciated in most communities. So there might be conversations going on on the campus, there might be some conversations going on in the public health department, there might be some conversations going on in the hospital but these conversations are not brought together and they’ve got to be brought together for this to be effective.
I’d like to hear in your words (the Zero Suicide Initiative) can you kind of describe what that means?
I would describe Zero Suicide as more of a movement than an initiative and also I would describe it as a practical collection of proven new ideas about suicide prevention … in health care settings. The suicide prevention field has focused mostly on trying to prevent suicide by having better communities. That’s an oversimplification. If we could have better communities, that’s probably the best thing we could do but having better communities in the United States in 2017 is pretty difficult and so it’s high time we turned our attention to making health care safer and more effective for people that are suicidal.
It turns out that most people that die by suicide were receiving health care, but health care failed to prevent them from dying. They may not have been asked about suicidal thoughts or feelings. They probably weren’t asked. If they were asked, the support they got was probably inadequate, which is what I contribute to their death.
And we’ve learned a lot in the last 10 years about what’s effective.
So there Zero Suicide idea is both a movement to make health care suicide safe, and it’s also a collection of very practical ideas — many of them simple — that are effective.
The concept seems like a no brainer. We strive for that in other areas of health care and treating disease. So how have we approached suicide prevention in the past and what do we need to do moving forward?
As you said, it should be a no brainer, but it’s not.
Most health care settings don’t think of suicide prevention is part of what they do. They think it’s somebody’s job in the schools who’s supposed to help kids grow up healthier or something or if they think about suicide prevention as part of health care, they think it belongs on the in-patient psychiatric unit because that’s where people go isn’t it? If they’re if they’re suicidal and most people never get there.
Many people who died by suicide were also just on an inpatient unit. So suicide prevention has not until recently been seen as a priority for health care by either the health care establishment or by the suicide prevention field.
So for example, the first national strategy for suicide prevention in the United States was in 2000 and it did not include as a goal making health care suicide safe so that the update of that strategy in 2012 did include that as a as a goal. And health care hasn’t adopted this. For example there are no measures of suicide and health care promulgated by any of the national organizations, there are no quality standards really for suicide care and those that do exist are inadequate. So for example, there’s a health care expectation that’s incumbent on health insurance plans that everybody who is discharged from a psychiatric unit ought to have a visit with a therapist within a week.
Now the national performance on that goal in 2015 was 50 percent, actually 51 percent, so that’s very bad performance. And it also turns out that if somebody is suicidal a week is too long to wait. They don’t necessarily need an appointment the next day, but somebody ought to reach out to them the next day to say, ‘How are you doing?’
Those caring contacts are very effective. So the suicide prevention field hasn’t until recently embraced health care and the health care field hasn’t embraced suicide prevention so that’s what we’re trying to change.
What would that look for somebody? Is that in their primary care?
The one way to respond to that is to say that being at risk of suicide is a treatable health condition just like other treatable health conditions just like diabetes. If you’re going to treat a condition, you should have a plan. You should screen to find out if the problem exists and then you should treat according to whatever you find out in your screening. You should do what’s indicated and you should continually measure how you’re doing. So somebody that has diabetes, they would get a blood sugar check. We would check their A1C levels. We would give them a medication to try and control that. We’d advise them about their diet and we need a similar approach to suicide. We need to see if there’s risk, and then if there’s risk, we have to take the necessary steps.
The two troubles with this: one it hasn’t been embraced until recently as a goal and second, the practical tools for what I call suicide care are almost all new within the last 10 years, so a tremendous amount of research. But because the tools are new, even though they’re proven by research, most people don’t know about them yet. So we’re both trying to change an attitude and trying to change practice. And changing a practice and changing an attitude at the same time is tough.
You’ve been in health a long time. Why has it taken so long, or why is it taking so long … to change this attitude?
It’s a little bit of a long answer but Atul Gawande, the surgeon, wrote an article about changing health care that he called “Slow Ideas” and he used two examples of (changes) in health care that were very significant – one of which was fast and one of which was slow. They were both in the area of surgery.
So the change that was fast: in the middle of the 19th century was the discovery that sedation was possible and that you didn’t have to have people conscious and thrashing around while the surgery was going on. Not surprisingly because that was good for the practitioners as well as the patients, that was adapted very fast. The other change that was just as important in terms of outcomes but took much longer to change was the idea of sterilizing the surgical suite and surgical tools and so on, so you know putting on the plastic gloves. That took much longer to change, and Gawande says that maybe that’s because that’s a change that was just good for the patients. It was inconvenient in some ways for the practitioners, but it was good for the patients so it took longer.
Suicide care is like that. It is very good for the patients but it takes a bunch of hard work, so it’s a more complicated task, more complicated than a new medicine for example which is simpler.
What are the challenges for and how would this affect a daily (health) practitioner?
The first example I would change that is simple and obvious, but also complicated to achieve is to find out if somebody is thinking about suicide. It turns out that the best way to do that is to ask them. But we don’t. We don’t ask them that for lots of reasons.
We don’t ask because we didn’t know that that was effective. It turns out that in one study, 60 percent of people who subsequently died by suicide had indicated on a questionnaire that they were thinking about it. Yet that was a tiny fraction of all the people. Most people said no and so people that were not at risk said they weren’t at risk mostly weren’t at risk. So screening for suicide is twice as accurate according to research studies as a cholesterol score is to predict a heart attack, but a cholesterol score has now become pretty standard. So screening is an example of something that’s effective but because it’s new and because it has consequences. We don’t have the time for it. What are we going to do? What do we do if we find out about it? It takes a while to change.
Are there any examples of places or communities that are doing this well, getting toward Zero Suicide?
We have a number of health care organizations that are further on the journey. I don’t know of another community that is thinking about these issues in as broad a collaborative way as the people here in Tompkins County are.
To some extent, this Zero Suicide idea grew out of a very successful reform program in mental health at the Henry Ford System in Detroit where they set out to try and deliver psychiatric care in a fashion that was error-free, so they called their program “Perfect Depression Care.” So it was not a suicide prevention program but they decided to measure suicide as kind of an ultimate measure of whether their care was getting better. When they focused on this as an outcome, they ended up reducing suicide among that population by 75 percent and keeping that at a sustained level.
We’ve had similar experiences with a number of other organizations, both primary care and mental health organizations that have taken this on. But this whole idea of working toward Zero Suicide is only three or four or five years old.
You mentioned Tompkins County. I’m in the Tompkins County bubble so I only see what we’re doing here, but comparatively do you think we are doing things well? Do you think we can do things better?
Yes and yes. The things that I see here are that are more advanced, specifically with respect to suicide prevention, I would have a short list. Although it’s not perfect, the mental health and suicide prevention programs at Cornell are world class. So they’ve inspired much of this change.
Second, the community health care organizations are starting to focus on this both individually and in a collaborative fashion. So (Cayuga Medical Center), Child and Family Services, the county health department and community services office are all engaged in thinking about this. What’s more unusual is they’ve come together to talk about. … A lot of the work hasn’t been done yet, but the conversation is further along here than I’ve seen almost any place else.
Why are you so passionate and involved in the Zero Suicide movement?
I spent 25 years trying to run a state mental health systems. So I think I was also always concerned about quality, but when you’re doing something like that you don’t get to do the few short things that are on your priority list because you’re so busy trying to drain the swamp.
In the different states that I was in principally in Ohio where I was for 16 years and then in New York, we were trying to do those things in suicide prevention that were thought to be important, but I didn’t think they were working. And so this quest that focused ultimately in on how can we make health care suicide stay safe started when I was commissioner of mental health in New York included a visit to Cornell to see what they were doing and then led to a group of us nationally developing a test … we found out about Henry Ford who we find out about some of the things that had been done. We talked to the researchers and essentially we built a model for suicide care. Suicide has touched me, not as closely as it has touched some other people, but it’s touched me.
By my best calculation, while I was commissioner of mental health in these three states, about 3,500 people died under my care. That’s just looking at the trends in the data.
If being touched by it personally and having numbers like that doesn’t make you passionate about something I don’t know what would, particularly because we now know that we can do much better if we have these programs like the program at Henry Ford that reduced suicide by 75 percent. Shouldn’t we be doing that?
Is there anything else you’d like to add or anything else you’d like the public to know on this topic?
I would like people in Ithaca and Tompkins County to know that there is work going on in this arena.
I would want people to think about whether their health care organization is taking steps to keep them safe and family members safe. I’d like people to know that if they’re troubled and struggling that help is available, that it might be a little complicated because health insurance is complicated and it might take a little while because a lot of therapist offices have lines in front of them. I mean metaphorically speaking but help is available and it’s quite effective and I guess that I ultimately hope that the work that this meeting has coalesced goes forward in such a way so that three years from now, five years from now, 10 years from now no one is dying by suicide in the county.
For resources on suicide, visit ithacacrisis.org. For immediate help, call 800-273-8255 or text 607-269-4500.
Featured image: Dr. Michael Hogan discussing Zero Suicide at a conference Monday at Cornell University. Provided by Scott MacLeod.