Setting Sights on Zero Suicides

Teenager Hannah Baker calmly walks into her family bathroom, runs water for a bath, sits in it with her clothes on and then proceeds to methodically slit her wrists. Her horrified mother finds her dead in the tub moments later.

This extremely graphic scene, part of the controversial Netflix series “13 Reasons Why,” is not real. But it certainly could be.

The number of suicide deaths in the U.S. has increased to 44,000 per year, 105 per day – or one every 12 minutes. They are the result of many things including depression, substance abuse, bullying, traumatic stress disorder – just to name a few.

And as much as some psychiatrists and providers might not want to admit it, even in the best of circumstances suicides can happen under their watch. Research shows that 50-70% of psychiatrists will have a patient commit suicide while in their care at some point in their careers. It’s not easy to take. It’s not easy to talk about. But it needs to be addressed.

At the Institute of Living (IOL) and across the Hartford HealthCare Behavioral Health Network, staff members are working to decrease the number of suicides. They are doing this through the Zero Suicide initiative, an evidenced based approach to establish more focused assessment and timely follow-up care for patients who are at risk of suicide. A national suicide prevention movement backed by the National Alliance for Suicide Prevention, Zero Suicide involves fact finding, research, education, staff champions and utilizing proven tools to help end the dramatic uptick in suicides.

The IOL was an early adopter of Zero Suicide. In 2015, the IOL was one of the first 20 organizations worldwide to be accepted into and trained by The Zero Suicide Academy, a two-day training for senior leaders of health and behavioral health organizations seeking to reduce suicide among patients in their care and in the community. Since then, the IOL has implemented what it has learned and is spreading the initiative across the rest of the Hartford HealthCare (HHC) Behavioral Health Network. A “kickoff meeting” was held in August to engage HHC’s other behavioral health organizations.

Dr. Harold I. Schwartz, IOL Psychiatrist-in-Chief and HHC Vice President of Behavioral Health, said reducing the number of suicides to zero, while not a realistic goal, is an “aspiration that will lead us to do more and do better… and a state of mind that one suicide is too many.”

Dr. Linda Durst, the IOL Medical Director who is overseeing the initiative, said it provides a framework for a focus on safety and error reduction, consistent with HHC’s status as a high reliability organization.

“This is a very comprehensive and methodical way of addressing prevention,” Dr. Durst said. “Before [Zero Suicide], there was an assumption that staff members were trained to assess for suicide risk and knew exactly how we should treat patients at risk. [In the past,] patients at risk were given an assessment but no one was really sure if we were using the results effectively in our efforts to prevent suicide.”

Under the Zero Suicide initiative, a set of best practices and tools are utilized. For example, patients are assessed using the highly regarded Columbia Suicide Severity Rating Scale (C-SSRS). C-SSRS uses a series of simple plain language questions asking patients, for example, whether and when they have thought about suicide; what actions they have taken to prepare for suicide; and whether and when their attempted suicide was either interrupted by another person or stopped of their own volition.

Zero Suicide also includes training clinical and non-clinical staff to focus on suicide risk, establishing policies to ensure safe handoffs between caregivers, and effective engagement of at risk patients – including a follow-up phone call within 24 hours after discharge.

  • Connecting with teenagers about suicide and issues that can lead to suicide starts with conversation. The ‘13 Reasons Why’ series…has helped us facilitate that conversation.

    - Dr. Schwartz

Dr. Schwartz said progress can only begin with conversation, both internally and externally. Internally, you have to be willing to admit that suicides do occur when patients are in the midst of treatment. The HHC Behavioral Health Network is currently conducting a review of patients who have committed suicide either during or after their care. The review includes determining common issues and risk factors so they can be systematically addressed going forward.

However, community conversations are just as important. With rising numbers of pro-suicide websites, new online suicide “games” such as the Russian Roulette-like Blue Whale Challenge and the recent Netflix series “13 Reasons Why,” all of which are just one click away, the IOL is engaging the community in public conversation about suicide – especially as it relates to teens and their vulnerabilities. These Town Hall-style conversations are being held in churches, schools and theaters, from the inner cities to suburbs.

“As with many things in life, connecting with teenagers about suicide and issues that can lead to suicide starts with conversation,” said Dr. Schwartz, who has moderated and served on panels about the Netflix series that captured the attention of teens nationwide. “The ‘13 Reasons Why’ series, despite some negative reviews about its graphic nature, has helped us facilitate that conversation.”

Laura Saunders, v, ABPP, a clinical psychologist at the IOL who also served on the panels, agreed that “13 Reasons Why” is helping to create conversations about depression, mental illness and suicide that wouldn’t have happened years ago.

“The conversations are helping to reduce the stigma associated with suicide and mental illness,” Saunders said. “Being depressed is not your fault. Being assaulted is not your fault. People need to hear that.”

Dr. Schwartz said he is convinced that the Zero Suicide Initiative, combined with ongoing community conversations and other measures, can help reduce the rising numbers of suicides.

“In suicide prevention, we must look hard in the mirror at the way we do things and challenge ourselves to change,” he said. “We will all be rewarded with the additional lives saved.”