At a recent suicide prevention symposium hosted by the NYS Office of Mental Health (Disclosure: I am the agency's Medical Director), Dr. Lee Goldman, Dean of Columbia Medical School, began the day by remarking that there has been an 80 percent (!) reduction in deaths from heart disease in the past 50 years. Dr. Goldman was highlighting how what seemed like inevitable mortality rates two generations ago could be systematically and dramatically altered by reducing risk and intervening early and effectively; lives can be saved and pain and suffering for potential family survivors can be blessedly mitigated.
That was a heartening opening in light of why this meeting was called: 10 years ago a national strategy to reduce suicides in this country was launched built on a platform created by Former Surgeon General David Satcher. Yet despite many well considered efforts there has been no reduction in deaths, which now are greater than ever, about 36,000/year according to the latest statistics. NYS Mental Health Commissioner Mike Hogan called this New York meeting to consider what this state of near to 20 million people might do to reduce deaths by suicide, and the grim consequences they cast. Our work would build on and resonate with a national effort underway.*
We began by hearing several success stories. First, we heard how Henry Ford Health System in Michigan, a large health insurance plan with some 500,000 members that delivers medical services to its subscribers and others (~10,000 visits/business day), set a goal for what they called "Perfect Depression Care." The vast predominance of people who complete suicide have an active mental illness, particularly depression. Not willing to tinker around the edges, they pursued a radical approach that set zero deaths as their goal. They implemented screening, proven principles and practices for the care of all chronic illnesses (including diabetes, heart disease and depression), immediate access to appointments, and continuous and robust quality improvement -- and after several years of progressive reductions in deaths they achieved and maintained 2 ½ years of zero deaths by suicide.
We next heard how Kaiser Permanente of Northern California, an HMO with over 3 million members and 20 medical centers, instituted a remarkable plan for primary care suicide prevention (i.e. in general medical services not mental health clinics). They introduced screening for depression, anxiety, substance abuse, and intimate partner violence, coupled that with treatment practices known to work, and scrutinized every suicide for what improvements could be made.
Finally, we heard how Magellan Health Services, a large national mental health managed care company, implemented suicide prevention in Arizona by focusing on those people whose risk for suicide was 6 - 12 times the general population, namely those people with a serious mental illness. They trained clinicians, standardized the provision of best practices, stressed community based care, and engaged families and those who survived an attempt; they have reduced deaths by 48 percent and inpatient admissions among their subscribers by 51 percent, indicating risk reduction as well as cost savings.
What was so notable from the presentations was that "suicide ... was just the tip of the iceberg," as the last speaker remarked. The vast problem below the surface, one that can be avoided, is not doing the right thing. We actually know what is right: setting very high standards (don't be afraid of perfection); systematically identifying people at risk; relentlessly providing proven methods of intervention; crossing boundaries between general medical and mental health care and staying with people when they move from one care setting to another (like from hospital to home); regularly assessing performance with measures that are as clear and understandable to patients and families as they are to clinicians; and zealously pursuing opportunities for improvement when problems appear, as they always do.
Deadly consequences happen, in effect, from suicide just like from heart disease, when we do not do the right thing as unfailingly as we can. Good medical care does not know the difference between illnesses. The same principles govern health care for every disease, physical and mental. Reducing rates of suicide is about improving health care. We will need to abide by these very same access and quality standards in order to manage the diseases that afflict our generation, especially those that derive from habit disorders and age, including diabetes, hypertension, asthma, obstructive lung diseases, Parkinson's and Alzheimer's disease, and the multiplicity of ails that derive from smoking, overeating, sedentary life styles and stress.
A colleague from the NYS Health Department, Dr. Foster Gesten, in the summing up at the end of the day suggested that strategies for saving lives could be "deep and wide." Deep are those that health care systems with accountability for identified individuals or populations could implement in NYS -- as we learned are going on in Michigan and Northern California (as well as the very notable work throughout Washington State). Wide are the practices known to work universally that are ready for prime time and wide application, like screening to identify high risk people, treatment care paths, open access to appointments, careful attention to transitions from one service site to another, informed and 'activated' patients and families, and health information technology that provides decision support and communicates essential information to those who need to know. Reducing death by suicide would be one of many fortunate outcomes from improving our health care system.
Achieving change in health care is very hard to do. It entails an unwavering ambition for excellence and zealous attention to details. I am reminded about something Michelangelo was reported to have said: "Trifles make for perfection, but perfection is no trifle."
*Last year, Federal Secretaries Sebelius (Health and Human Services) and Gates (Defense) launched the National Action Alliance for Suicide Prevention bringing together government and military officials, experts, people with mental illnesses, family members, foundations, and others to fashion a plan that would be more focused and successful than the efforts of the past decade. Commissioner Hogan and a number of those who attended the NYS symposium are members of the Action Alliance.
The opinions expressed here are solely my own as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
Visit Dr. Sederer's website at for questions you want answered, reviews, commentary and stories -
www.askdrlloyd.com
Jeffrey Fishberger, MD: Three Simple Words to Help With Depression
We know demographics and statistical risk factors. And yet we still don't help people and we sure don't save them. Perhaps if each of us really knew the risk factors ourselves, we could help others in the community.
- Natasha Tracy, Mental Health Writer
it robs the spirit
people turn away
they do not
want to be near it
an aloneness that
one should never
have to feel
for all those suffering
out there
sure hope you heal
I'm still depressed today, and I do think about suicide almost every day. I understand that isn't normal, though I'm never at a point where I really consider doing it; I just fantasize about it. With that said, even if I were at a dangerous point where I was an imminent threat to myself, I would not tell a soul, and I would not seek help. Why? Because I've experienced the sort of "help" that our medical system provides people in distress, and I would sooner embrace death that accept such unfathomable degradation and dehumanization as a lifeline.
I have nightmares all the time about the stuff that happened there. If I was suicidal when I came, I was doubly suicidal when I left.
In my 11 days stuck in the psych ward, I lost 15 pounds because the food was so horrendous it was inedible. I refused medication the whole way through, especially because I saw them hold my one friend against her will for an extra 5 days because when she was about to be allowed to go, they switched her medication and then forced her to stay so they could "see how the medication affected her." In fact, the only reason I even got out in 11 days was because my psychiatrist on the outside make a huge commotion on my behalf because the head of the ward did not appreciate the fact that I didn't take this whole thing seriously, and I can only assume wanted to teach me a lesson (and make more money from my insurance... $1,100/day for my stay in the ward).
I left the hospital feeble, famished, and more depressed than before. Being dehumanized and stuck there was the worst experience I have ever had in my entire life -- and I've had TONS of truly miserable experiences -- and the ONLY reason I didn't take my life in the ward was there was that one girl who was in the same boat I was in. (smart, depressed, expecting actual treatment, and surrounding by absurdity)
My "belligerence" prompted one of the "nurses" to call up the guards so I could be forcibly medicated against my will, and it wasn't until I demanded to see the attending psychiatrist and made a promise that my first phone call would be to an attorney that they let me not take "my" medication and made a note in my file that I was refusing treatment. (The pills, by the way, included a large dose of seroquil, which is an anti-psychotic).
I had assumed that being in a ward would involve serious therapy sessions and other things that were designed to help. This, of course, was unrealistic. The days were filled with pre-school and kindergarten level activities like painting, drawing with crayons, colored pencils, and markers, stretching, sing along, and endless hours of sitting in the common room playing cards, watching horrendous television, and the occasional outburst that required someone to be forcibly drugged. After 3 days of not participating in the ridiculous activities, I was informed in my first of two brief 15 minute discussions with the psychiatrist that I would not be released unless I showed a willingness to participate on the kindergarten style activities.
Truly depressed people aren't going to bother to tell you they are depressed.
Having attempted suicide myself, I think I have something to contribute to this discussion. To be frank, the treatment for people who plan to contemplate suicide and the people who attempt it is abysmal. Being forcibly institutionalized is the wrong thing to do, mostly because these institutions are nightmares. You are dehumanized. A psych ward at a hospital is how the hospital makes its money. They are woefully understaffed, they provide almost no treatment, and they try to force you to stay longer so they can make more money. After my attempt and period of time in the actual hospital, I was shipped up to the psych ward where I was stripped of my clothes, given a hospital gown and nothing else, and told to join the rest of the prisoners... I mean patients. The patients consisted almost entirely of the truly mentally ill, drug addicts, and a large number people who just checked themselves in for the free bed and free food. Miraculously for me, there happened to be one intelligent, albeit depressed, girl there with whom I could spend my days talking. Without even speaking with a psychiatrist, the pill distributor had a bunch of pills that she wanted me to take shortly after arriving. Considering I was not on any mediciation, and the fact that I have medical complications with most medications, I politely refused this medication that was not prescribed to me by any doctor.