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.
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