Suicide Prevention as a Population Health Problem: A Study of Forefront Suicide Prevention’s Approach

QUESTION

Forefront Suicide Prevention’s Wheel of Change: Catalyzing a Social Movementto Prevent Suicide Working to make Washington a model suicide prevention state and implications for the field ofpopulation health.

Introduction

In 2013, a new suicide prevention organization, Forefront Suicide Prevention, was formed as a

multidisciplinary collaboration of University of Washington (UW) faculty. Its co-founders were a public health professor who specializes in health policy and a social worker turned suicide prevention expert.

Today the organization’s programs and approaches incorporate collaborations with other departments and schools across the UW campus. Forefront Suicide Prevention is leading a social movement in the state of Washington to implement a comprehensive approach to suicide prevention with the long-term goal of disseminating approaches developed in Washington to nearby states with the highest suicide rates. Forefront’s roots in heartache highlight the importance of personal stories to catalyze social change. The personal story in this case was that of Matt Adler. Matt was successful attorney, husband, and father of two young children. On February 18, 2011, he ended his life with a firearm. In the three months leading up to his death, Matt was in contact with three mental health professionals, each with their own independent clinical practice, who were attempting to treat Matt’s anxiety disorder and worsening depression. Matt’s mental health disorders were related to the downturn in the economy and the potential implications for his law practice. After Matt’s death, as his widow, I secured his medical records in the hopes of gaining greater insight into why Matt killed himself. What I read was disturbing—each of the three mental health professionals who had contact with Matt knew of his suicidal thoughts and knew of a specific plan; however, none took any significant action. Possible actions they should have taken include completing suicide risk screening, formal suicide risk assessment, creating a safety plan, contacting family or friends to assist in keeping him safe, and/or advocating immediately for more stepped-up treatment such as inpatient hospitalization or more assertive outpatient treatment with a provider who had specialized skills in suicide care.

Using my academic appointment as a bully pulpit, I researched best practices in suicide care, contacted suicide prevention experts across Washington, and then reached out to a state legislator with a background in community mental health to tell my husband’s story and the failures of his care. To be clear, I saw the concurrence of these three providers acting ineffectively in addressing my late husband’s suicide risk as a systems failure. Suicide prevention care has not been prioritized within primary care, mental health, or treatment for substance abuse despite the fact that mental health and substance abuse are the leading risk factors for suicide.3 These actions brought to light a systemic problem in Washington’s legislature that was also documented by research: namely, that most mental health professionals do not have adequate training to prevent suicide.4 This is the equivalent, in my mind, of a cardiologist not being trained to respond to a patient’s heart attack.

Study Design and Execution

The study design took the form of an initiative in this case. The frame of patient safety was key to

moving state legislation to address this problem. The two leading individual risk factors for suicide are

mental health and substance abuse disorders.1 With the support of mental health and substance abuse providers, the Matt Adler Suicide Assessment, Management, and Treatment Act of 2012 (EHB 2366) was quickly passed.5 EHB 2366 requires these professionals to be trained in how to assess, manage, and treat individuals who are at risk for suicide and to receive ongoing training to maintain licensure. This law was the first of its Milbank Memorial Fund • www.milbank.org 5 kinds in the nation and has led to similar laws being passed in 10 other states.6 Professional skills training in suicide prevention is now being disseminated on a larger scale than suicide prevention experts believed was possible during their lifetimes. Forefront came to exist in part to assist with the implementation of EHB 2366 by training behavioral health professionals. However, co-founders Sue Eastgard and I realized that to reduce suicide in one state would also require a much more comprehensive, multisystem approach.

Even within health care systems, training of mental health professionals on its own is inadequate to

ensure appropriate suicide care for at-risk patients. In reality, most people who die by suicide never see a mental health professional leading up to their deaths. An estimated 45% of suicidal patients saw a primary care provider within one month to one year preceding their death, compared with 20% who saw a mental health care professional in that same time.7,8 Thus, training in appropriate suicide care must extend beyond mental health professionals to other types of providers. And, even with all health

care providers trained in relevant care, providers will struggle to take the appropriate actions to address patients’ suicide risk without systems-based approaches.7 For example, a systems-based approach would put into place a screening tool for all patients inclusive of follow-up and care transition plans for patients who are at risk. Forefront’s conceptualization of a comprehensive approach to suicide prevention is consistent with a population health approach. A population health approach would describe the role that every single person can play in suicide prevention. There are skills every person can learn in order to recognize and respond when a person is at risk for suicide. This is not dissimilar totraining laypeople in CPR. It would ensure systems that people live and work in, including health care, educational, employment, criminal justice, and correctional systems, have prioritized suicide prevention.

Teachers, corrections officers, human resources personnel, academic advisers, journalists, pharmacists, and firearms retailers must all understand their roles in suicide prevention. This extends into both their personal lives and professional settings, and they need to be supported by our societal systems to fulfill these roles. Forefront’s mission is to reduce suicide by empowering individuals and communities to take sustainable action to prevent suicide, by championing systemic change and restoring hope. Forefront’s current geographic focus is Washington, with a suicide rate of 15.7 per 100,000, compared to a national rate of 13.9 per 100,000.9 The first goal of the organization is to demonstrate that reducing suicide is possible within one geographic region, with the longterm aspiration of disseminating innovation to other nearby states with the highest suicide Milbank Memorial Fund • www.milbank.org 6 rates.

Although a new organization, Forefront’s budget and staff have grown exponentially in a short time. In this case study, I will describe the conceptual underpinning of Forefront’s goal to make Washington a comprehensive suicide prevention model state, with the long-range goal of reducing suicides. I will emphasize how it seeks to change policies and systems and what the catalysts are for policy transformation. But first, an overview of the current state of the suicide prevention field.

In the United States each year over 44,000 people die by suicide. However, this figure is considered an underestimate due to misclassification of some lethal accidents and drug overdoses. After cancer and heart disease, suicide accounts for more years of life lost than any other cause of death.1 Suicide deaths are the tip of the iceberg: The Centers for Disease Control and Prevention estimates that there are approximately 25 suicide attempts for every reported suicide death, with many suicide attempts resulting in expensive hospitalizations and emergency room care.2 Suicide attempts and deaths have devastating ripple effects. For every individual lost to suicide, research-based estimates suggest that 147 people are exposed (6.3 million annually). Among those, 18 experience a major life disruption. The leading risk factors or characteristics that make it more likely that an individual will consider, attempt, or die by suicide include: 1) mental health disorders; 2) alcohol and substance abuse disorders; 3) history of trauma or abuse including a family history of suicide; 4) extremely distressing life events such as a major physical illness, financial ruin, or a significant relationship breakup; and 5) easy access to lethal means.

Risk factors do not cause suicide. Common warning signs include talking about or wanting to kill oneself, looking for a way to kill oneself (such as searching online for means or buying a gun), feeling and/or expressing hopelessness, being in unbearable pain or feeling a burden to others, and notable changes in behavior such as extreme mood swings or changes in sleep behavior. It is when risk factors combine with multiple warning signs that concerns about suicide increase. Most suicides are preventable, and approximately 80% of at-risk individuals express “warning signs.” The Healthy People 2020 goal is to reduce the rate of suicide by 10%.

1. Why is suicide as a significant population health problem?

2. How do ethics, culture and vulnerable populations/health disparities fit into this study?

3. Apply Forefront Suicide Prevention’s program to Maine by looking back at how it was applied to

make Washington a model suicide prevention state.

4. What does this study say the catalysts are that make policy and systems change possible?

ANSWER

Suicide Prevention as a Population Health Problem: A Study of Forefront Suicide Prevention’s Approach

Introduction

Suicide is a significant population health problem in the United States, with over 44,000 individuals dying by suicide each year. It is the cause of more years of life lost than any other cause of death, after cancer and heart disease. Suicide attempts and deaths have far-reaching effects, impacting not only individuals but also their families and communities. Recognizing the urgency and complexity of this issue, Forefront Suicide Prevention was established in 2013 as a collaborative effort among University of Washington faculty. This organization aims to lead a social movement in the state of Washington to implement a comprehensive approach to suicide prevention, with the long-term goal of disseminating effective strategies to other states with high suicide rates.

Importance of Suicide as a Population Health Problem

Suicide is a critical population health problem due to its significant impact on individuals, families, and communities. It is a complex issue influenced by various risk factors, including mental health disorders, substance abuse, history of trauma or abuse, distressing life events, and easy access to lethal means. Suicide not only results in loss of life but also leads to numerous suicide attempts and the exposure of a large number of individuals to the ripple effects of suicide. Addressing suicide requires a population health approach that involves multiple sectors, including healthcare, education, employment, criminal justice, and correctional systems. It is essential to prioritize suicide prevention and ensure that individuals and communities have the knowledge and support to recognize and respond to individuals at risk.

Ethics, Culture, and Vulnerable Populations/Health Disparities

Ethics, culture, and vulnerable populations play crucial roles in understanding and addressing suicide prevention. Ethical considerations emphasize the duty of healthcare professionals and society as a whole to prioritize suicide prevention and provide appropriate care to individuals at risk. Cultural factors influence help-seeking behaviors, stigma surrounding mental health, and the effectiveness of prevention strategies. Additionally, vulnerable populations, such as individuals with disabilities, racial/ethnic minorities, or low socioeconomic status, may face unique challenges in accessing mental health services and support systems, further exacerbating their risk of suicide. Addressing health disparities and promoting culturally sensitive interventions are vital for reducing suicide rates in these populations.

Applying Forefront Suicide Prevention’s Program to Maine

Forefront Suicide Prevention’s success in making Washington a model suicide prevention state provides valuable lessons for other regions, including Maine. The approach focuses on comprehensive strategies that involve training mental health professionals, as well as other individuals in key roles such as educators, corrections officers, and pharmacists, to recognize and respond to suicide risk. By implementing similar legislation, such as the Matt Adler Suicide Assessment, Management, and Treatment Act, Maine can ensure that healthcare providers receive the necessary training and support to address suicide risk effectively. Additionally, collaboration among various sectors and the integration of suicide prevention into existing systems can enhance the reach and impact of prevention efforts.

Catalysts for Policy and Systems Change

The catalysts that make policy and systems change possible in suicide prevention include advocacy, personal stories, and research-based evidence. In the case of Forefront Suicide Prevention, the personal story of Matt Adler, who tragically ended his life despite being in contact with multiple mental health professionals, highlighted the systemic failure in addressing suicide risk. This story, combined with advocacy efforts and research on the need for improved training and systems-based approaches, led to the passage of legislation requiring mental health professionals to receive training in suicide prevention. Similar catalysts, including personal stories, evidence-based research, and grassroots advocacy, can drive policy and systems change in other states and regions.

Conclusion

Suicide is a significant population health problem that requires a comprehensive, multidisciplinary approach. Forefront Suicide Prevention’s work in Washington highlights the importance of training healthcare professionals and individuals in key roles to address suicide risk. It emphasizes the need for systems-based approaches, collaboration among sectors, and cultural sensitivity in prevention efforts. Applying Forefront’s program to other regions, such as Maine, can help create model suicide prevention states and reduce suicide rates. By recognizing the significance of suicide as a population health problem and addressing it through policy and systems change, we can work towards preventing unnecessary loss of life and promoting mental well-being in our communities.