The suicidal thoughts started when Kristina Mossgraber was 17. A loud voice in her head told her that she was a bad person, a failure, better off dead. She cut herself in secret and told no one about the thoughts slamming around her brain, except her pediatrician, who dismissed them as normal teen angst. But her suicidal thoughts and behaviors didn’t stop. “I was so good at hiding it and kind of normalizing it.” She remembers thinking, “I just need to keep these to myself.”
She did, all through her 20s and early 30s, until one September day in 2014 she drove three hours from her home in Rochester, N.Y., where no one would find her, and cut her neck and the veins down her arms. After struggling to hide her wounds for four days, she went to an emergency room. A doctor sent her home. “They didn’t think I was suicidal enough,” she says.
Mossgraber was referred to an outpatient treatment program, but she couldn’t absorb any of the information; she went through the motions, all the while planning how she was going to kill herself. She withdrew from friends and skipped Sunday dinners with her family. “I was falling deeper and deeper into this despair,” she says.
Three months later, she bought a jug of antifreeze, mixed it with Gatorade and woke up days later in the intensive-care unit. Once inside, she had a different experience. After doctors stabilized her, the psychiatric team helped her write a safety plan, a personalized guide for Mossgraber to follow to help her cope when she feels suicidal. They matched her with a specialist in a type of behavioral therapy that treats suicidal thoughts and actions. And they connected her to an outpatient program, where she would finally be diagnosed with bipolar disorder and given medication that worked. “I had a lot of great people who encouraged me to keep going, and get better, and go home and start this hard work of recovery,” she says. “People listened to me and treated me like a human being.” It saved her.
Suicide is one of the most urgent health problems facing America today. It is the 10th leading cause of death in the U.S., claiming 47,000 lives per year—and likely more, given that many suicides are not reported. Recent federal numbers indicate that the nation’s suicide rates are the highest they’ve been since World War II; they’re rising in nearly every state and across age groups and ethnicities. Alarmingly, suicide rates for young people are now the highest this century; among people ages 10 to 24, the rate increased 56% from 2007 to 2017, according to federal data from October 2019. Suicides among active-duty members of the military have also increased over the past five years, the Department of Defense reported in September, and a Department of Veterans Affairs (VA) report from the same month found that suicides by veterans are on the rise. Ten million Americans seriously considered suicide in 2018. “It’s an extremely serious problem, and the fact that suicide is increasing shows that we all need to do more and do better,” says Richard McKeon, chief of the suicide-prevention branch at the Substance Abuse and Mental Health Services Administration (SAMHSA), a branch of the Department of Health and Human Services (HHS).
Suicide is complex, and it’s not clear what’s driving the rise, but experts speculate that many factors may be contributing, including high rates of drug abuse, stress and social isolation. It’s an expensive problem too. Attempted and completed suicides cost the U.S. up to $94 billion per year in lost work and medical expenses.
But a new approach is starting to yield positive results. For all the disparate reasons people die by suicide, they tend to have something in common: research suggests that 83% visit some kind of doctor in the year before their death. So health care facilities are logical places to prevent suicide.
Hospitals and behavioral-health centers are now redesigning their practices to include research-backed interventions that have been studied for years but haven’t, until now, been widely used. In a world of high-tech, high-cost medicine, the new protocols for treating suicidal patients are surprisingly straightforward. They include thoroughly screening people, often with the help of electronic health records, in order to target those at risk; collaborating with patients to write safety plans to help them cope with suicidal episodes; quickly treating a person’s suicidal thoughts and behaviors rather than waiting to treat any underlying mental illness first; removing lethal means like guns (which are used in nearly half of all suicides and 69% of suicides by veterans in the U.S.) from patients’ homes; and supportively following up with patients via letters or phone calls in the days and weeks after they leave care, which is when many suicides happen.
health systems face in preventing suicide is losing touch with people when they’re vulnerable. In most U.S. hospitals, a person who arrives at an emergency room after a suicide attempt is generally hospitalized, stabilized and, once deemed to be at lower risk, discharged with guidance to follow up with a mental-health professional. But many don’t take that advice. Even under less acute circumstances—when they’re receiving routine care—people fall through the cracks.
The new best practices emphasize putting people on the grid and not letting go. Few places do it as well as Centerstone, a large community mental-health center based in Tennessee that obsessively follows up with patients. By reprogramming its digital health-records system, Centerstone made screening for suicide risk mandatory; patients who respond a certain way are automatically designated at risk and seen more frequently. If one of these patients doesn’t show up for an appointment and can’t be reached within a few minutes, a 24/7 crisis team is pinged. “They’re gonna come after you—in a loving, kind, gentle way, but they’re going to pull out all the stops to make contact with you so that we know that you’re not in any kind of major crisis,” says Becky Stoll, vice president for crisis and disaster management for Centerstone. One of these routine phone calls reached a patient as he was standing on the edge of a bridge ready to jump; the caller persuaded him to return to the clinic. Within two years of making this change and others in 2014, the rate of suicide deaths at Centerstone had dropped by 64%.
Using electronic health records may even predict who’s at risk for suicide attempts or deaths in the wider population. In October, Kaiser Permanente will begin using a combination of patients’ health records and their answers to a short depression questionnaire to predict who’s most at risk in one of their mental-health clinics. (They plan to later expand to primary care.) When analyzed together, this data—which includes strong predictors like a person’s mental-health diagnoses and substance-use history—can instantly flag patients who are most at risk for suicide to a “surprisingly accurate” degree, says Dr. Gregory Simon, a psychiatrist and researcher at Kaiser Permanente Washington. Once it’s implemented, when at-risk patients have a doctors’ visit, their provider will be alerted to assess their risk for suicide. And if they don’t show up, someone will reach out to them.
Once clinicians know whom they should be targeting, they can begin to intervene. One effective way to keep people safe from suicide is to take guns, pills or other lethal means out of their homes through discussions with patients and their families. “Most people who might be thinking of ending their lives have a particular means in mind,” says Mike Hogan, a suicide-prevention expert. “Ending your life is hard—it’s hard psychologically, and it’s hard physically—and if you take that one means away, most people won’t do something else.”
Without the tools to carry out a plan, “if you can ride the wave a day or two, when the thoughts are at their most powerful, then the thoughts begin to abate,” says Julie Goldstein Grumet, director of health and behavioral-health initiatives for the Suicide Prevention Resource Center. “If you can really increase the time and the distance between the thoughts and the access, then we know the rates of suicide will go down.”
Knowing how to fill that time is crucial. That’s where a safety plan—a guide that a patient and a provider write together, detailing what the person can do and who they can call when they’re in suicidal crisis—has been shown to be valuable. “We have typically worked on the development or implementation of more complex treatments for suicidal people,” says Barbara Stanley, co-developer of the safety planning intervention and professor of medical psychology at Columbia University Irving Medical Center. “And here you find something that is incredibly simple, very easy to train, pretty easy to implement, yet it seems to get just as good results in preventing suicide.” Health systems are rapidly adopting safety plans because of their simplicity and efficacy. Safety planning is now standard at every VA medical center.
There are signs that health systems across the country will soon step up their suicide care. In July, the Joint Commission, the major accreditor of health care organizations in the U.S., imposed new rules requiring hospitals and behavioral-health centers to approach suicide prevention more systematically, with enhanced screening and improved counseling and follow-up care when at-risk patients leave care. “It used to be our standards were to refer someone to a suicide hotline, and that’s just not the state of the science at this point,” says Dr. David Baker, executive vice president for health care quality evaluation at the Joint Commission. The Veterans Health Administration, the country’s largest integrated health care system, has long prioritized suicide prevention but is also raising the bar; in 2017 it started offering same-day access to mental-health services across the VA, and in 2018 it began screening everyone for suicide risk. SAMHSA is funding $46 million in grants to help health systems implement suicide prevention and intervention programs. And researchers are currently testing how effective these types of interventions are at reducing suicides on a much larger scale: across six health care systems, including several Kaiser Permanente sites. It is one of the largest mental-health studies of all time.
It might seem perverse that health care organizations don’t already prioritize suicide care. But for the most part, they don’t. “This whole notion of preventing suicide is quite radical,” says Dr. Justin Coffey, chair of the department of psychiatry and behavioral health at Geisinger Health System. “For many of us, it’s antithetical to what we were taught in our clinical training. Suicide is traditionally understood as this tragic yet inevitable outcome of serious mental illness.” The old thinking was that you couldn’t stop people who have decided to kill themselves, so most providers received no formal training on how to care for suicidal patients. “And yet now we know it is indeed preventable,” Coffey says.
This shift in thinking—and the hands-on approach now gaining traction—has its foundation in work started nearly 20 years ago. In 2001, the behavioral-health department of the Henry Ford Health System in Detroit remade itself around the goal of completely eliminating suicide among its patients, using science-backed techniques like giving them quicker access to care and keeping in closer contact with them. Within two years, suicide rates among these patients dropped by more than 75% (and remained as low for over a decade). In 2008, the program reached its goal of zero suicides, a trend that lasted for more than a year.
People in the suicide-prevention field took notice. “Nobody had ever seen results like this,” says Hogan. “This was the most effective suicide-prevention program, based on the data, that had ever been seen in the world.” With the Henry Ford experiment and the VA’s suicide-prevention program, which launched in 2007, as examples of what was possible in health care, in 2012 HHS published a national suicide-prevention strategy that prioritized health care systems for the first time—and set the goal of “zero suicides.”
The name stuck. Zero Suicide became a collection of best practices for health care systems to use to reduce suicides among people under their care. “Over 1,000 organizations are now using the skills and tools of the Zero Suicide initiative,” says Goldstein Grumet, who is also director of the Zero Suicide Institute, which helps health care systems transform in this way. Baked into each step is the directive to acknowledge each patient’s pain, empower them to make safe decisions and build hope for recovery.
a person leaves care is delicate. Suicide risk rises sharply the first week after discharge from a psychiatric facility and remains high even years later. But there are opportunities to reduce suicide risk even after treatment is over. Back in the 1970s, Dr. Jerome Motto, a San Francisco psychiatrist, wanted to see whether writing patients a series of short letters to show them they weren’t alone—that someone cared—helped keep them alive. “The point always was, just be there for somebody,” says Chrisula Asimos, one of Motto’s former researchers.
Motto and his colleagues found more than 800 people who had recently been hospitalized because they were severely depressed or suicidal, but who had refused further treatment. Half were left alone, and the others were sent a regular stream of short letters from a staff member who had met them in the hospital. “It has been some time since you were here at the hospital, and we hope things are going well for you,” one of the letters read. “If you wish to drop us a note we would be glad to hear from you.” They sent the letters every so often for the next five years.
“Initially I was a little skeptical, because working with these patients in the hospital when they first came in, they were just acutely depressed or suicidal,” Asimos says. “But it became really clear when we started getting responses back that those contact letters were really a way to open the door.”
The group who received letters had a lower suicide rate all five years of the study. Many wrote back. “I was surprised to get your letter,” read one response. “I thought that when a patient left the hospital your concern ended there.”
“You will never know what your little notes mean to me,” read another.
“You are the most persistent son of a bitch I’ve ever encountered,” read another, “so you must really be sincere in your interest in me.”
This kind of follow-up contact for patients leaving care—which is also effective by phone, recent research suggests—is cost-saving and scalable through automation and electronic health records. A 2017 study found that follow-up letters and calls to people at elevated risk for suicide who left emergency departments reduced the likelihood of a new suicide in the next year by about a third and was cost-effective. “That’s a huge effect from something that’s super low intensity,” says study co-author Michael Schoenbaum, senior adviser for mental-health services, epidemiology and economics at the National Institute of Mental Health. “The holy grail in health care is something where you get more and pay less. And caring communications overwhelmingly seems to be that.”
After Kristina Mossgraber left the hospital, she slowly got better. “Recovery is the hardest job I’ve ever had,” she says. “It’s physically and emotionally exhausting. But it’s worth it. My life is back to the way I’ve always wanted it to be.” She now works as director of education and community outreach at her local chapter of the National Alliance on Mental Illness, talking to kids in schools about mental health and suicide prevention. She’s also on an advisory board at the same hospital where she was once turned away—and later given tools, hope and access to a better life.
“Unfortunately, the system has been one way for so very long. And the public perception of mental health and suicide has been one way for so very long,” she says. “It’s going to take a while. But I’m encouraged. I really think things are changing.”
Mandy Oaklander at mandy.oaklander.