1

Introduction and Overview¹

On October 5, 2002, Taryn Hiatt, a founding member of the Utah chapter and area director for Utah and Nevada of the American Foundation for Suicide Prevention, lost her father to suicide. He had lived with serious mental illness that went untreated for most of his life. Her family knew that he was ill. Over the course of his life, he had more than 22 surgeries to treat his esophagus from the effects of acid reflux. In the weeks before his suicide, he was taking 30 Ambien per day in addition to a variety of other medications. “His depression was always treated with medication,” Hiatt said, some of which were probably needed and some of which were probably not needed. But, Hiatt added, he never received any behavioral treatments so that he would better understand what he was grappling with, and neither did his family.

Hiatt’s father was ashamed “for having an illness that he thought was somehow his fault,” she said. After his death, her family was ashamed, too. They wondered what to tell people. They talked about whether they should say he had died from a heart attack. “I remember saying no,” said Hiatt. “I wanted to share the word. We’re done doing this. We’re done being quiet.”

On September 11–12, 2018, the National Academies of Sciences, Engineering, and Medicine (the National Academies) held a workshop in

___________________

¹ The planning committee’s role was limited to planning the workshop, and the Proceedings of a Workshop was prepared by the workshop rapporteur as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus.

Washington, DC, to discuss an issue that could have saved Hiatt’s father and the lives of thousands of other people every year in the United States: preventing suicide among people with serious mental illness. Suicide prevention initiatives are part of much broader systems, said David Rudd, president of the University of Memphis and member of the workshop planning committee. Such initiatives are connected to activities like the diagnosis of mental illness, the recognition of clinical risk, improving access to care, and coordinating with a broad range of outside agencies and entities around both prevention and public health efforts. Yet, suicide is also an intensely personal issue that continues to be surrounded by stigma, Rudd pointed out. “Sometimes it is hard to remember that behind every number is a person, is a family, is a network, and that many people and many lives are touched in each and every one of these instances.” It is a national problem, he said, yet it remains hard to have these conversations. “I can think of case after case after case where we have a difficult time saying suicide.”

The workshop was designed to illustrate and discuss what is known, what is currently being done, and what needs to be done to identify and reduce suicide risk among people with serious mental illness. Box 1-1 provides the workshop Statement of Task. Appendix A contains the workshop agenda and Appendix B provides biographical sketches of

the workshop speakers, panelists, facilitators, planning committee members, staff, and consultants. A video archive of the workshop can be accessed on the Health and Medicine Division of the National Academies’ project page.²

THE NEED FOR INFORMATION AND COMMUNICATION

Individuals and families need the same education to prevent suicide that they would receive for other health issues, Hiatt said in her presentation during the opening session of the workshop. If her father had been living with cancer, diabetes, dementia, or Alzheimer’s, Hiatt noted, his family would have received the information they needed to support him and encourage him to get the help that he needed. But they did not receive the information they needed. Today, others reach out to Hiatt for help, and she refers them to the resources that are available. “But we need more,” she said, adding:

Suicidal behavior is an attempt to cope, as is all behavior, she said. A person in that moment of intense pain and crisis has a belief system that is altered. The workshop began on September 11, and she drew an analogy to the event that occurred 17 years earlier on that date. As the Twin Towers in New York City began to burn, people at the tops of the towers began to jump.

By definition, they took their own life. They died of suicide. Yet, none of us sat on our couch and said, “Oh my gosh, you coward, how selfish of you. How could you do that to your friends and family?” Did they jump because they wanted to die? No. They jumped because they were desperate to escape pain and anguish. They jumped because their thinking was anything but rational in that moment and their crisis point had been reached.

People who are thinking of suicide need the same level of compassion, Hiatt said. They have reached a point where they feel they cannot live, whether because of their mental illness, their life experiences, or their trauma. Hiatt made her own suicide attempts as a teenager, she said. “I understand what it’s like to live in that dark night of the soul.” When she

___________________

² See http://nationalacademies.org/hmd/Activities/MentalHealth/SuicidePreventionMentalIllness/2018-Sep-11/Videos/Opening-Videos/1-Welcome-Video.aspx (accessed November 27, 2018).

tried to end her life as a teenager, she did not want to die, but she did not know how to live with what was happening to her. Yet, she survived and has gone on to live a full and meaningful life. “There’s hope in that. There’s hope for recovery, and that’s the message we need to continue to get out there. Suicide can be prevented.”

Everyone needs to know the warning signs for suicide the same way they know the signs for heart attacks and strokes, she observed. Everyone needs to be capable and willing to administer the care that people need in their moments of crisis. Her father is someone who would have benefited from the sharing of electronic health records, Hiatt said, so that the emergency room doctor he saw on the day of his suicide would have seen that he had attempted suicide before and that he was getting medications from multiple doctors. It would have been an opportunity, she added, for a physician to talk with him about his pain and not simply prescribe the medications that he used to end his own life. Hiatt now has her own suicide safety plan. When she needs help, she gets in to see a therapist.

A few weeks before the workshop, the Church of Jesus Christ of Latter-day Saints in Utah, where Hiatt lives, said that it will no longer consider suicide a sin. Crying in her car when she heard the news, Hiatt was immensely grateful for the progress of recent decades that made such a decision possible. But she also recalled that society continues to put a great burden on suicidal individuals. “We’re talking about a person who’s desperate to escape unbearable pain.” Telling them not to take their own lives, she observed, is like telling someone with cancer to choose to live without giving them the tools, treatment, and care they need to do that.

“I decided 16 years ago I wasn’t going to rest until we stopped suicide,” Hiatt said. “I want this to no longer be the health issue of our time. We do that by these conversations. We do that by taking note. We do that by creating awareness. We’re aware suicide is a problem. We need to take action.”

SUPPORT FOR THE WORKSHOP

Richard McKeon, chief of the Suicide Prevention Branch in the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (SAMHSA), briefly spoke about why SAMHSA supported the workshop. Suicide rates have increased significantly in the United States in recent years, he observed. A recent report from the Centers for Disease Control and Prevention (CDC) showed that suicide had increased in 49 of 50 states between 1999 and 2016, and in half the states examined the increase was greater than 30 percent (Stone et al., 2018). “There is clearly a need for us to do more and better,” said McKeon, “to increase the effectiveness of our suicide prevention efforts and to try to save as many lives as possible.”

Rates of suicide are significantly elevated among those with serious mental illness and serious emotional disturbance, McKeon observed. This has practical implications for SAMHSA, since its mental health programs are by statute required to focus on adults with serious mental illness or youth with serious emotional disturbance. Currently, SAMHSA has an array of suicide prevention initiatives. These include support for the Zero Suicide approach described in Chapter 2. SAMHSA recently made 14 suicide prevention grants to states, health care systems, and tribes. It also has a significant youth suicide prevention initiative, the Garrett Lee Smith grants, that have gone over the past 12 years to each of the 50 states.

SAMHSA is interested in identifying those who are at risk for suicide who may also experience serious emotional disturbance, how best to intervene with them once they are engaged in the health care system, and what are the best approaches to use. These “are vitally important issues for SAMHSA,” said McKeon, and he welcomed the “advice, guidance, wisdom, and discussion that I’m sure all of you will provide.”

OVERVIEW OF THE WORKSHOP

The workshop consisted of six plenary panel presentations, a breakout session on the second day, and opportunities to report back from the breakout sessions and comment on the major themes and messages that emerged from the workshop.

In the first panel presentation, which is summarized in Chapter 2, Holly Wilcox, associate professor in the Johns Hopkins Bloomberg School of Public Health’s Department of Mental Health and the Johns Hopkins University School of Medicine’s Department of Psychiatry, and Christine Moutier, chief medical officer of the American Foundation for Suicide Prevention, provided broad overviews of the prevalence of suicide, changes in prevalence over time, and the links between suicide and serious mental illness. Critical windows exist for suicide risk, such as the week after discharge from a psychiatric admission or emergency department presentation for suicidal ideation or attempt, the first weeks after starting an antidepressant, and during significant life transitions. Both universal and targeted interventions have proven effective in improving suicide rates, but they require continued support and attention to the quality of implementation, the presenters observed.

During the second panel (summarized in Chapter 3), C. Edward Coffey, professor of psychiatry and behavioral sciences and of neurology in the Baylor College of Medicine, traced the origins of the Zero Suicide movement back to the 2001 Institute of Medicine (IOM) report Crossing the Quality Chasm: A New Health System for the 21st Century. Initially successful at the Henry Ford Health System, this approach, which uses a care

protocol for suicide risk and quality improvement principles, has since been adopted in other locations around the world, as pointed out by David Covington, chief executive officer and president of Recovery Innovations, Inc. It is an especially effective way, noted Mike Hogan of Hogan Health Solutions, to ensure that people with suicidality do not make their way through successive gaps in care and to integrate care for those with both serious mental illness and suicidality.

The third and fourth panels of the workshop looked at two groups at high risk for suicide: military service members and veterans, and American Indians and Alaska Natives. In the third panel (summarized in Chapter 4), both Mike Colston, captain in the U.S. Navy Medical Corps and director of Mental Health Programs in the Health Services and Policy Oversight Office of the Department of Defense, and Keita Franklin, national director of suicide prevention for the Office of Mental Health and Suicide Prevention in the Department of Veterans Affairs (VA), pointed out that the suicide rate among active duty service members has increased in recent decades. Colson described the range of effective interventions that are now available that can save lives. Franklin discussed the universal, selective, and indicated prevention components of a comprehensive public health campaign to prevent suicide among veterans. She also advocated for a “whole of government” and “whole of industry” approach that could coordinate and intensify suicide prevention work with this population, including those veterans who are not enrolled in care with the Veterans Health Administration.

The next panel (summarized in Chapter 5) considered Native American and American Indian communities, many of which have especially high levels of unmet health needs. The panel highlighted examples of approaches for suicide prevention and mental health in both communities and health systems. All four presenters—James Allen, professor in the Department of Family Medicine and Biobehavioral Health at the University of Minnesota Medical School; Allison Barlow, director of the Johns Hopkins Center for American Indian Health; Laurelle Myhra, director of behavioral health at the Native American Community Clinic; and Jennifer Shaw, a senior researcher at Southcentral Foundation—made the point that effective suicide prevention is culturally tailored to the population it serves. Shaw, for example, observed that interventions need to be targeted at all levels of human experience, respect autonomy, and honor community, which requires that they be tailored to or developed from within local cultures and patterns of being, communication, and relationship. In addition, Myhra noted that meeting the mental health needs of Native communities requires workforce development, including the training of Native behavioral health providers, community health workers, and people who can provide peer support.

In the fifth panel (summarized in Chapter 6), Nikole Jones, a suicide prevention coordinator with the VA Maryland Health Care System; Alfreda

Patterson, a substance use counselor and housing coordinator with Concerted Care Group in Baltimore; T. J. Wocasek, a clinical supervisor for the Southcentral Foundation in Anchorage, Alaska; and Keith Wood, clinical director of an intensive outpatient service with Emory University School of Medicine, described the approaches they and their organizations take toward individuals with suicidality, including those with serious mental illness. Several of the presenters had their own personal experiences with suicide, which have served as a guide and inspiration for them in developing relationships with their clients.

The final panel (summarized in Chapter 7) offered perspectives ranging from the direct patient experience of systems of care and outreach to the design of behavioral health systems at the state and city levels. Marcus Lilly, an outreach worker for Concerted Care Group, observed that partnerships between health care providers, mental health services providers, and community-based self-help groups could increase the availability of suicide prevention services and provide for long-term comprehensive treatment. Julie Goldstein Grumet, director of health and behavioral health initiatives at the Suicide Prevention Resource Center and director of the Zero Suicide Institute at Education Development Center, pointed out that investments both upstream and downstream from suicide prevention could link public health and mental health. Arthur Evans, chief executive officer of the American Psychological Association and previously the commissioner in Philadelphia for the Department of Behavioral Health and Intellectual Disability Services, called for approaches that address the challenge at the levels of providers, systems, and the community. He also made the point that the implementation of evidence-based treatment, including provider training in suicide prevention for people with serious mental illness, will require substantial investments of resources.

On the second day of the workshop, participants broke into two sessions to discuss major issues that arose over the course of the first day’s discussions. Participants in one session discussed the financing and other policy issues associated with integrating suicide prevention into care for people with serious mental illness. Participants in the other session discussed issues associated with a focus on what providers need, which also encompassed political leadership. Chapter 8 summarizes the reports from those breakout sessions and the discussion that followed in the subsequent plenary session.

The final session of the workshop (summarized in Chapter 9) provided an opportunity for workshop participants to identify what they considered to be important messages they were taking away from the workshop.

In a follow-up to the workshop, a Twitter chat was hosted on October 4, 2018, by the National Academies’ Health and Medicine Division (@NASEM_Health). This was a moderated public discussion in real time

tied to the hashtag #SuicidePreventionChat. It continued the conversation about the intersection between suicide prevention and serious mental illness. The following questions were posed to participants in the chat:

• How does what is known about how to prevent suicide need to be adapted for people with serious mental illness?
• What can be done to better equip providers in behavioral health and mental health care for suicide prevention?
• How can more comprehensive disposition planning and follow-up after acute crises help stop suicide for those with serious mental illness?
• How can health systems improve tracking of suicide-related outcomes to inform better care for those with serious mental illness?
• What is your key message about improving suicide prevention for those with serious mental illness?

A link to the chat can be found on the website of the National Academies’ Health and Medicine Division.³

REFERENCE

Stone, D. M., T. R. Simon, K. A. Fowler, S. R. Kegler, K. Yuan, K. M. Holland, A. Z. IveyStephenson, and A. E. Crosby. 2018. Vital signs: Trends in state suicide rates—United States, 1999-2016 and circumstances contributing to suicide—27 States, 2015. Morbidity and Mortality Weekly Report 67(22):617-624.

___________________

³ See http://nationalacademies.org/hmd/Activities/MentalHealth/SuicidePreventionMentalIllness/2018-Sep-11/twitter-chat-suicide-prevention.aspx (accessed November 27, 2018).