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Special Communication
October 2, 2019

The Need for Innovation in Health Care Systems to Improve Suicide Prevention

Author Affiliations
  • 1Department of Psychiatry, New York State Psychiatric Institute, Columbia University Vagelos College of Physicians and Surgeons, New York
JAMA Psychiatry. 2020;77(1):96-98. doi:10.1001/jamapsychiatry.2019.2769

Suicide rates have continued to rise in the United States. Speculations for this rise proliferate but the causes for the increase remain unknown. While research focuses on identifying causes, the health care system is an important site for identification of patients at risk. Forty percent of individuals who die by suicide were seen in primary care in the month prior to suicide. The Zero Suicide model describes a comprehensive approach for health care systems to aid in identification and intervention of suicidal patients. While this model promises to improve care of suicidal patients, the need for innovation in our approach to understanding and caring for suicidal patients is pressing. Use of technology to enhance moment-to-moment monitoring of at-risk individuals offers promise and the possibility of intervening close to escalation of acute suicidal states. Further, once identified, suicidal individuals are often difficult to engage in treatment. Novel approaches to engagement and treatment that are effective and acceptable to suicidal patients ought to be developed. Specifically, males are much more likely than females to die by suicide. At the same time, males are less likely to seek and remain in the treatments we have to offer. Innovation should seek to identify strategies that are acceptable to males. Additionally, while about half of psychiatric inpatient admissions are suicide related, there is a paucity of suicide-specific psychosocial interventions available for inpatient settings. Innovation in monitoring and treatment offer promise in helping to reduce suicidal behavior in the United States.

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2 Comments for this article
"Zero Suicide" may have increased awareness, but has produced no evidence of efficacy.
Mike Martelli, PhD | Private Practice
I believe the only empirically supported effective suicide intervention (i.e., is shown to lower actual suicide rates, not just admitted ideation) is the Acute Suicide Short Intervention Program (ASSIP). ASSIP is an innovative and brief program designed for primary care. It is creative and intuitively appealing and built on principles that are neglected in almost all assessment and treatment protocols. Increasing studies of its application are emerging. But, in the several presentations on the DOD's Zero Suicide protocol and associated suicide prevention interventions, and several revisions of guides for the Air Force and VA, none of the presenters or trainers or writers, and none of the clinicians in Psychology, Psychiatry or Family Health (or any of the others I worked, consulted with or presented to) had ever heard of it. That tops a "Suicide Prevention" program name that pretty much violates basic rules of Behavioral and Social and I/O Psychology, marketing and multiple other fields - imagine naming a service or program any of the following: zero family disease clinic/program; zero mental illness clinic/program; zero child psychopathology clinic. The "zero suicide" effort may have successfully increased awareness, but there is no evidence of any efficacy using currently practiced programs and methods, and one has to wonder if the negative focus has shapes conceptualizations and killed creativity and innovation. Working within a hospital system and in the military system, the focus is too often dominated by clinician fear of suicidal patients, fear of making mistakes, and quick referral decisions to the ER's where the former often discourages reporting and/or report severity often dwindles, and discharges result in poorly arranged outpatient f/u's or inpatient admission for which there is no evidence of efficacy and treatment does not inspire confidence. Innovation and creativity is represented in the ASSIP program. Even before I knew of that program, clinical experience had taught me some of the lessons it has incorporated. I recommend that the first step in a search for innovation should be the searching (google, PubMed, Researchgate, etc.) for studies evaluating the ASSIP program that somehow seems to have been missed by the entire massive personnel and multimillion dollar budget resources of the Department of Defense and most other programs.
Five suicide factors and your "hypothesis-generating approach"
pankaj agrrawal, PhD | University of Maine
Dr. Stanley and Dr. Mann, just saw your JAMA Psychiatry paper (October, 2019). The Zero Suicide model is very innovative and we hope that public health officials will pay heed to your "hypothesis-generating approach" [psychological autopsies + wearable technologies] and recommendations. There is about an 18-month window of opportunity where intervention can prevent many of the potential suicides and the resulting loss of human capital.
Also, thank you for including our research finding from PLoS One (Agrrawal, Sandweiss and Waggle) among one of the 5 dimensions that you list as contributory factors towards the increasing suicide rate in
the United States.