Megan Brooks

May 17, 2016

ATLANTA ― A rigorous programmatic approach to suicide prevention led by Magellan Health Services, in Arizona, that involves the local behavioral health community is achieving promising results.

In the first 90 days of implementation, there were no reported suicides in the Marcopia County Medicaid behavioral health population in Arizona. The Magellan Driving Suicide to Zero Initiative also decreased the suicide rate (number of suicides per 100,000) by 67% for the population and by 42% in people with serious mental illness.

Shareh Ghani, MD, psychiatrist and chief medical officer, Magellan of Arizona, discussed the program here at the American Psychiatric Association (APA) 2016 Annual Meeting.

'One Suicide Is Too Many'

With Arizona ranked 7th in the nation for the number of reported suicides, Magellan zeroed in on one of the groups at highest risk: individuals with mental illness.

"It is a fact that individuals with severe mental illness are 6 to 12 times more likely to die from suicide than the general population," Dr Ghani said.

"Even one suicide is too many," said Dr Ghani. The Magellan program "looks at suicide differently, as a systems issue, not a one therapist, one doctor issue. That's a big culture change." The program is "quite laborious, but it is very effective, is what we have learned," he noted.

A collaborative committee made up of clinical leadership from Magellan and healthcare providers was created to address high rates of suicide in Arizona. After a thorough review of best practices, the committee identified the need to train the behavioral health workforce in suicide prevention and adopted the Applied Suicide Intervention Skills Training (ASIST) program to do this.

Magellan successfully trained more than 90% of the target workforce in ASIST. They found that after ASIST training, there was a significant increase in the number of providers who "felt strongly" they could engage and assist those with suicidal desire and/or intent. Before the training, many reported feeling inadequately prepared to deal with suicidal patients, and 38% reported that someone in their care had died by suicide.

Key components of the suicide prevention program include standardized suicide risk screening. If a screening is positive, a full assessment of suicide risk is conducted, and appropriate interventions are taken to ensure safety, treatment, ongoing care, and close follow-up. As part of the program, a comprehensive clinical decision support tool was implemented in the electronic medical record.

The program was implemented in 12 outpatient mental health clinics within the Maricopa Behavioral Health System. During the first 90 days of implementation, more than 15,500 suicide risk assessment screens were completed. Screening results were positive in 8.5% of individuals screened. Those patients then received comprehensive suicide risk assessment and follow-up. Within 48 hours, patients received a telephone call or had a face-to-face visit. There was coordination with people in the patient's support plan, and a "caring letter" text or email was sent to the patient.

Continuity of care is a key element of the program, said Karen Chaney, MD, copresenter and chief medical officer, RI International. "One patient said the caring text 'kept me alive because I felt someone cared.' "

The program successfully drove the suicide rate to zero in the first 3 months, and it has significantly decreased the suicide rate in Arizona, Dr Ghani reported.

This effort shows that it is possible to employ a "rigorous, data driven, scalable, and reproducible population health approach to suicide prevention, creating a sustainable ecology of support around the individual and community," Dr Ghani concluded.

Novel Concept

In an interview with Medscape Medical News, Steve Koh, MD, chair, APA Scientific Program Committee, noted that "driving suicide to zero is a fairly novel concept. It's well known that even with the advent of antidepressants and what not, the overall rate of suicide has stayed steady.

"We still don't know how to adequately screen for suicide," Dr Koh added. "A lot of people see their doctor, and within a month or 2 months they commit suicide. So we are clearly still not there."

On the concept of driving suicide to zero, incoming APA President Maria A. Oquendo, MD, of the New York State Psychiatric Institute and New York–Presbyterian/Columbia University Medical Center, New York City, said, "The idea is that all suicides should be preventable, and the strategy for that is early intervention and early identification of individuals at risk. Some of the interventions are pretty simple, like just staying in touch with the individual. When you have an integrated health system, you have a much better opportunity to do that, because all members of the care team have a way of communicating, for example, using the electronic health record."

Christine Moutier, MD, chief medical officer of the American Foundation for Suicide Prevention, told Medscape Medical News that "it's probably not possible to drive suicide down to zero, but what is really exciting is that suicide prevention is entirely possible, and you can get better outcomes with not only proper training of healthcare practitioners but also with systems changes that try to make sure that patients don't fall through the cracks."

The authors report no relevant financial relationships.

American Psychiatric Association (APA) 2016 Annual Meeting: SCR-Suicide, No. 1, presented May 15, 2016.


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