Michigan doctors challenge others to join them in a quest for "Zero Suicide"

This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

In a 2019 study, Henry Ford Health (HFH) doctors Brian K. Ahmedani, Cathrine Frank, and their co-authors found that almost all people who die by suicide have a health care visit not long before their death. Now, Ahmedani and Frank are leveraging that data to train health care providers to screen patients for risk of suicide — and connect them with resources to prevent suicide if the risk is high.

Ahmedani and Frank's study found that nearly 30% of individuals who die by suicide had a health care visit in the week before their death, more than 50% had a health care visit within a month before death, and more than 90% within a year. Their effort to turn those statistics around is called the Michigan Mental Health Innovation Network for Clinical Design (MI Mind), a quality improvement initiative awarded to HFH through Blue Cross Blue Shield of Michigan (BCBS). The program offers suicide risk screening, assessment, and treatment options to partnering health care organizations.

"For the first time, there are screening tools that we can actually use to help identify people who are at risk for suicide. Those tools are really good at identifying increased risk over a 90-day, one-year, or two-year period — out in the future," says Ahmedani, who is also director for the HFH Center for Health Policy and Health Services. "It doesn't guarantee that someone will have a suicide attempt, but very much like with a cholesterol score or Framingham score for risk for heart attack, this set of questions does the same for identifying increased risk for suicide attempt."
Dr. Brian Ahmedani.
Currently wrapping up its first year, MI Mind is training more than 200 health care providers across Michigan to properly screen patients for suicide and provide them resources to help prevent suicide.

"Our goal in the next few years is to onboard all of the provider organizations in the state of Michigan. That includes primary care and mental or behavioral health," Ahmedani says. "Right now, we have onboarded seven organizations that represent not only a geographically diverse set of providers, but also providers that offer a large amount of care across the state."

MI Mind's screening tool can be used in the emergency room, by primary care doctors, or with outpatient medical specialties — anywhere in the health care system. The program adopts the Henry Ford Zero Suicide approach, which holds that all deaths by suicide are preventable for individuals under the care of health care systems. Ahmedani says HFH developed a Zero Suicide framework 20 years ago, which has led to a nearly 80% reduction in deaths by suicide among HFH's patient population.
A folder of information about MI Mind.
"If there's a positive screen, then we do suicide risk assessment, which is a more in-depth understanding of the factors that may be contributing to suicidal ideation," he says.

Based on the result of the risk assessment, the health care provider helps the patient come up with a safety plan and then links them to care coordination that sets them up with additional behavioral health care services, such as psychotherapy-based treatments for suicide risk.

"You treat both the suicide risk and whatever other ongoing medical or mental health conditions that that person has, basically treating suicide risk as a separate diagnosis," Ahmedani says.

Screening saves lives

For health care providers, simply asking patients if they are feeling suicidal is not enough. That's where the MI Mind screening tool can mean the difference between life and death.

"We know that if somebody says yes, that's certainly something that puts them at risk. But if they say no, it doesn't mean they don't have risks," says Frank, who is also chair of the HFH Department of Psychiatry and Behavioral Health Services. 
Dr. Cathrine Frank.
So, under HFH's and MI Mind's Zero Suicide model, providers also look for suicide risk factors in patients.

"We screen in our medical-surgical units. We screen in our emergency rooms," Frank says. "Screening is the key. And if the screening is positive, then we do a more thorough suicide risk assessment."

Frank shares that MI Mind takes a two-pronged approach to preventing suicide: teaching behavioral health professionals how to implement the program, and teaching primary care providers how to screen for suicide.

"Research indicates that about half of individuals who die by suicide and about 92% of those who attempt suicide have had a health care visit in the months leading up to their death," Frank says. "We want primary care docs to partner with us to identify those people at risk."

The other reason that primary care providers should be involved in suicide prevention is that only half of people who die by suicide have an identifiable mental illness.

"There can be all sorts of psychosocial stressors," Frank says. "Job loss, breakup with or loss of a loved one — a number of things can lead people to that moment when they feel overwhelmed and hopeless, which will lead ultimately to suicide."

The first of its kind

The Zero Suicide model has gotten a lot of attention nationally and internationally — and has been adopted by health systems across the country and in more than 20 countries around the world.

"What we're trying to do new with MI Mind is partner with a health plan [BCBS] to actually help incentivize or reimburse these services," Ahmedani says. "So health systems deliver the services and then the health plan incentivizes the delivery of those services to be provided at patient visits at each of these providers."
Dr. Brian Ahmedani.
Kevin Fischer, executive director of the National Alliance on Mental Illness-Michigan, welcomes the idea of Michigan's health care providers screening for suicide risk. He believes providers need to learn how to be better listeners and provide follow-up treatment when a patient appears to be a danger to themselves or others.

"Unfortunately, a lot of emergency department personnel and regular doctors and nurses don't adequately screen, but most importantly, they don't follow up. A lot of them probably are unaware of what the resources are," Fischer says. "Many people are turned away in emergency departments if they don't present with physical illnesses or injuries. They're not taken seriously when they do present as a danger to themselves. They're simply released."

Fischer notes that people with physical illness, especially terminal illnesses or conditions that cause chronic pain, are at higher risk for suicide. In addition, many prescribed medications can increase the risk of suicide. It's even more crucial for health care providers to screen these folks for suicide risk. 

"Many studies have looked at certain types of chronic severe illness that can increase suicide, particularly those with chronic severe pain," Frank says. "We also know that having a traumatic brain injury in the last year can be a risk. Bottom line, a number of illnesses put people at risk, and that's one of the reasons why primary care would be good partners."

While MI Mind provides the tools providers need to reduce suicide, Fischer also encourages loved ones and family members to be proactive.

"A lot of family members know that a loved one is in danger of taking their lives. But for a variety of reasons, the primary one being stigma, they simply won't act. They will just hope it gets better," Fischer says. "We have to act. We have to directly ask the question, 'Are you thinking of taking your life?' It's a hard question to ask, but we have to ask it directly because that tends to yield the most honest response."

If the response is yes, Fischer advises to never leave that person alone. Instead, offer to go with them to seek help and make sure that they do not have access to lethal means.

"We have to act — that's the biggest key," Fischer says. "And remind them, tell them, 'I love you. I'll miss you if you're gone.' And ask, 'How can I help you?'"

Estelle Slootmaker is a working writer focusing on journalism, book editing, communications, poetry, and children's books. You can contact her at [email protected] or www.constellations.biz.

Photos by Steve Koss.