At the end of both days of the workshop, individual workshop participants discussed the main messages they heard emerging from the workshop.
THE ELEMENTS OF EFFECTIVE INTERVENTIONS
Research over the past 15 years has demonstrated the need to build on the commonalities of effective interventions, said David Rudd, president of the University of Memphis and member of the workshop planning committee. Mike Hogan identified several of these in his presentation, Rudd noted, including “ask,” “engage and act for safety,” “reduce lethal means,” “treat suicidality,” and “provide support when needed” (see Figure 3-4 in Chapter 3). To these, Rudd added compliance facilitation, which is “a part of everything you do.” Whenever providers in his institution ask a patient to do something, they have the patient rate on a scale of 1 to 10 how likely they are to do it. If the patient responds with a 1, meaning that the patient is not going to do it, they ask the patient why. “Tell us exactly why you can’t do that element of treatment.” They then explain why that element is important. “We go back to the model and explain why this is a critical element of treatment and what role it serves.”
Another feature of the common elements of effective interventions is they are relatively simple and straightforward, though they may be delivered differently by individuals and organization with different theoretical perspectives. The one modification Rudd suggested is that, as part of safety planning, health care providers teach people how to ask for help. “You can’t assume that somebody knows how to ask for help. You have to role
play it, you have to walk through scenarios, and you have to help them understand the language of asking for help.” Shame “is one of the biggest barriers to compliance,” he noted. He and his colleagues elevate that issue and address it with every single person with whom they work.
In addition to the commonalities of effective interventions, Rudd identified three major topics discussed at the workshop: education, clinical delivery, and systems integration. Clear evidence pointing to what should be done exists in each area. The challenge now is not what to do but how to do the right thing organizationally and politically. “We have good foundational places to start; we just need to start implementing.” Saying that the problem is complex tells Rudd that someone is ashamed of it, because that means “we’ll never solve it, we’re not accountable for it, we’re not responsible for it, and as a result we don’t know what to do.” Rudd said that he was encouraged not to have heard a single time at the workshop that the problem is complex.
Rudd observed that the range of material presented at the workshop “demonstrates not only the breath but the creativity of people who are working to meet these challenges—and these are very significant challenges.” The task before the field is now to integrate innovative interventions into the care of people struggling with serious mental illness. For example, are innovations more effective within a Zero Suicide initiative or within an integrated wellness effort? Does that help with some of the shame and stigma that prevent people from getting help?
FUNDING AND FOLLOW-UP NEEDS
Andrey Ostrovsky, chief executive officer of Concerted Care Group (CCG), cited the need to fund both research and service delivery. “Suicide prevention, and in particular suicide prevention in people with serious mental illness, is grossly underfunded in order to get the comprehensive approaches that are needed to meaningfully move the needle.” One concrete idea emerging from the workshop is bundled payments to help align financing with the desired outcomes. “The more I’ve been tweeting about it and researching analogs, the more I get optimistic at how doable this will be—especially now [with] the political winds that are blowing.” What needs to happen, he said, is to get the people who control policy in the same room with those who oversee the funding of programs to figure out how to implement the science.
Another critical need that he identified is to reduce stigma. The presence of people at the workshop who were willing to talk publicly about their experiences is exciting, he said, because “most people will not talk about [this] publicly, and we have to talk about it publicly. If we don’t talk about it publicly, it’ll just keep getting stigmatized.”
Ostrovsky said that he and CCG are willing to follow-up on the ideas presented at the workshop, whether reaching out to governors or implementing the knowledge that already exists. “We may fail, and that’s fine, but let’s fail fast, fail cheap, fail often. We have to get out there and do it, not just talk about it, not just publish, but get out there and do it.”
COLLABORATION AND TRAINING
Nadine Kaslow, professor of psychiatry and behavioral sciences at the Emory University School of Medicine, wondered why the two main topics discussed at the workshop—suicide prevention and serious mental illness—remain such different worlds when they overlap so extensively. A major way to reduce the distance between them is to create collaborations among stakeholders that represent suicide prevention and the treatment of serious mental illness.
This split is reflected in clinical training, she pointed out. In psychology training, working with people who are suicidal or have a serious mental illness is generally ruled out, while psychiatry training follows the opposite model, giving new trainees responsibility for people with the most serious mental illnesses. Neither of these models “makes a lot of sense to me,” said Kaslow. “We need to begin to think in a different way of how do we train people to be prepared to do this work,” not just asking them if they are ready to treat people with serious mental illness. One of the reasons Kaslow became interested in suicide was from losing a patient to suicide early in her career, after which she participated in a program run by the American Foundation for Suicide Prevention to meet with others to discuss what happened, including the psychiatry resident with whom she had treated the patient. “It was a pivotal experience for us in terms of healing.”
Suicide prevention requires that providers adopt an ecological model encompassing the individual, the family, the clinician, and society, she continued. In that respect, root cause analysis that tries to determine what went wrong “is extremely problematic and difficult.” It encourages providers to feel that they have failed and to avoid treating people at high risk of suicide again. An ecological model also emphasizes the importance of culture in treatment, assessment, and prevention, including cultural adaptations to interventions or interventions that emerge from a particular cultural group.
The workshop demonstrated the need to include people with lived experience at the table. In most settings, people still do not feel safe to share their stories, Kaslow said. Creating this safety is critical so meetings do not consist of people who have been identified as having lived experiences and people who have been identified as not having those experiences, since suicidality occurs on a continuum and “we all live on that continuum somewhere.”
STAKEHOLDERS, RESEARCH, AND INFRASTRUCTURE
Lisa Jordan argued for the need to include nurses at the table as well, because caring is central to their profession. Some of the first community health workers were nurses, she said, and nurses have constructed models of caring that incorporate patients into the plan of care. In addition, nurses can help other health care providers care for themselves when a patient ends his or her life. “We have to be there with you, because we believe as nurses that we are the conduits to get many of the other professionals that are working with a patient together and to keep everybody abreast.”
Scott Dziengelski from the National Association for Behavioral Healthcare called attention to the fact that people with serious mental illness have a much higher mortality rate than the general population. “These individuals are dying 25 years sooner than everybody else in the population,” he said. “They’ve been left out of the longevity revolution. . . . This is part of a greater conversation about serious mental illness and mortality.”
James Allen, professor in the Department of Family Medicine and Biobehavioral Health at the University of Minnesota Medical School, mentioned the need to align the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) research with that of the National Institutes of Health to study the implementation of the ideas discussed at the workshop. Suicide is a low base rate event, he said, but many distal indicators can be used to identify effective prevention and treatment approaches. Work in fields as distant as process engineering can lead to innovative methods in suicide prevention, he added, which points to the value of collaboration among professions.
Amy Loudermilk, state initiatives manager for the Suicide Prevention Resource Center, emphasized the role of the infrastructure developed by the states for suicide prevention. Working on this infrastructure can elevate the issue and reflect its multidisciplinarity, which Ostrovsky added could be done through such organizations as the National Association of State Medicaid Directors.
COMMITMENTS TO ACTION
Arthur Evans, chief executive officer of the American Psychological Association, like Ostrovsky of CCG previously, committed his organization to following up on the major issues and ideas raised at the workshop. He also observed that the subject matter discussed at the workshop needs to be disseminated as widely as possible so every community has someone who is involved in the issue. Getting people in government, system administrators, and many others involved will be required to influence the social determi-
nants that affect suicide, he said, which will require leadership within many different communities.
In follow-up to the workshop, Christine Moutier of the American Foundation for Suicide Prevention committed her organization to stay engaged in actionable strategies as an outgrowth of the workshop. She reiterated her observations made during the first panel: that the openness and readiness of the nation is ripe, and that health care systems, payers, and policy makers must make the changes needed to meet the public health crisis and the growing demand on the part of patients and families. She observed that the American Foundation for Suicide Prevention is well positioned to advocate for changes like bundled payments for postdischarge care, to cooperatively fund research related to suicide prevention, and to catalyze health systems to implement suicide prevention training and system changes.
OUTCOMES AND TECHNICAL ASSISTANCE
Richard McKeon, chief of the Suicide Prevention Branch in SAMHSA’s Center for Mental Health Services, discussed the need to track outcomes. Part of the reason the Department of Defense and the Department of Veterans Affairs have focused on suicide prevention is they have the data about the people they are losing to suicide, and many health care systems do not have those data. In addition, the Interdepartmental Serious Mental Illness Coordinating Committee has recommended generating these data more quickly, he reported, which could further increase accountability. “That information potentially can be made available more quickly than the 2-year wait for the CDC [Centers for Disease Control and Prevention] statistics that specify suicides.”
On the data issue, Ostrovsky mentioned a treasure trove of data is available in the form of claims data held by Centers for Medicare & Medicaid Services. These data are available after just 1 month for every state and territory in the nation and could be made available through the Transformed Medicaid Statistical Information System if they were accessed by researchers or other government agencies.
Finally, McKeon cited the new regionally based technical assistance centers being established by SAMHSA as a source of information. The stakeholders in suicide prevention could help guide what the most productive role of these centers would be.
The link between suicide and serious mental illness “will be an abiding concern for SAMHSA over the next number of years,” McKeon concluded. “We need to be able to have more of these conversations.”
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