Suicides are on the rise nationwide, and have been for some time. But no other part of America feels that increase quite as much as rural America.

A recent study published by the Centers for Disease Control and Prevention examined suicide rates throughout the United States between 1999 and 2015. While suicide rates increased nationally during this time period and reached their highest overall rate in 2015, smaller communities and rural areas saw the acceleration beginning in 2007-2008.

Rural areas have long had higher suicide rates than urban areas, and that trend has only gotten worse in the last decade. In order to protect the lives of people at risk of dying by suicide, we need to understand the risk factors that contribute to suicide rates in rural areas.

Lack of access to care, limited resources put rural residents at risk

Nationwide, we have an under-funded and under-equipped mental health system that fails to adequately care for people at risk of suicide. In rural areas, where the healthcare system is stretched thin to begin with, competent psychiatrists and mental health professionals are almost non-existent.

Politico recently reported on this lack of service with an account from an emergency room doctor in a small, rural community in Georgia, who often needs to care for patients at risk of suicide while also attending to those with acute medical issues. Because psychiatric hospitals rarely have beds available, these patients are left to board at the ER for days or weeks on end, receiving little if any treatment from medical professionals who are undoubtedly well-intentioned, but not trained or equipped to adequately care for individuals in crisis.  Good intentions don’t count; solid training in suicide prevention does.

And even when care is available, many people in rural communities find that it is inadequate to meet their needs. For example, many rural residents are still without health insurance and are unable to afford medications or follow-up care. Time and distance can also be prohibitive, as even if the patient can get an appointment, the nearest specialist may be hours away.

Telecommunications is part of the answer

In the day of telecommunications, it is troubling that lack of access to care is a problem for the mental health industry. Imagine you or your loved one is suicidal somewhere in rural America.  You are taken by paramedics or police to the nearest ER, where you are told that there are no mental health providers around. But luckily, the ER has videoconferencing equipment connecting it to psychiatry departments based in larger hospitals in other cities. These mental health providers are then able to screen for suicide and recommend proper interventions, all from a distance. In this way, telecommunication technology in healthcare or “telemedicine” could play a key role in saving the life of someone who needs to be protected from suicide, but is too far away from mental health specialists to physically reach this needed critical care.

How about proper training for emergency department physicians?

Telecommunications may not even be needed if the rural emergency room physician is properly trained in screening for suicide; they should be. If they are not they should demand the training from their medical schools.  What part of “emergency” do the medical schools not understand? The Suicide Prevention Resource Center has made training easy for the emergency physician. There is a “Consensus Guide for Emergency Departments” which trains the emergency doctor on what to do when a patient at risk for suicide presents at the emergency department.  Google it!

A comprehensive approach is needed to help prevent rural suicides

Other factors not directly related to medical care can also contribute to risk of suicide. Historically, rural residents have depended on friends and family for support; as families grow further apart, they may be left with increased stress and fewer options, especially in an economy that is increasingly unfavorable. There’s a strong stigma against seeking help with mental health issues in many rural areas that can be a further impediment to treatment, even when treatment is available. Moreover, there is a perception that inhabitants of rural communities are still acceptable targets for disrespect from city dwellers, which can add literal insult to injury in too many cases.

Because so many risk factors contribute to rural suicides, there is no single solution that can be identified to protect the lives of people at risk. Rather, a comprehensive strategy is needed to improve access to care, provide adequate training and resources for care providers, and encourage community engagement and social connectedness to help rural residents access the resources they need to mitigate the risk of dying by suicide.

In places where mental health resources are limited, friends and family members of people struggling with suicidal ideation need to be the first line of defense. They need to understand the warning signs, be vigilant, and advocate for their loved ones – and understand that there is no shame in seeking help.

An awesome place for gate-keeper training is the QPR institute. See http://www.qprinstitute.com. The QPR training will give you and your loved ones a great chance to live until professional help arrives, like CPR. By “professional help” I mean professional trained in suicide prevention; those who know how to properly assess for suicide and take the correct interventions to protect life.

Suicide has become a top cause of death for middle schoolers

Youth is supposed to be bright, radiant, full of opportunity and self-discovery. In middle school, this journey is often just beginning, and it can be an incredibly challenging one to undertake at such a young age. Children are introduced to a new social dynamic in middle school, one that has made itself notorious for bullying, cliques, and social pressure all while students undergo the changes that come with puberty. Not all of those changes are welcome.

The CDC reported that in 2014, more middle school students died by suicide than in car accidents. Car accident fatalities have been on a steady decline, with a few hiccups here and there, but the suicide rate among youth ages 10-14 has set itself to a painful beat, increasing steadily year by year. In the 7-year span before the CDC report, 425 children within that age bracket were victims of suicide. What went wrong, and what is currently wrong, with treatment and acknowledgement of mental health?

What causes suicide?

Teen and youth suicide is a growing health concern. As recently as January, two girls aged 12 and 14 leapt to their deaths from the top of a parking garage, with the reasoning surrounding the incident left unclear. According to the Jason Foundation, an organization devoted to addressing and preventing youth suicide, there are over 5,000 suicide attempts daily among young people from grades 7-12.

Many youth who feel like social outliers are often targets for bullying, a theme so ingrained into our society that it’s hard to find any form of entertainment with a middle or high school setting that doesn’t include the token “outcast”, often a “geeky”, “alternative”, or otherwise non-conformant youth. However, they aren’t the only targets. LGBTQIA youth are often preyed upon by cruel peers, and even teachers. Religious and ethnic minorities, along with troubled or disabled students often fall into their sights as well.

High Speed Connection to Harassment

Whether it be by personal computer, tablet or phone, access to social media and the internet as a whole is widespread and often unsupervised. Cyberbullying is a particularly potent form of harassment: the anonymity provided by the Internet gives bullies more freedom to inflict pain on their victims, and students often feel like there is no escape because the harassment follows them home after school hours. One victim died from suicide after enduring years of online harassment, her weight being the target for torment.

In Alamo Heights, a 13 year old girl died from suicide, harassed by classmates on an anonymous Instagram account. It wasn’t the community’s first encounter with youth suicide, with a previous loss leading to the implementation of “David’s Law.” Anti-bullying seminars are being held and bills passed, counselors are available, but the continuing epidemic has yet to be solved. Even emergency room providers sometimes fail to stop what is an exceptionally preventable cause of death.

Addressing Mental Health

Due to neglect from schools to fully address the problem, mental health issues in youth are often on the back burner, if addressed at all. Identifying at-risk students is critical to preventing youth suicide. Middle school students aren’t too young to develop serious mental conditions that often have high suicide rates, such as:

• Bipolar Disorder
• Eating Disorders
• Anxiety Disorders
• Depression

In addition, ADHD and autism spectrum disorders may go unchecked, and have the potential to impact grades and a student’s social life during a critical development period. The services students have access to at school, including academic and counseling resources, are often too few and under-utilized due to stigmas surrounding mental illness.

Look for the Signs

Parents, educators, friends-everyone involved in a student’s school life should be willing and able to spot warning signs of potentially life-threatening behavior in youth. “Picky eating” or “moodiness” due to oncoming or onset puberty are common dismissals of problematic behavior in youth, especially in girls. Talk of death, a disrupted sleep pattern, loss of appetite, sudden fears and social withdrawal are all common identifiers and red flags that may be easier to spot if adults combined seminars and programs with listening.

Survivors Aren’t Alone

Where the mental health system falls short, families of victims are left with few answers. The public is left with mounting concerns for the care of the suicidal, and those who may be inching closer to being at risk.  The last group anyone wanted to consider a risk pool is undoubtedly our youth. The Law Offices of Skip Simpson take every case seriously. Children should not only have access to adequate mental health care, but to understanding support networks and opportunities to flourish academically and socially. Suicide prevention attorney Skip Simpson is dedicated to this cause, and to finding justice for survivors who have been let down by flaws in the system. If this tragedy resonates with you or someone you know, contact us today.

More than 60% of the United States’ 30,000 annual gun-related deaths are due to suicide, outnumbering homicides. This is a startling statistic, one that leaves countless families with empty places at the dinner table and loved ones with questions that can never be answered. What caused this? What could have been done to stop it? And why is it often too late?

While most of us are concerned about the grim daily news reports and the safety of our communities from firearms (and rightfully so), there is also a population at risk of suicide, and access to a gun increases the risk of death. Suicide rates have increased over the years, becoming the 10^th leading cause of death in the United States in 2013.

Are we equipped to deal with this? We’re told to watch for warning signs of active suicidal ideation that might become reality such as a loss of interest in activities, talking about death, and withdrawal from socializing. Mental illnesses, especially bipolar disorder, schizophrenia, anorexia nervosa, and major depression can make everything more complex as they are at a much higher risk for suicide attempts. In addition, a sudden negative life event like a breakup, loss of a job, or financial crisis, can trigger thoughts of self-harm.

One key to understanding suicide risk is to realize that decisions to end one’s life are often, even if they’ve been planned, impulsive. Given time, the acute desire for suicide will pass. This means that anyone with access to a fast way to end their life is in far more danger.

Guns provide the means for many deaths by suicide

A gun in the home provides a lethal, and accessible, means of carrying out suicidal thoughts. Currently, there are an estimated 55 million Americans who own guns, and there are about 21,000 suicides by firearms yearly.  In April 2009, the eased process of becoming one of those millions of gunowners proved itself to be deadly with the purchase of a gun in New Hampshire. A young man visited a gun shop near Manchester, and within hours of leaving, had died by suicide. He was one of three people that week who had done the same thing after buying guns from the same store.

This prompted a nationwide movement, Means Matter, to partner suicide prevention with gun shop owners. There was, and still is, no telling what reason someone has to buy a gun. However, there is now a national call to attempt to educate shop owners on how to potentially spot a suicide risk in their business.

• Providing pamphlets and posters advertising suicide hotlines and help centers for shop owners to keep in the open. Hopefully, these materials will catch the attention of at-risk buyers.
• Dialogue: if a customer says they only need a small amount of ammunition, or that they’re not particular about a certain gun or learning about its use, this should send a red flag to the clerk to try and dissuade a purchase. Engaging in targeted dialogue can also cause a person to think twice; again, suicidal ideation usually passes with time.
• Distribution or encouragement to purchase gun locks. Access to firearms is all too easy. The more protection a gun has, the longer it’ll take to access, and the more time there is to prevent suicide.

Minors are especially at risk for suicide. Texas has seen too many youth gun-related suicides where the gun was already in the home, easy to access. Many were the result of bullying, one even prompting the passing of “David’s Law” that made cyber bullying a misdemeanor. In one such case, a Texas girl died by suicide in front of her family after relentless cyber harassment. Why was that gun so easy to access?

Texas has no state registry for firearms, and there is no waiting period to purchase one. While guns must be locked and kept away, that initial access needs to take less than a walk-in visit to a gun store, and homeowners need to keep an eye on their loved ones, another on the gun safe. This is a long process, involving the action of the public—gun owners and not, medical staff and psychiatrists, and the de-stigmatization of mental illness so people can find help.

There are too many questions, but there can be answers.

Contact the Law Offices of Skip Simpson for a free case evaluation if suicide has affected you or your loved ones, and if it could’ve been prevented by better action of practitioners. Accessing the means to self-harm is one step, ensuring the safe care of suicidal patients and at risk people is another. Give us a call today.

For years, facilities operated by the Department of Veteran’s Affairs have seen an epidemic of inpatient suicides. Over the last decade, an initiative taken to address suicide risks in patients’ physical environments has done a great deal to curtail that danger.

The VA is leading the way for civilian facilities in many different ways and I commend them for doing so. I hope the new commander-in-chief will keep up the good work—I am optimistic.  Patient safety starts with excellent leadership—that means from the very top.

Introduced in 2007, an “environmental checklist” was meant to help secure safer surroundings for those veterans placed in inpatient care to help curb the persistent suicide epidemic. The “checklist” has 114 items for VA hospitals and inpatient centers to tick off when identifying environmental risks that would pose opportunities for an attempt to complete a suicide. Items such as hooks, clothing rods in closets, door knobs and electrical sockets can be more than part of standard furnishing in a patients’ room; they can pose a deadly opportunity for veterans already at risk to act on ideations.  If the patient is psychotic, the patient must be observed line of sight or one to one. If not the patient can stuff food, clothing, toilet paper, or anything down his or her throat.

Thankfully, more than 150 VA hospitals have sought to implement the checklist; installing shelving and cubbies that lack sharp edges, removing hooks from walls and backs of doors, and moving towards making electrical outlets tamper proof. Eliminating these physical hazards takes stress off of hospital staff and allows them to focus on direct patient care; checking on the patients more frequently and receiving more elaborate training on how to identify, care for, and report patients at a risk for suicide. With the high turnover of staff and without the physical change of the patients’ environment, some precautions might be overlooked. Dr. Vince Watts, leader of a study on the checklist, commented that “hardwiring” changes into the facilities means that new or rotating staff couldn’t be forgetful regarding modifications.

Thankfully, the program seems to have had some success. During the duration of Dr. Watt’s study, the average length of stay in VA mental health facilities dropped from 11 days to around 7 days.

Has this method made a significant impact on veteran suicides?

While completed suicides among veterans remain far too prevalent in our society, the evidence shows that this is beginning to change. Prior to the checklist being implemented, the National Center for Patient Safety’s database reported a rate of 4.2 suicides per 100,000 admissions. Without such precautionary measures such as the checklist system in place, every patient could be one step away from taking their life. After the checklist was put into place, the suicide rate plummeted to 0.74 suicides per 100,000 admissions, showing that there is hope for the mental health care that our veterans deserve after their dedicated service.  However environment of care is just one part of the triad to protect patients: the other two parts are proper observation levels and medication.

The risk of suicide for veterans is currently 21% higher than the civilian population, but preventative measures are steadily helping to decrease that number. Crisis lines are actively hiring new responders and putting them through extensive training to properly handle the calls and issues they will face, measures to identify high risk veterans are being taken so a crisis can be stopped before it even takes place.

The VA’s example shows that something as seemingly trivial as a checklist for inpatient facilities to follow can save lives, and civilian hospitals ought to follow suit. By removing physical dangers from a patients’ presence and replacing them with more continuous, educated and accessible care, we can hope to see more lives continue and zero end too soon.

Hospitals responsible for multiple inpatient suicides are shielded by 1999 law

Just before last Thanksgiving, a Vermont family lost their son, a patient at the renowned Menninger Clinic in Houston, to suicide. A.G. was 25 years old when his parents sent him to Menninger after he had presented at acute risk of suicide. After a few weeks in care, his parents told his doctor he wasn’t getting better – that on the phone, he sounded more hopeless than ever. The psychiatrist assured them that the facility was doing everything possible to help him.

One day later, even though his condition had clearly not improved, the facility allowed A. G. to go to a restaurant with other patients. While at dinner, he stood up, asked to use the bathroom, left the table – unsupervised and unaccompanied – and then walked out the back door. Seventeen hours later, he had died by suicide.

A state investigation revealed what should have been obvious to Menninger staff: A. G. should never have been allowed to go into the community by himself. The clinic failed to meet its duty of care by not doing enough to protect him. But the results of that investigation were not made public.

That’s because The Menninger Clinic, like most other inpatient facilities in Texas, is protected by an unintended consequence of a 1999 law.

1999 legislation bars state department from releasing investigation results

The law at the center of the issue, which went into effect on September 1, 1999, was intended to give subpoena powers to state licensing boards that oversee medical providers such as family therapists and dietitians and was created at the request of the Texas Department of Health. The Texas Hospital Association, an organization that represents hospitals and healthcare providers statewide, requested an amendment requiring those investigations to be secret.

Former state Rep. Patricia Gray, who authored the law, has stated that she never intended the law to be used as it is applied today. The secrecy regulations serve only to protect the reputation of hospitals – at the expense of patients’ safety and families’ right to justice.

At Menninger alone, at least four incidents in which patients died by suicide or made suicide attempts went unreported in the decade prior to A. G’s death. Had his parents had access to that information, they may not have decided to place him at a clinic 1,600 miles away from their home – a decision driven by the clinic’s sterling reputation that is protected by Texas law. His mother, D. L., herself a psychiatrist, spent days vetting the clinic and saw plenty of positive information, but none of the deadly safety concerns.

Lack of access to information puts thousands of patients at risk

And given that Menninger is a nationally known and well-funded facility, the risks to patients at other hospitals and clinics throughout Texas are likely even greater.

“If these kinds of safety lapses are happening at the much-celebrated Menninger Clinic,” said inpatient suicide attorney Skip Simpson, “can you imagine what’s happening out of the public eye at facilities that operate on a fraction of their budget?”  Skip knows too well how and why hospitals hide the ball from families—never disclosing to families how their loved ones died; especially in a place with one primary duty: to protect the patient.

A touted reason behind not disclosing the facts to families about their loved one’s suicide is so staff and doctors can openly address their poor decisions—behind closed doors—with no one being blamed for the death.

The proper purpose for studying hospital suicide is to employ the Stop-It-Next-Time rule. When a hospital, has something go wrong which allows a suicide, the hospital must investigate why – and then try to keep the same thing from going wrong and injuring someone again.  Instead, hospitals are not learning—just hiding. Families learn nothing about the details of the suicide unless a lawsuit is filed.

The truth is that so many families are left with unanswered questions; A. G.’s parents were explicitly told by a DSHS employee that the information they needed was in a report they would never see because of the state law. And this isn’t just a concern for a few families—it’s a major public health concern that puts thousands of patients in Texas and nationwide at risk.

Families have a right to accurate safety information about the facilities they will entrust with their loved ones’ care. Dangerous clinics and hospitals must be held responsible for the injuries and deaths they cause. And that means critical information about tragedies such as A. G.’s death cannot be hidden behind a veil of secrecy, always serving the hospital and doctors but rarely the public.

Patients, and the public, deserve better.

Inpatient psychiatric care is supposed to keep patients at acute risk of suicide safe and provide them with the assessment and standard of care they need to recover. But often, the nurses responsible for caring for these patients lack the training and proper experience needed to prevent suicide.  Hospital leaders, including all physicians, must ensure all staff—including psychiatric nurses– are trained and properly supervised to protect patients from injury or death. Sadly some hospitals put profits before safety and training takes from the bottom line.  Nurses, who believe they are not competent to protect patients must obtain proper training to become competent and not attend to patients until they are properly trained.

According to a report published in the Journal of the American Psychiatric Nurses Association, there are no standard competencies for assessing and managing the suicide risk for psychiatric mental health (PMH) nurse generalists – even though the majority work with acutely suicidal patients in inpatient psychiatric settings.

The language used in this report is chilling for anyone with an interest in the well-being of patients at risk of suicide. The APNA’s report indicated there are “serious gaps in nursing education” in suicide risk assessment, prevention and intervention, and there are “no developed structures and processes” for these generalist nurses who provide care and treatment to patients at risk of suicide.  Hospitals, to their detriment, are often relying on nursing schools to properly train nursing students on patient safety as it relates to suicide prevention.  The nursing schools don’t know what they don’t know about patient safety for suicidal patients. Consequently nursing students are being graduated not equipped for their duties in psychiatric hospitals.  Furthermore licensing boards are not properly testing nurses for suicide prevention in hospitals.

Other care providers in these same inpatient settings, such as most psychiatrists and some—but few– mental health clinicians, have specific training in suicide prevention. But because generalist nurses have, according to the APNA report, “the greatest contact with suicidal patients,” their lack of training exposes these patients to significant risk. The warning signs of suicide are often subtle and intermittent, and they can easily be overlooked by a psychiatrist or clinician who spends limited time with the patient. Meanwhile, the nurses who provide at-risk patients with direct care rarely understand how to recognize those warning signs – or how to appropriately intervene.  Most inpatient nurses do not know that death by hanging is the number one way patients die in psychiatric hospitals; nor do they know that patients will have irreversible brain damage in just a few minutes when brains are deprived of oxygen by hanging.  If nurses knew these facts they would resist any physician order requiring a suicidal patient to be watched only every 15 minutes.

Psychiatric nurses themselves identify a significant risk to patients

Perhaps most concerning of all, these PMH generalist nurses have self-identified the issue as being dangerously unprepared to work with suicidal patients. In one study cited in the APNA report, not one of the PMH nurses interviewed believed they were adequately educated to work with suicidal individuals. Most stated that they felt a “sense of inadequacy” when caring for patients at substantive risk of suicide – and those feelings of inadequacy could well cause those nurses to fail to intervene at critical moments.

Yet despite these significant warning signs, too many inpatient care facilities throw these generalist nurses, who will work with their most vulnerable patients, into a so-called “baptism by fire.” They are expected to learn on the job with little continuing education or support – and that dangerously inadequate level of care puts their patients at extreme risk of dying by suicide.

Fortunately, the APNA has stated that it will take steps to train psychiatric nurses in suicide assessment, prevention and intervention to provide a higher standard of care to future patients. However, inpatient care facilities are responsible for the safety of their patients. When patients at acute risk of suicide come to inpatient care, their care cannot be left in the hands of medical professionals not adequately trained in suicide prevention. And when patients die by suicide after not receiving adequate care, those negligent inpatient facilities must be held accountable.

Deaths by suicide can be prevented when services are in place

According to The Department of Health and Human services, a staggering 55% of counties across the US do not have a single psychiatrist, psychologist or social worker. Incredibly, every one of those counties is rural. That means that for a person who is living in one of these areas who is at a high risk of suicide, a visit to the closest psychiatrist’s office to get the help they need requires hours of travel and missing up to a day of work, something that may not be possible.

According to a recent New York Times article, the isolation and loneliness that can come from living in a rural town, combined with lower income, health problems and family issues can have a negative impact on any resident. For those who are at risk of suicide, that impact could be much greater, especially when the help they need is hours away. Some posit that this isolation could be one reason for the increase of suicides in rural areas over the last few years.

Stigma associated with mental health puts patients at risk

There is still a great deal of stigma associated with seeking help from a mental health professional, so much so that some people who need help actively won’t seek it for fear of  being seen coming or going from a psychiatrist’s office. This stigma is especially strong in rural areas, where the perception is that there is little expectation of privacy.

When there aren’t any dedicated mental health professionals in their area, a person may try to find help through other means. Some rely on friends or family members. Others may turn to drugs and alcohol. But many who need help seek it from their primary care doctors, whom they know and are comfortable with. According to a 2002 analysis published in the American Journal of Psychiatry, nearly half of the people who died by suicide had visited their primary care physicians within a month of their death. Most reported minor symptoms such as trouble sleeping or headaches.

Bridging the gap with integrated care

Unfortunately, this tendency to see the primary care doctor for mental health issues is quite dangerous. Most primary care physicians are not properly trained in identifying risk factors for suicide, which means they cannot protect those patients in the ways that are most needed. If those patients who went to their doctor for headaches or sleepless nights could then see a medical heath professional on the same day, they would have access to the standard of care they need to reduce the risk of dying by suicide. Because those services are rarely available in rural areas, thousands of people are put at elevated risk.

Experts cited in the Times article have suggested adding a mental health component to primary care practices, either by having an affiliated psychiatrist practicing in the same building or by using video conferencing to get patients immediately evaluated by an off-site psychiatrist. That way, patients can seek mental health services without having to go to a building specifically dedicated to mental health – and thus avoid the weight of the social stigma.

However, with limited space and resources available, adding these services in rural areas is a challenge. Additional resources are needed to provide those essential mental health services to those who are most in need of help. Just as importantly, the public needs to be educated about the high cost of letting mental health services suffer – and the social stigma needs to be replaced with an understanding that seeking treatment for mental health is no different from seeking treatment for any other medical issue.

If you or a loved one has been effected by a death by suicide, contact Skip Simpson today. He knows that a person who is at high risk of suicide cannot seek help that isn’t there. Contact him today for a free and confidential case evaluation.

If you are a mental health provider, you absolutely must read “Constant Observation of Suicidal Patients: The Intervention We Love to Hate,” by Mark J. Russ, MD (Journal of Psychiatric Practice, 2016;22;382–388). This study is a must-read for psychiatric and general hospital risk managers, staff, and attending psychiatrists – because it provides valuable information that can help you protect your patients from serious harm or death.

Constant observation (CO) is defined by Dr. Russ as maintaining uninterrupted, physically close visual surveillance of a patient. He says it has been a mainstay of the inpatient care of the acutely suicidal patient. But sadly, in many hospitals, rehabilitation centers and other residential facilities, patients at acute risk for suicide are not put under CO. This is a dangerous decision.

Though CO is the standard of care for these patients, some argue against its effectiveness. One argument against it is a lack of evidence to support its use. This is a tired excuse. Another is that CO is too expensive and time-consuming, as it requires a staff member to be with one patient at all times. This excuse, at its core, puts profits over patient safety.

Even with a clinician, nurse or other health-care professional allegedly near the patient, there have been a few reported deaths by suicide that have occurred while the patient was under CO. None however, explain how the attempt was made.

Attorney Skip Simpson has a case in which a patient was able to tie a sheet to a vent and hang herself while she was allegedly being constantly watched. The reason for this death was an unsafe environment of care, poor staff training and supervision, and lack of leadership in the hospital. These are all common root causes of suicide listed by the Joint Commission.

It costs money to have a safe place to keep suicidal patients, train and supervise staff and have solid leadership. It always comes back to money—money that bean counters don’t want to spend to protect patients. Skip Simpson will not give hospitals and incompetent leaders a pass, nor will juries.

Most, if not all of the cases of suicide by patients supposedly under CO involved clinicians and staff who did not uphold the strictest level of constant observation. Any time there is a shift change or other circumstance in which a patient is left unobserved, even briefly, there is the risk of a suicide attempt.

Patients deserve the highest level of care

Given the state of our knowledge for the past 20 years, at least, an argument against the effectiveness of CO cannot be made, according to Dr. Russ. Skip Simpson agrees. The axiom asserting that “the absence of evidence is not evidence of absence” applies in this circumstance. There may be weak reasons not to recommend CO as a strategy to mitigate suicide risk in the hospital, but lack of effectiveness cannot be one. The very fact that it would be unethical to test the question with a randomized controlled trial—where some patients are properly protected and others are not—speaks to the validity of its effectiveness.

Many experts agree that CO, like most other procedures, is most effective when all medical professionals are adhering to all safety protocols. The risk of suicide can be prevented by ensuring that all staff are properly trained and follow the proper care procedures. This process also relies heavily on communication between health professionals.

Another method of care for patients who are at risk of suicide is routine 15-minute checks, or Q15. However, this has proven to be ineffective and is dangerous. With this method of observation, patients at high risk of suicide are left alone for 15 minutes at a time. This puts highly vulnerable patients at even greater risk of a successful suicide attempt. Hundreds of patients die by suicide every year while being watched every 15 minutes.

In this respect, the healthcare field is lagging behind virtually every other field. For instance, the reason most new bridges are now safe – ironically – is that so many collapsed in the early days. Whenever a bridge collapsed anywhere, bridge engineers flocked to the site to learn why. Once they found out, they made sure no one ever allowed that problem to arise again. They followed the “stop-it-next-time” rule. In contrast, hospitals do a root cause analysis of their suicides and bury the results. The public, other hospitals, researchers, the CDC, and even the hospital’s own staff don’t know why the suicide on a Q15 occurred.

Predicting a person’s exact moment of suicide is difficult; this is a reason at-risk patients are hospitalized. Every 15-minute watch for acutely suicidal patients must be eliminated. Medical professionals must be properly trained in using appropriate safety protocols, including CO. Overall, there needs to be improvement in the quality of care to help reduce the risk of suicide. This is easy—it means that the priority in healthcare must be the patient, not the pocketbooks of healthcare executives.

If you have lost a loved one to suicide while they were in an inpatient program, hospital or residential facility, contact Skip Simpson today. He has the unique expertise to help you get through this difficult time.

In a recent ruling, the Florida Supreme Court found that the husband of a Sarasota County woman who died by suicide nearly eight years ago can pursue a lawsuit against her physician.

Jacqueline Granicz was 55 years old when she died in October 2008. She had a history of depression. Her husband, Robert Granicz, took legal action against her primary care physician, Joseph Chirillo, arguing that the doctor’s failure to meet his duty of care resulted in her death by suicide.

They day before her death, Jacqueline called her doctor’s office to report that she was under mental strain, crying easily and having gastrointestinal problems. She did not speak directly with her doctor. Dr. Chirillo changed her antidepressant medication and referred her to a gastroenterologist when he learned about the call from an assistant, but he neither called her nor scheduled an appointment to meet with her.

This primary care physician failed his patient; he had to know he failed as soon as he heard of the suicide.

Jacqueline’s case highlights a major hazard to people who are already at risk of suicide: mental health malpractice. When a doctor-patient relationship exists between a person struggling with mental illness and a physician, the physician has a duty to provide competent care that would be reasonably expected of a doctor in similar circumstances.  Doctors and clinicians have long known what is expected of them in protecting suicidal patients, yet they fly in the face of danger by not doing what they should do. Only juries can correct this situation.

Some common types of mental health malpractice include:

• Improper diagnosis.
• Failure to conduct a proper risk assessment. If a physician or other mental health professional has reason to believe a patient may be at risk of self-harm or suicide, he or she has a duty to properly assess the risk of suicide. This assessment includes asking screening questions, eliciting information about suicidal thoughts, plans and behaviors, and establishing a rapport with the patient.
• Failure to properly protect patients at high risk for suicide.

Medical providers and mental health professionals have a duty to appropriately and competently treat their patients, especially patients who are at risk of suicide. When that duty of care is breached and a patient dies by suicide, the victim’s family has the right to seek justice and hold those providers accountable.

The Zero Suicide Approach is a new treatment plan that focuses not only on the patient but also on the importance of the mental health professionals and loved ones in a patient’s life and the role they can play in treatment. This takes suicide prevention a step beyond an individual seeking help and makes it a collaborative group effort.

By using the eight steps laid out in the Zero Suicide Plan, mental health professionals can try to ensure that patients don’t die by suicide; not that fewer patients die by suicide but that no patients do. Zero is the number.

Lead 

As with any treatment plan, the best way to implement new strategies is to have strong leadership. This means all mental health professionals must make it their priority to learn about any new tools or training methods that are available and use them to the best of their ability. Leadership has long been stressed by the Joint Commission (JC), an agency which accredits hospitals. Leadership also means that the Joint Commission stops giving high marks to hospitals with any suicides.  Giving high marks to hospitals with a suicide is misleading the public—the same public the Joint Commission should protect.  The JC should also stop hiding important information from the public. It should mandate that all sentinel events be reported to the JC with a full explanation on why the sentinel event occurred. At this point the public does not know how many attempted suicides have occurred in hospitals or within 3 days of discharge.  The public should know that the estimates of suicides in hospitals is around 1600 patients every year.   

Train

Wanting to help someone at a high risk of suicide isn’t enough. All mental health professionals should receive the proper training to help their patients in the best way possible. The right tools make all the difference. Solid training should start early in professional schools but—mostly —the training is inadequate; this is another leadership issue. 

Identify

It is important for mental health professionals to identify and assess the suicide risk factors for each patient in their care. Such risk factors include: family and personal history of suicide or prior suicide attempts, feeling like you are a burden to others, feeling like you don’t belong, substance abuse, mental illness, recent loss (such as losing a home or a loved one), other drastic life changes (such as losing a job), and psychological conflict or trauma. Knowing each client’s history and risk factors will help mental health professionals find the best ways to treat their patients. However, knowing risk factors is not enough; professionals must learn how to elicit suicidal thinking. 

Engage

Interpersonal connection is a vital part of life and even more so for those who are at high risk of suicide. A high risk patient might experience feelings of loneliness or isolation. Regular contact with loved ones and the mental health professionals in their lives though phone calls, visits and messages reminds those patients they are not alone. This method should be used as often as possible.

Much as there are standards of care are when dealing with a patient with ailments such as high blood pressure or diabetes, so too should there be standards of care for treating patients with high suicide risk.   “Standard care” is what everyone does and most often wrong.  The test is “THE standard of care.”   “Standard care” is going 70 mph when “THE standard” is 55 mph. No policeman will accept “well everyone was going 70.”

Safety Planning

This method is replacing the common practice of the No-Harm Contract. One reason for this shift is that the No-Harm Contract has not been proven to be effective, nor does it encourage continued care. Unlike the contract, A Safety Plan is created by the clinician and the patient together. They discuss different strategies, triggers and coping techniques the patient has at their disposal and how best to implement them. Through this collaborative effort, the patient is more involved in their own care and they take a more active role in their treatment. 

Treat

This plan breaks treatment down into two categories:

Cognitive behavioral therapy: This method focuses on helping patients recognize the thoughts or feelings that may overwhelm them and teaching them alternative coping skills. Research has proven this to be an effective tool for suicide prevention.

Dialectical behavior therapy: There are four main components to this therapy: individual treatment, a skills training group, consultation team meetings and phone coaching. As with cognitive behavioral therapy, this method has also proven effective. 

Transition:

The Zero Suicide Approach also focuses on continuing care. Initial treatment isn’t enough. It is imperative that all mental health professionals continue to be involved in a patient’s life, to continually reinforce the teachings and tools provided in the treatment plan.

Improve:

The medical and mental health professionals must stay on top of a patient’s treatment. They need to use all of the most effective tools at their disposal and know how to integrate those tools into the patient’s treatment plan.

To learn more about the Zero Suicide Approach, click here.