Could asking the right questions help prevent suicide? North Texas hospitals think so
If you or a loved one is experiencing a crisis or suicidal thoughts, call the National Suicide Prevention Lifeline at 800-273-8255.
The number of people dying by suicide in Tarrant County has risen steadily over the last two decades, from about nine suicide deaths per 100,000 people in 1999 to about 12 in 2020, according to federal data.
Suicide is preventable through a range of treatments and different tools that can keep people safe. But prevention is complicated by the need to identify those who are at risk for killing themselves and getting them care.
The challenge is daunting. But some hospitals have found early success using a relatively simple tool: Asking every patient if they have thought about killing themselves, whether they’re in the emergency room with a broken arm or at a community clinic with strep throat. And then, for those patients who have thought about hurting themselves, connecting them with health care workers who can help keep them safe.
Parkland Health and Hospital System in Dallas was the first and largest health network to add universal screening practices throughout most of its massive system in 2015. Fort Worth’s JPS Health Network followed suit in 2017, and now screens every single patient who walks through the door to see if they could be at risk for suicide.
One of the leaders in the field of suicide prevention, Dr. Brian Ahmedani, said adding just a few questions at intake has saved thousands of lives in Michigan, where screening was added first for all behavioral health patients within the Henry Ford Health System. Ahmedani said that in the face of rising suicide rates, health care providers needed to go beyond addressing existing behavioral health patients.
“If we really want to make a measurable impact in this country, and drop suicide rates substantially for the whole population, then we really need to get upstream,” he said.
Psychiatry staff at Parkland and JPS hospitals in North Texas said they’re seeing a similar life-saving impact here.
How universal suicide screening works
The idea behind universal screening stems from the fact that a large number of people who kill themselves don’t get any kind of behavioral or mental health care before their death. But some of those people will get other types of health care, meaning that if a patient at risk for suicide goes to the hospital with the flu, that might also be an opportunity to get them connect them with a psychiatrist. One study looking at people who had died by suicide found that 45% of them had seen a non-mental health provider in the month before their death. Just 19% of the group had had contact with a mental health provider.
When Kim Roaten, a psychiatry professor at UT Southwestern Medical Center, set out to design a screening protocol at Parkland, she and her colleagues found no road map. No health system had incorporated a new screening across such a big and diverse public hospital. But over the course of several years, Roaten and her colleagues developed a system that allowed just a few questions to be asked of almost all patients, and an action plan for the people who were at risk. (Suicide screening is in place in Parkland’s emergency room, inpatient and outpatient clinics, but it is not currently used in the health system’s smaller specialty clinics.)
Once people are identified as being at risk for suicide, Roaten said, Parkland’s team of health care workers and social workers steps in to determine how serious the risk is and what support the patient needs. Roaten’s early research found that only a small minority of patients — less than 4% — screened positive for suicide risk. And even fewer are at immediate risk, Roaten said, meaning that adding the screening did not cause an influx of behavioral health patients that Parkland wasn’t able to handle. Evidence-backed steps, like agreeing on a safety plan and identifying any lethal weapons or items someone might have access to and then working to secure those items, are highly effective at keeping people safe from suicide, Roaten said.
Ahmedani, who leads the Center for Health Policy and Health Services Research at Henry Ford, compared suicide screening to tests for cholesterol levels. Alone, a test that says you have a high cholesterol won’t reduce your risk of heart attack, he said. But using that test to get treatment can reduce the risk and, ultimately, save your life.
In Tarrant County, behavioral health has consistently and repeatedly been identified as a major need without enough resources available. Suicide was the 11th leading cause of death in 2020, claiming at least 257 county residents, according to death certificate data. Even as suicide rates have increased in Tarrant County, the mortality rate for the county’s leading cause of death, heart disease, has decreased dramatically.
Officials at JPS, Tarrant County’s public hospital system, began considering adding universal screening in 2012, as interest in the idea was growing, said Cynthia Claassen, PhD, the director of research and education at JPS. The protocol was started in 2017, and now any patient age 10 and older is asked a few questions to determine their risk when they seek treatment.
“It’s a no wrong door policy,” Claassen said. “You are screened no matter where you walk in.”
Other hospitals and health systems have added suicide screening to their emergency departments, which is where patients are at highest risk. But fewer health systems have implemented screening beyond the ER, throughout every part of their system.
The evidence
The existence of suicide screenings is also based on a now confirmed fact about suicide: Asking someone whether they’ve thought of hurting themselves or whether they want to hurt themselves doesn’t make them more likely to do so, or plant the idea in their heads.
“We have data to suggest the reverse is true, that screening for suicide risk actually conveys concern, hope, optimism,” Roaten said.
There are some limitations. First, not everyone will answer the screening questions truthfully, because of the stigma around depression, or recognize their own risk, Claassen said. And people who experience suicidal thoughts don’t experience them at the same intensity all the time.
“The day that they’re coming in to talk to somebody at JPS, they can be feeling really good,” Claassen said. “And then maybe within a day or two of getting hit with something very difficult, they’re very suicidal.”
And although the screening protocols at Parkland and JPS have promising early results, the benefits only apply to patients within those two hospital systems. People going to other hospitals, or who forgo medical care altogether, won’t benefit from universal suicide screening.
Parkland’s Roaten said more evidence still needs to be gathered to definitively link screening to a decline in suicide.
“We need answers about mortality,” she said. “We need to be able to go to literature and say, ‘You have to implement screening because it saves this many lives.’ And we’re not there yet.”
Roaten is currently working on research that will examine suicide rates for five years before Parkland added the screening and the six years after, to see whether suicides decreased among Parkland’s patients. Roaten said she expects to see a decline, because the hospital’s system links patients at risk with tools that have been proven to be effective at keeping people safe.
“We are already doing the things that we know work,” she said.
This story was originally published May 27, 2022 at 5:30 AM.
