Each year, nearly three times as many Americans die from suicide as from homicide. More Americans kill themselves than die from breast cancer.
As Dr.Thomas Insel, longtime head of the National Institute of Mental Health, prepared to step down from his job in October, he cited the lack of progress in reducing the number of suicides as his biggest disappointment. While the homicide rate in the U.S. has dropped 50 percent since the early 1990s, the suicide rate is higher than it was a decade ago.
"That to me is unacceptable," Insel says.
It hasn't been for lack of trying. The U.S. has a national suicide hotline, and there are suicide prevention programs in every state. There's screening, educational programs, and midnight walks to raise awareness. Yet over the past decade or so, the national suicide rate has increased. In 2003, the suicide rate was 10.8 per 100,000 people. In 2013, it was 12.6.
An effort that began in Detroit in 2001 to treat the most common cause of suicide — depression — is offering hope. With a relentless focus on finding and treating people with depression, the Henry Ford Health System has cut the suicide rate among the people in its insurance plan dramatically. The story of the health system's success is a story of persistence, confidence, hope and a strict adherence to a very specific approach.
That approach saved the life of a woman who prefers to be known only by her first name, Lynn. She agreed to share her medical history on the condition that we not use her full name to protect her privacy.
Lynn, who's now in her mid-50s, has had bipolar disorder, also known as manic-depressive illness, for nearly 30 years. The depressive part of her illness "is like the pain of having a cancer," she says. About 15 years ago, she started getting irresistible urges to take her own life and she started making serious attempts — at times almost monthly.
"When I was in the depths of depression, I was being pulled and sucked into this black tunnel," she says. "I was desperately trying to grab onto something to stop from being sucked in." Sometimes she couldn't find anything to hang on to. "Those are the times when I finally let go and attempted suicide," she says.
The program that saved Lynn almost didn't get off the ground.
Fifteen years ago, suicide prevention care at Henry Ford, like in many places, was mostly reactive. When patients came in talking about suicide, health providers took notice. But little was done to find people before they reached that point.
Some of the health providers in the psychiatric division decided they could do better. So they applied to a foundation for a grant to provide something they called "perfect depression care" for the 200,000 patients in the health system. The goal: zero suicides.
The mental health division failed to win the grant, but the health system went ahead with the proposed changes anyway.
The plan it developed is intensive and thorough, an almost cookbook approach. Primary care doctors screen every patient with two questions: How often have you felt down in the past two weeks? And how often have you felt little pleasure in doing things? A high score leads to more questions about sleep disturbances, changes in appetite, thoughts of hurting oneself. All patients are questioned on every visit.
If the health providers recognize a mental health problem, patients are assigned to appropriate care — cognitive behavioral therapy, drugs, group counseling, or hospitalization if necessary. On each patient's medical record, providers have to attest to having done the screening, and they record plans for any needed care.
Therapists involve patients' families, and ask them to remove guns or other means of suicide from their homes. Clerks are trained to make sure that patients who need followup care don't leave without an appointment. Patients themselves come up with "safety plans."
Lynn has two copies, one by her nightstand and one in her kitchen. Each lists things she can do when she feels depression coming on. She could sit on her balcony, or do some drawing or painting. The list includes her therapists' phone numbers. And there's a reminder that the feeling will pass — it has before.
Before the zero suicide plan went into effect, says psychiatrist Doree Ann Espiritu, acting head of the zero suicide program at Henry Ford, you might make a contract with a patient where the patient agrees not to commit suicide. Studies show it doesn't work very well, she says.
Today, providers are trained to be comfortable asking their patients about suicidal thoughts. "There is a fear among clinicians that if you ask questions about suicide, you are giving the patient an idea that this could be an option," says Espiritu, "and if you ask about guns or pills, that you are giving them some hints on how they can carry out a plan." The Henry Ford therapists are trained to break that barrier.
For Lynn, the key was persistence — her therapists', and her own. "I recall one time with my psychiatrist, who kept trying to encourage me and help me find ways of coping, and I can remember saying, 'I don't believe there's hope, I don't see it, I don't feel it, I need you to hold on to that for me because it's not there,' " she recalls.
Her therapists never gave up. "There is no question that the message I got from Day 1 is that they knew they could help me, and they would help me," Lynn says. Over the years she's been in group therapy, day treatment, and, when things got bad, the emergency room.
The Henry Ford approach is catching on. A stream of visitors from U.S. health insurers and from the United Kingdom have made site visits. The Suicide Prevention Resource Center has run two zero suicide training academies for teams from health care systems based on the Henry Ford principles. Other health systems have adapted the plan, including Group Health Cooperative in Seattle and the behavioral health provider Centerstone in Tennessee.
Espiritu started work at Henry Ford just as the program was starting, and she remembers the initial staff meetings: "There was a lot of, 'How can you do this? How can you aim for zero? How can you expect your clinicians to be perfect and follow this protocol?' " Some people didn't think it could be done, she says, or even attempted.
Still, the health system went ahead, and the rewards were nearly immediate. Henry Ford epidemiologist Brian Ahmedani studies the numbers. In 2009, for those being actively treated for a mental health problem or substance abuse, "we had a rate of zero per hundred thousand," he says. It's crept up to 20 per 100,000 per year, but that's still 80 percent lower than it was when the program began. The rate is five per 100,000 in the organization's general population, which is well below the national average and has remained steady despite an increasing rate of suicide statewide.
There's reason to think a full-bore effort to treat depression could reduce health costs, because untreated depression is associated with higher medical bills for chronic illnesses such as diabetes and hypertension. But there are training costs involved, and the Henry Ford system has had to keep its staffing up to be able to provide care for people who need it.
Officials at Henry Ford say they haven't analyzed the costs. But Centerstone has. The behavioral health provider in Nashville implemented the Henry Ford approach for nearly 200 patients who'd already made a suicide attempt. Reductions in emergency room visits and hospitalizations over the course of a year resulted in savings of more than $400,000.
Why push for zero, rather than just a reduction? "Because if you say we're OK with five a year, one of those might be your brother or your friend," says Espiritu. "We aim for zero because it reminds all of us of what we would want for ourselves." Maybe it is not possible, she says. But it is a goal.
And as for Lynn, she doesn't consider herself cured. She says with the treatment she's received at Henry Ford, she's learned to live, even thrive, with bipolar disease. And she's alive. That, she says, makes her a big success story.
STEVE INSKEEP, HOST:
Today in Your Health, we explore whether it is possible to prevent every single suicide, driving the suicide rate to zero.
RENEE MONTAGNE, HOST:
That's an ambitious goal, to say the least. The suicide rate in the U.S. has actually grown slightly in the past decade.
INSKEEP: Some people are trying for zero suicides all the same. It is the goal of a health system in Detroit, which has enjoyed impressive results. Reporter Joanne Silberner begins this story with one client of that health system who is still around to tell her story.
JOANNE SILBERNER, BYLINE: Thirty years ago, Lynn developed a disease that would eventually threaten her life - manic-depressive illness. Fifteen years ago, it overwhelmed her, and she overdosed on some pills.
LYNN: I couldn't go on. I couldn't handle the pain anymore.
SILBERNER: Lynn is sharing her medical history and her fight to live on the condition that we don't share her full name to protect her privacy. Though she survived that time, she would attempt to end her life again and again and again, as often as monthly at one point.
LYNN: There are times where you overdose or attempt to hurt yourself where you really just want to die. And then there's other times where I've overdosed where it's like I just want the pain to stop.
SILBERNER: She says what pushed her to the brink time after time was something inside.
LYNN: When I was in the depths, the very depths of depression, I was being pulled and sucked into this black tunnel that was just pulling me and pulling me. And I was desperately trying to grab onto something to stop being sucked in.
SILBERNER: Others have spoken and written about the deep pain Lynn felt. Author William Styron once described his own depression as the pain of drowning. Around the time Lynn's suicide attempts started, she signed up for health insurance with the Henry Ford Health System in Detroit. And soon after she signed on, the health system began a formal program, a deliberate and concerted effort to reduce suicides among their population to zero.
NICOLE GLICKMAN: Come on in.
SILBERNER: Recently, Lynn came to a Henry Ford clinic in Detroit.
GLICKMAN: How are you?
SILBERNER: These visits are part of what this zero-plan does. It starts with primary care doctors who screen every patient for depression. Patients who come up positive are encouraged to try talk-therapy, group counseling, drugs or hospitalization if warranted. Administrative staff are trained to make sure any patient who needs follow-up gets an appointment. Therapists involve patients' families and ask that guns or other means of suicide are removed from their homes. Patients write their own safety plans. All that attention to prevention pays off.
GLICKMAN: So how have things been going?
LYNN: This week's been a real mixed week.
SILBERNER: Lynn felt a depression coming on and was upset by a conversation with a friend. She talked to therapist Nicole Glickman about thoughts she had had of taking some pills, of overdosing to escape from the pain.
GLICKMAN: What prevented you from taking them out?
LYNN: Knowing and believing that it was going to pass.
SILBERNER: Lynn has two safety plans written out - one in her cupboard and the other by her night stand. They're specific - therapist phone numbers, things to do - call for help, sit on her balcony, do some drawing or painting and remember that this feeling will pass. It has before.
GLICKMAN: Are you feeling safe now?
LYNN: I am feeling safe now. I'm not feeling as depressed as I was then.
SILBERNER: Getting health providers at Henry Ford to accept zero as the goal meant a fundamental change in belief systems about suicide, says Brian Ahmedani. He's an epidemiologist who joined Henry Ford a few years ago to measure how things are going.
BRIAN AHMEDANI: Traditionally, we had always addressed suicide as something that was inevitable, something that we couldn't really do much about. If somebody wanted to die, that they were going to do that, regardless of what we did.
SILBERNER: When Lynn came into the Henry Ford Health System, providers were being told the opposite - never to give up on suicidal patients.
LYNN: There is no question that the message I got from day one is that they knew they could help me, and they would help me.
SILBERNER: And Lynn hasn't made any suicide attempts in the last five years.
LYNN: I guess I'm one of their big success stories, then. I'm one of those zeros.
SILBERNER: She's clear about what would've happened without Henry Ford.
LYNN: I wouldn't be here. I wouldn't be here.
SILBERNER: Brian Ahmedani says the numbers in the high-risk mental health population support the program.
AHMEDANI: For 2009, it was possible. We had a rate of 0 per 100,000, and everyone always told us that that was not possible.
SILBERNER: Especially in the middle of some trying economic times for people in Detroit. Now, the zero suicide rate only held for two years. It's up now to 20 per 100,000 per year in the high-risk population, but that's still 80 percent lower than before the program started. And for the general population, it's 5 per 100,000 - way below the rate for the rest of Michigan. And regarding cost, the folks at Henry Ford say they haven't yet done a comprehensive analysis, but a similar program modeled on Henry Ford actually reported some cost savings. Zero suicide seems to be catching on around the country. Clinicians here, like Jeff Devore, say zero is worth striving for.
JEFF DEVORE: Is it possible to completely prevent suicide - have zero suicides? Well, anything's possible, right? I mean, isn't it? That's the goal.
SILBERNER: And Lynn? Lynn credits perseverance by staff of the Henry Ford Health System and her own.
LYNN: I have persevered in learning to speak up for myself and that I should and that I deserve it. And I hope others can hear that. The mentally ill person, their family - there is always hope, and I am living proof of it.
SILBERNER: Several years ago, Lynn got a tattoo on her left arm - hope, it says. And the next year on her right arm - joy. Recently, she told me something she would not have said 10 or 15 years ago - I will never attempt suicide again. For NPR News, I'm Joanne Silberner. Transcript provided by NPR, Copyright NPR.