Trust Article

Questions That Help Save Lives

August 28, 2023 By: Carol Kaufmann Read time:

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Questions That Help Save Lives
Some health providers conduct suicide screening for all patients—and it’s beginning to make a difference. Pew is launching an effort to help make suicide prevention and care more routine.

When Greg Whitesell was a junior at Arlee High School on the Flathead Indian Reservation in western Montana, he was a star basketball player. But he loved to play football as well. Against his parents’ wishes, he went to practice nearly every day and sustained concussions almost as frequently. One of them was particularly nasty.

“It sent me to a really dark place,” Whitesell, now 22, says about his head injury. “I wasn’t allowed to do anything and had to stay at home with the lights off. I was in a pretty bad spot.”

Whitesell became depressed, his outlook plummeting so low that he was ready to end his life. He texted two friends that he didn’t “want to be alive anymore.”

Before he could act, his friends came pounding on his front door. They talked to his mom, and the family went to the local hospital’s emergency department, where Whitesell answered many questions from the staff. The hospital team also talked to his parents and connected him with a therapist, one that helped him for the next few years.

Questions and connections saved his life. He received the help he needed at a critical point.

At a park in Missoula, Montana, Whitesell shoots hoops, exercising a long-held passion. He has many more passions these days, including connecting with others who are struggling, and doesn’t shy away from talking about his experience. “We’ve come a long way,” he says. “With my generation, it’s OK to talk about your feelings.”
Tailyr Irvine for The Pew Charitable Trusts

But many Americans do not.

From 1999 to 2019, the suicide rate in the United States increased 33% across all sexes, races, and ethnicities, according to the Centers for Disease Control and Prevention. In 2021, suicide was the nation’s 11th leading cause of death. That same year, more than 48,000 people died by suicide, which is one death every 11 minutes. A total of 1.7 million people made a suicide attempt in 2021, and 12 million adults had serious thoughts about suicide.

“Developed countries have seen a decline in the rates, but the U.S. is an outlier. Suicide rates have skyrocketed over the past 30 years,” says Kristen Mizzi Angelone, who directs Pew’s suicide risk reduction project. Research also shows that nearly half of people who die by suicide interact with the health care system in some way in the month before their death. “This gives us a prime opportunity to intervene,” she says.

Simple screening tools are available to gauge whether any hospital patient may be in danger of self-harm—a practice called universal screening—but they are not used at every hospital across the country. Currently, hospitals are required to screen only patients who are being evaluated or treated for psychiatric or behavioral health conditions.

Research shows that nearly half of people who die by suicide interact with the health care system in some way in the month before their death.

That’s why Pew partnered with the Education Development Center’s Zero Suicide Institute (ZSI) on a new initiative, the Suicide Care Collaborative Improvement and Innovation Network (CoIIN). This network will link a diverse group of hospitals and health centers around the country in metropolitan and rural areas.

Over the next year, the nine health care systems will adopt more comprehensive practices of screening and assessing patients for suicidal thoughts and implement interventions for those experiencing suicide risk—all based on a model that’s designed to help health workers make rapid improvements in the way they care for patients. As part of the program, they will share with one another what protocols and tools are most effective at reducing suicide risk and connecting people to treatment.

Unfortunately, not all health care providers are trained in suicide prevention. Depending on state law, such training may not be a requirement for medical licenses of health care workers in many departments—pediatrics or emergency, for example.  Evidence-based suicide screening tools that have shown to effectively identify suicide risk exist, but health care providers need instruction on how to use them.

“The questions have to be asked the right way, and the workers must know why they’re asking,” says Julie Goldstein Grumet, ZSI’s director. “For example, if a nurse says, ‘I have to ask this question: You don’t think about hurting yourself, do you?’ a patient may not be inclined to share dark thoughts. It’s a tremendous burden to provide care for something you received no training in, don't really understand, and don't feel prepared to handle.”

The health care systems that Pew has convened have a few examples to follow. Parkland Health & Hospital System in Dallas, one of the nation’s biggest health care systems, began universal screening in 2015. The system was the first in the country to do so, and providers had some trepidation, worried that patients would react negatively.

Despite those initial concerns, Kimberly Roaten, a clinical psychologist who leads Parkland’s universal suicide screening program, says data indicates that screening does not lead to an increase in suicidal thoughts or plans.

Nurses typically complete screenings during triage in the emergency department or during check-in, asking questions such as “In the past few weeks, have you wished you were dead?” and “In the past week, have you been having thoughts about killing yourself?” Roaten says that once providers at Parkland became familiar with the questionnaire and learned they could use it to identify patients experiencing suicide risk and connect them to care, support among the staff grew.

Parkland has identified suicide risk in approximately 2.3% of pediatric and adult patients seeking nonpsychiatric care, a group that would have previously gone unrecognized. The staff was able to discharge most of the patients who screened positive after providing additional assessment and connecting them with outpatient help. 

"If you use universal screening, regardless of why the patient is there, you will increase detection for suicide risk."

At Hennepin Medical Center in Minneapolis, Dr. Laura Schrag, an emergency room physician, had similar doubts about requiring staff in the ER to screen every patient who came in. “It seemed like it might be off-putting,” she says. “A person comes in and says, ‘I cut my finger and you asked if I hurt myself’?”

When the medical center decided that it would also provide universal screening, Schrag was concerned about the extra workload on an already overtaxed department. “It just seemed like one more thing to do. We weren’t in our lane,” she says. “But it is in our lane. It’s everyone in medicine’s lane, whether in primary care, ER, or psychiatry.”

Schrag quickly realized that patients did not mind being asked questions about self-harm, along with questions about other standard topics, such as potential COVID exposure, smoking habits, and alcohol and drug consumption.

The staff at Hennepin asks the suicide screening questions in a structured way, starting with a question such as “Do you ever feel like you need to talk with someone?” and then progressing to others, such as “Have you ever thought of hurting yourself?” This approach opens the door for someone who is struggling to say so and helps the providers make connections for those who need them, Schrag says. “Like the warning signs of chest pain before a heart attack, you miss warning signs of suicide if you don’t ask.”

Schrag now views suicide screening as part of a day’s work, and the standard protocol is not seen by the staff as “extra.” Schrag says that it’s much easier for health care providers—and better for patients—to ask questions about mental health, detect suicide risk, and connect patients to care before a person attempts self-harm.

“One of the realizations for me is that working in a Level 1 trauma center and using the screening is that it’s not the sexy, grandiose part of medicine,” Schrag says.
“But we’re here for the patients. It’s our jobs and privilege to ask the questions and let patients tell us what they’re struggling with.”

Schrag now counts herself as a big supporter of suicide screenings. “I definitely was a naysayer and I’m 100% flipped,” she says.

Edwin Boudreaux, who is vice chair of emergency medicine at the University of Massachusetts Chan Medical School, has led suicide intervention work with hospitals across the country. “If you use universal screening, regardless of why the patient is there, you will increase detection for suicide risk,” he says. But perhaps as important as asking the questions is the approach that a health care provider takes with the patient—something that hospitals participating in the pilot program will also be monitoring.

“Even if it’s a 30-second conversation…‘You have a lot going on, would you like to talk to someone?’ Give them a list of books, websites, consumer-oriented products,” says Boudreaux. “If you turn the encounter into a one-minute compassionate reaction, the person feels heard, connected, and more satisfied.”

Erin Goodman (left), a survivor of suicide attempts, meets with a woman in a Rhode Island park. Goodman is now a certified peer recovery specialist, a professional who is trained to listen and offer comfort to those at their lowest points—most often in emergency rooms but also wherever clients want to meet.
Tira Khan for The Pew Charitable Trusts

For some, this sort of compassionate approach is life-changing—and can be lifesaving.

Ten years ago, Erin Goodman, a wife and mother of two, had been in various forms of psychiatric care and counseling but nothing seemed to work. She had gone for a month without sleeping, was experiencing psychosis, and was losing hope.

“My brain wasn’t functioning, and I couldn’t coherently explain what was wrong,” she says. During a visit to her psychiatrist to discuss her medications, the doctor asked her how she was, and she began to cry. “I’m not OK,” she told him. But he put up his hand to signal her to stop talking. “No. That’s for your therapist,” he said.

Six weeks later, she survived a suicide attempt.

Passersby saved her. She was rushed to the emergency department of the local hospital in the small Rhode Island town where she was living. After her discharge, she was still suicidal and eventually entered another hospital. There, she met a new psychiatrist. Instead of sitting across a desk from her, he sat next to her and had a conversation.

“He listened to me, talking to me as if he needed my input. He brought in my parents and sister and formed this amazing support system around me.” When she was discharged from the hospital into an outpatient program, he went with her to introduce her to her future provider. “From that point on, I’ve had compassionate care.”

Goodman is now a certified peer recovery specialist, someone who is trained to respond to behavioral health crises. When her local hospital identifies someone in crisis, she will meet the person anywhere—in the emergency department, on a rolling bed in the hallway, or on the phone.

“As painful as it is to be there, I want to provide some little sliver of hope, tell them of the big changes that can happen in your life,” she says. “It’s a pretty quick connection when I tell them my own experience. Then I’m quiet and I listen.”

“May I be an instrument of peace” is written on Goodman’s forearm. “I have no judgment,” she tells her clients. “I’m here to help you navigate and find the care you need and want.”
Tira Khan for The Pew Charitable Trusts

Hospitals and health care systems, in combination with empathetic providers who listen to patients and follow up with further treatments or referrals, can play a pivotal role in identifying people at risk and connecting them to the care they need, says Pew’s Mizzi Angelone.

Throughout the CoIIN project, the hospitals will make adjustments and measure progress as they go. Each month, initiative organizers from Pew and ZSI will meet with hospital providers, record patient outcomes, and publish the results. Mizzi Angelone expects that by next summer, the hospitals will be able to scale up how they are caring for patients at risk of suicide—and pass their knowledge about how to implement the screening to other health care organizations.

“It’s a continual quality improvement project,” says Mizzi Angelone, “and we’ll have good information at the end of it.”

Carol Kaufmann is a Trust staff writer.

Lead photo: Greg Whitesell walks his dog, Thor, as the sun sets in Pattee Canyon, Montana. In high school, he wanted to end his life, but after receiving proper care, Whitesell now looks forward. Tailyr Irvine for The Pew Charitable Trusts

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