I have pointed out
several times on this blog that a number of non-medical forces in the state of Minnesota have been successful in making a mediocre mental health system into one that is on the brink of becoming a travesty. My curiosity was naturally piqued when I heard that we now had a suicide prevention plan released just in time for Suicide Prevention Week and Suicide Prevention Awareness month. How is suicide prevention and awareness possible in a seriously deteriorating nonsystem of care? Who are the people writing this report and what does it say? As a person actively involved in suicide prevention every day of my career - I decided to read it and give my impressions here. The full text is available to anyone off the Minnesota Department of Health
web site.
Scanning the document, it is very readable. The main body is about 23 pages long with relatively large font and much if it is organized more like an outline rather than a document. For reasons I will outline below - it could have been a lot briefer. Task Force member are listed and it appears that none of them are psychiatrists. Of the 19 listed Task Force members - one of them is a physician. The stated goal of the work is:
"To reduce suicide in Minnesota by 10% in five years, 20% in ten years, ultimately working towards zero ....." (page 7)
That is certainly a laudable goal. There are recent reviews and ongoing debates about whether suicide can be eliminated and a recent consensus statement says no (1). Buried on page 19 is the statement "Encourage health care systems to implement the
Zero Suicide Model. There is a
link provided to SAMHSA on this model and it is the product of non-experts. Because of its promotion of managed care I do not consider SAMHSA to be a reliable source of information or expertise. A review of what is available the
Zero Suicide Model (4) illustrates that it is basically a management heavy model of what used to be considered standard psychiatric care before psychiatric care was disrupted by business interests with the usual EHR kowtowing.
As far as reduced rates or total suicides in the state a useful question is whether or not the trends in suicide rates or total number of suicides is a real trend in Minnesota or it reflects expected variation. The second important question is whether it is a population wide phenomenon or it reflects subpopulations that are impacting on the statewide rates. The authors attempt to answer these questions by showing an increase in the rates of suicide from 8.9 per 100,000 (n=440) in 2000 to 12.2 per 100,000 (n=683) in 2013 - the last year of complete data for the report. The ratio of men:women who died by suicide was 4:1. The rate across the US was 12.6 - the Minnesota rate is slightly less than the national rate. Among subgroups of the population the American Indian group had the highest rate at 17.2 per 100,000 (n=70) followed by White at 12 per 100,000 (n=2,941). Black or African Americans had the lowest rate at 6.9 per 100,000 (n=104). American Indian Youth (10-24) had the highest rate at 28.0 per 100,000 (n=30).
A standard method to determine if death trends related to risk factors or illness are significant is
joinpoint regression analysis developed by the National Cancer Institute to analyze trends in cancer deaths. Since then it has been used by both the CDC and researchers (3) looking at trends in suicide rates. I did not see the application of this kind of analysis to the rates over the 14 year period of time discussed in the article. That does not mean it was not done, just not apparent. At the minimum an analysis of longer term trends should be accomplished along with comparisons to other macro indicators like economic variables would be interesting as a basis for preventive recommendations.
The authors leap into their model called a
social ecological model of suicide that was adapted from the World Health Organization. A graphic is included in the statement. The model appears to be
generally applied - it has been widely adopted by the WHO and the CDC as a way to address suicide and violence but also
colon cancer and a host of other medical problems. It seems to be a modern equivalent of the old
nature versus nurture or
schizophrenigenic mother argument. Cataloguing all of the perceived deficiencies in the environment is not the same thing as discovering the mechanism or cause of a specific problem in a specific person. Obvious examples abound. The vast majority of people who have had significant childhood adversity in the environment do not attempt or commit suicide. That is a relevant question because a better approach may be studying those people and trying to figure out how they survived and either adapt to chronic levels of insomnia, anxiety, and depression or resolve it. A
consciousness based model may be the best approach. The authors here seem to say that all of these social and economical factors need to be addressed and that is the approach that they are going to use to reduce the suicide rate. Even using that approach they overstep the limits of the model and end up using a familiar political approach.
The political approach that I am referring to is to assume that somehow they know more about suicide than the professional trained to address it. I speak only for psychiatrists, but this is a serious overstepping of authority. I was board certified in Psychiatry in 1988 and it was well known at the time that if a candidate did not demonstrate that they could interview a person and assess their potential for suicide and aggression that they would fail the oral examination. Psychiatrists have been focused on timely assessments of suicide and aggression for decades and it is incorporated into treatment guidelines at every level. Those assessments are done very day by practically every psychiatrist working that day. And yet the Minnesota Plan has the following guidance:
4. Train professionals and community/cultural leaders to increase awareness of suicide and prevention efforts and mental health and wellbeing. (p.15)
3. Train professionals and community/spiritual/cultural leaders to better understand how to talk to and encourage those at risk to access help. (p. 16)
Objective 2.2 Expect providers who interact with individuals at risk for suicide to routinely assess for access to lethal means. (p. 17)
The authors here can make these statements because they are as non-specific as possible. Psychiatrists are not mentioned at all in the document. Neither are other mental health professionals. Speaking only for psychiatrists again, we are practicing psychiatry with people who have the most severe forms of mental illness because we can assess and treat suicide and aggressive behavior. We are certainly not looking to any state agency for training or accountability. We are accountable to the people we treat and professional standards. Furthermore we are acutely aware of the deficiencies in care in this state and input from psychiatrists would probably have been useful. The tactic of pretending to tell professionals how to do their job and generally behave has been used by the managed care industry for years. It is disappointing but not unexpected to see in in a document from a state who has been so friendly to that industry.
I can say without a doubt that most Minnesotans seeking acute care for a family member with suicidal thinking or suicidal behavior will be disappointed. The severe rationing of psychiatric services has resulted in a lack of resources that would be comparable to any other medical emergency. Families are frequently directed to hospital emergency departments where mental disorders are viewed creating congestion and inconvenience. The social workers making the assessments there know that placement options are extremely limited. The legislative response to their own rationing of psychiatric services has been to mandate that the patient be transferred to the nearest bed and that can be hundreds of miles away. Once hospitalized most people realize the the inpatient units that were supposed to help them are grim and unsanitary places where they main goal is to convince the psychiatrist that they are no longer suicidal so that they can be discharged home. The family may find themselves in the uneasy position of monitoring their suicidal family member at home while they are trying to get them adequate treatment. It is the logical progression of events to a government and insurance industry standard that dangerousness is the only reason a person can be admitted to a psychiatric unit these days. Managed care reviewers call the physicians and nurses in charge looking for that day when the patient doesn't use the word suicidal. At that point according to the insurance industry - the patient must be discharged. They always have the excuse that it is up the the attending psychiatrist - but that has become a modern day joke. The psychiatrist's own administration will insist that the patient be discharged or he/she might need to find another job.
How should it work? Crisis care for suicidal or aggressive people should be based on an informed approach to the problem. Risk factors (and protective factor) analysis is really an insufficient approach. The approach that suicide is an epiphenomenon of other psychiatric disorders is also a limited approach. There are certainly correlates of high suicide rates in most major psychiatric disorders - but how that person came to consider suicide is generally a unique pathway even in the case of most extreme mental illness. First, emergency department triage must go. The only reason it exists is that there is inadequate funding for community mental health centers and their own crisis services. The paradigm for this model is Dane County Mental Health Center in Madison, Wisconsin. This has been one of the epicenters of community psychiatry in the US. They have an active crisis service that runs all day long until 11PM. They a have a walk in crisis center. They are adequately staffed to avoid long waits and they do active crisis psychotherapy. Second, inpatient psychiatry needs serious revision. We can no longer accept the idea that a person in crisis sits on an inpatient unit until they say they are no longer suicidal. Granted there are always social interventions along the way but a lot more needs to happen. The units need to be clean, calm and comfortable places. They need to provide an array of active services to treat both severe problems and address suicidal thinking. They need to keep longitudinal data on the efficacy of their interventions. They need to provide assessments and treatments for alcohol and substance use disorders. There are many people who become suicidal only under the influence of alcohol or street drugs. Most importantly, they need to admit people with severe problems even if they are not saying that they are suicidal at the time. The reasons for that are twofold. The majority of people with significant mental illnesses are not being treated. If they cannot function this is a logical point to provide treatment and reduce the transition to suicide risk. The other reason is that there are many severely ill people who clearly cannot function with their current level of distress. They may have attempted suicide in the past. Their psychiatrist knows they are high risk in the community, but currently there are no hospital or residential settings where these people can be admitted.
Read the document and make your own assessment. The goals of modifying the social fabric in various communities in Minnesota seem unrealistic to me. I think that this group and the parent document is overreaching - not just in the scope of what can be done for apparently very little funding but also the gross inconsistencies in government and business. There are no bigger conflicts of interest these days than a government that seems to want to advertise that they are solving your problems when they are doing just the opposite and businesses that do the same. A functional state department of health should use the usual public health tools with education being at the top. Some more attainable and straightforward goals would be:
1. Public education on suicide - especially the statistics the risk factors, and the fact that suicide is a treatable and resolvable condition.
2. Means reduction - at a public health level these are some of the most successful interventions. As an example, people need to know that just having a firearm in the home is the single most risk factor for suicide. I get a letter every year telling me that I have to report the number of abortions that I performed last year and all of the abortion complications in Minnesota. These same people have access to all of my professional information and know that I have never performed an abortion. I have never investigated the origin of this letter but can only conclude it is a law written by an anti-abortion legislators hoping to shame physicians into not performing legal abortions. Why isn't anyone using a more functional approach and sending conceal-carry permit holders a letter on suicide and gun possession. Why isn't it being taught in public health classes in the schools? Why doesn't everyone know that most deaths by firearms in this country are from suicide?
3. Cultural permissiveness toward substance use - Minnesota has medical cannabis laws and an active group of recreational cannabis promoters. There is a current nation wide movement to view psychedelics and hallucinogens as medications and psychotherapeutic agents. There is very little discussion of the downside. We are also in the midst of a highly lethal opioid epidemic. As an addiction psychiatrist many of the people I talk with get to the point in their addiction that in their search for getting high - they don't care if they live or die. They knew they were taking lethal or near lethal amounts and did not care. In other cases, certain people with alcohol use problems will become suicidal
only if they are intoxicated. These correlates of substance use disorders and the suicidal lethality of substance use is practically unknown to most people. It is not trendy or cool to push back against overwhelming pressure to get high - but that is exactly what needs to happen. Stay sober and you reduce the chances of ever being suicidal.
4.
Don't depend on managed care companies to provide a reasonable system of care - The record is in and it is not a good one. The idea that
managers whoever they might be are going to teach or coerce professionals into providing better care for people with suicidal thinking when they have been working for three decades to do just the opposite seems absurd to me. If the government wanted to do anything, it would be to provide functional oversight of these companies and their ongoing rationing of care. Every state should have a physician review agency for treatments that is outside of the usual same company reviewers and insurance industry insiders placed on state regulatory boards. That board should have the last word in what treatments are necessary. Community mental health centers need to be refunded to provide adequate levels of care and they cannot be un like managed care companies.
These are a few of my thoughts today. I might add another couple of bullet points as they come to mind. This is a serious topic that deserves additional discussion and one I have been
thinking about most of the time with varying levels of intensity for 30 years.
George Dawson, MD, DFAPA
References:
1: Shain B; COMMITTEE ON ADOLESCENCE. Suicide and Suicide Attempts in Adolescents. Pediatrics. 2016 Jul;138(1). pii: e20161420. doi:
10.1542/peds.2016-1420. PubMed PMID:
27354459.
2: 1: Sullivan EM, Annest JL, Simon TR, Luo F, Dahlberg LL; Centers for DiseaseControl and Prevention (CDC). Suicide trends among persons aged 10-24
years--United States, 1994-2012. MMWR Morb Mortal Wkly Rep. 2015 Mar
6;64(8):201-5. PubMed
PMID: 25742379.
3: Puzo Q, Qin P, Mehlum L. Long-term trends of suicide by choice of method in Norway: a joinpoint regression analysis of data from 1969 to 2012. BMC Public
Health. 2016 Mar 11;16:255. doi: 10.1186/s12889-016-2919-y. PubMed
PMID:26968155.
4: Hogan MF, Grumet JG. Suicide Prevention: An Emerging Priority For Health Care.Health Aff (Millwood). 2016 Jun 1;35(6):1084-90. doi: 10.1377/hlthaff.2015.1672.
PubMed
PMID: 27269026.
Disclaimer:
I had no input into the Minnesota Suicide Prevention Plan and I know none of its authors. I accessed it online and read it.
