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In 2014, Axis staff assessed about 500 patients in crisis, and four years later, that number rose to about 890, according to Axis. About 180 of the patients in fiscal year 2018 were younger than 18.
These patients may be exhibiting high-risk behaviors or present a danger to themselves or others, said Molly Rodriguez, Regional Crisis Team and Acute Treatment Unit clinical manager.
Rodriguez cannot say why Axis is seeing such a rise in patients, but a greater awareness of services could be contributing. Axis is a private nonprofit health system that provides crisis care and physical and behavioral health care across the region.
“My hope is that it’s becoming less of a stigmatized issue,” she said.
When a patient in crisis walks into Axis’ Crossroads facility in Grandview, within 15 minutes, a crisis therapist will start to assess them or provide an intervention, she said. Suicidal patients who call 911 are taken to an emergency room where Axis staff will meet them, and in some cases, an Axis mobile crisis team will meet patients in their homes, Rodriguez said.
Mercy Regional Medical Center’s emergency room has seen a similar rise in patients in crisis. Often, patients in a suicidal crisis must be physically evaluated at the hospital before they can be released to Axis for care, said Paul Gibson, Mercy’s director of emergency services.
About a quarter of the patients who come to the ER in crisis are adolescents, he said.
To better serve patients, both health care providers are adopting a national model called the Zero Suicide Initiative, promoted by the Suicide Prevention Resource Center to reduce suicides in health care settings. Zero Suicide provides guidance about how to improve care by including suicide survivors in planning, training employees in effective therapeutic methods and using data to inform changes in health care.
The Zero Suicide Initiative is based, in part, on the success seen at Henry Ford Health System in Detroit, an urban system with 30,000 employees. The system has inpatient units for children and adolescents, and all of its psychiatry clinics employ pediatric psychiatrists and clinicians.
About 18 years ago, the staff set out to reduce the number of patient suicides to zero despite some daunting statistics.
About 15 percent of people with a major depressive disorder will die by suicide, and about 20 percent of those with bipolar disorder will take their own lives, said Dr. Cathrine Frank, chairwoman of psychiatry and behavioral health services at Henry Ford.
When it came to setting a goal to improve care, zero suicide was the only one that made sense, she said.
“If you have less than a goal of zero, I mean, is that my friend? Is it your relative? How is any goal other than zero acceptable?” she said.
In 1999 and 2000, the average suicide rate for patients treated by behavioral health services at Henry Ford was 100 per 100,000. It was less than 30 per 100,000 from 2002 to 2010, according to data provided by Henry Ford. In 2008, Henry Ford’s behavioral health services achieved its goal of zero suicides.
Other hospitals that have adopted the Zero Suicide model drastically dropped their suicide rates as well, said Julie Goldstein, director of the Zero Suicide Institute. The institute estimates about 400 to 500 health care organizations have adopted the model nationally, although it is difficult to track, she said.
The health care organizations that adopt the initiative generally adapt it to fit their population, and it generally takes about two years to see suicide rates decline, she said.
To achieve the ambitious goal, Henry Ford behavioral health staff, which includes pediatric psychiatrists, started assessing every patient’s risk for suicide and assumed all of their patients were at some risk of suicide, Frank said.
“I think still internationally and across the United States, most people rely on asking a patient if they are suicidal, and if they say, ‘No,’ you say, ‘Boy, that’s good,’ and you go on,” Frank said.
The Henry Ford staff determines a patient’s risk factors for suicide and then works with the patient to address those factors.
Risk factors can include depression, hopelessness, self-harm, substance abuse, a history of suicide in a person’s family and relationship problems, among other issues. They started asking about additional risk factors, such as traumatic brain injury and identifying as a transgender person, as the research around them developed.
A patient’s level of risk determines how quickly they should begin psychotherapy or how quickly they should see a psychiatrist for medication, Frank said.
Staff members work with patients to reduce the risk of suicide by removing weapons from their home, educating patients’ families about the warning signs of suicide and providing self-management tools, such as books, websites and apps, she said.
Some warning signs of suicide include talking about wanting to die, extreme mood swings and withdrawal, according the Suicide Prevention Resource Center.
The health system also established a consumer advisory panel to guide its work, started drop-in support groups, set up secure email for patients to communicate with their providers and included patients’ suicide risk into their electronic health records, among other steps, according to an article in the Joint Commission Journal on Quality and Patient Safety.
Henry Ford also trains all of its clinicians in dialectical behavioral therapy because it is a proven method to address a patient’s suicide risk, Frank said.
Axis staff also use dialectical behavioral therapy because it helps individuals develop skills to manage emotions, improve relationships and develop better approaches to solving difficult problems in life, said Stephanie Allred, Axis’ senior clinical director.
“Considering suicide is an attempt to solve problems that seem unsolvable,” she said.
The changes Axis is making through the Zero Suicide Initiative apply to its entire patient population, Allred said.
Since adopting the initiative last year, Axis has stopped treating thoughts of suicide as a symptom of other mental health conditions and started to identify and address suicide risk factors first, she said.
“Whatever is driving that urge to consider suicide is what we’re really targeting pretty intensely,” she said.
The suicide risk factors for youths can differ from those for adults and can include problems with peers, for example, she said.
Axis also changed how its staff assesses suicide risk. Staff members now monitor a patient’s risk of suicide at every therapy session and track suicide-risk screenings into electronic health records, Allred said.
To ensure that patients are receiving an appropriate level of care, the health system also runs a risk report weekly to see which patients have a moderate to high risk for suicide.
Clinicians at Axis work with patients on safety plans that identify a patient’s risk factors and specific steps to take, such as locking up firearms and disposing excess medications, as well as specific coping mechanisms and people to call.
If a patient calls the Axis crisis line in the middle of the night, the crisis therapist will review the steps of this plan with the patient, Allred said.
Axis is also training non-clinical staff, such case managers, billing staff and people who work at the front desk, to look for suicide warning signs, she said.
“For example, if a patient calls to cancel an appointment and perhaps makes a reference that they won’t be needing any more appointments, the staff member would inform a clinician who would follow up with the patient,” she said.
The health system’s staff successfully provides crisis intervention for hundreds of people each year, she said.
“We are able to intervene, connect them with supports to help them build that sense of connection or solve the problems that seemed insurmountable to them at the time. That is inspiring for us,” Allred said.
In 2016 and 2017, Axis completed 1,327 crisis assessments across its five-county region, and about 50 percent of those in crisis received follow-up care from Axis within one or two days, according to data provided by Axis. The Acute Treatment Unit at Axis cared for 17 percent of these patients. The unit cares for patients for an average of five days and stabilizes them.
Axis transferred 8 percent of patients in crisis out of the area for care, and the final 25 percent received outpatient care, had their needs met by the crisis intervention or could not be reached, according to data provided by Axis.
The health system follows up with 95 percent of its patients in crisis either by phone or in person, said Brian Ensign with the Acute Treatment Unit at Axis.
A Zero Suicide initiative is just getting started at Mercy as Centura Health, the hospital’s parent company, introduces changes at all of its locations, said Doug Muir, director of the Behavioral Health Service Line.
Mental health care is one of the major needs that Centura has identified in all the cities that it serves, he said. The system operates 15 hospitals in Colorado.
As part of the initiative, Centura is introducing depression screenings at all of its primary care clinics, he said. The pediatric clinics will screen patients 12 and older.
The health system also plans to work with the state Office of Suicide Prevention on its efforts, he said.
mshinn@durangoherald.com
