A system of care is a coordinated and integrated delivery system that provides mental health services across multiple sectors and levels of care. The goal of a system of care is to provide comprehensive, accessible, and coordinated care to individuals and families affected by mental health conditions, including suicide. Systems of care must be evidence-based, using best practices developed by suicide prevention specialists and researchers.
Evidence-informed care is the use of research and data to inform the development and implementation of mental health policies and programs. This includes the use of evidence-based practices, which are interventions and strategies that have been proven to be effective through rigorous research.
The National Suicide Prevention Programs (NSPP), initiated in the 1990s, encourages a holistic approach to combating suicide by improving public education and community engagement. The programs are designed to identify vulnerable groups, reduce stigma, improve the assessment and care of people with suicidal behavior, and improve surveillance and research (Lewitzka et al., 2019).
Best practice involves identification and assessment of an individual’s suicide risk followed by access to appropriate mental health services and treatments, such as crisis intervention, counseling, and medication management. Follow-up, continuity of care, and ongoing monitoring are crucial.
A number of evidence-based best practices have been shown to be successful in reducing suicidal ideation and behaviors. This includes resilience training, stress reduction, psychosocial interventions, and education. Addressing depression and PTSD, encouraging health-promoting behaviors, and the development of programs and crisis lines have also had a positive impact.
Resilience refers to an individual's ability to deal with challenging circumstances. It can mitigate the negative impact of distressing events and reduce the rate of posttraumatic stress disorders and burnout (Doo and Choi, 2022). Low resilience, defined as the inability to cope with daily stressors and overcome challenges, is a critical determinant of burnout (Nestor et al., 2023).
Healthcare providers who are resilient and experience traumatic events do not experience as many negative psychological symptoms as do people with less resilience. However, there is a belief or expectation—in some cases true, in others not—that nurses, as well as other healthcare personnel have a higher level of resilience than the general population. Nurses can erroneously feel that if they do not deal well with traumatic events, they lack resilience, and it is their fault (Doo and Choi, 2022).
Organizational support is a critical factor in improving resilience among nurses and other healthcare providers. However, during public health emergencies such as the COVID pandemic, many healthcare workers experienced an “unsafe environment and fear of abandonment” within their organizations, which has been related to psychological stress and depression (Doo and Choi, 2022).
Strategies to reduce the impact of stressors and increase support for nurses and other healthcare providers are needed at the organizational level. A systems level approach to hardwire coping strategies is important throughout nurses' careers. A new focus on how to process personal and professional grief is needed. Resources are needed for nurses and other healthcare providers traumatized by life (rape, childhood trauma) as well as work-related experiences (James et al., 2023).
The COVID-19 pandemic magnified the ongoing issue of healthcare provider burnout and has led to a marked increase in stress levels. During the height of the pandemic, healthcare providers were inundated with increasingly ill patients while simultaneously having to manage the fear of contracting the infection themselves. They also had to grapple with the risk of carrying the infection to their families—all of which contributes to their increased burden of stress (Nestor et al., 2023).
Hospitals, medical centers, and other institutions have struggled to cope with the toll that the COVID-19 pandemic is taking on healthcare providers. Many hospitals are pro-actively supporting provider wellness by offering coaching, behavioral, and wellness programs.
Health-promoting behaviors—including physical activity, spiritual growth, health responsibility, good nutrition, relaxation, reducing tension, and stress management—have been shown to decrease suicidal ideation. Those who engage in physical activity or participate in sports are at lower risk for suicidal ideation than those who do not. Individuals who feel they have a purpose in life report lower suicidal ideation than those who did not. In terms of social relationships, there is a significant body of literature identifying social support and healthy interpersonal relationships as a protective factor for suicidal ideation (DeBeer et al., 2016).
Did You Know . . .
Studies have shown that Transcendental Meditation is a practice that has been shown to be effective in the healthcare setting for reducing psychological distress and promoting well-being. In a study involving healthcare providers in Florida, 65 participants practiced TM at home for 20 minutes 2 times per day. The practice rapidly and dramatically reduced symptoms of burnout, insomnia, and psychological distress, while also improving overall well-being (Nestor et al., 2023).
Psychological and Psychosocial Interventions
Many types of psychological and psychosocial interventions—such as psychotherapy and peer support—can be beneficial for individuals who are experiencing suicidal ideation or behaviors. These interventions help people learn new ways of dealing with stressful experiences, recognize patterns of thinking, and identify alternative actions when thoughts of suicide arise.
Psychotherapy usually takes place in a one-on-one or group format and can vary in duration from several weeks to ongoing therapy. Treatment promotes collaborative and integrated care, which can engage and motivate patients, increase retention in therapy, and decrease suicide risk (Stone et al., 2017).
Peer support is an intervention that has the potential to address suicide risk. Peers providing emotional support and sharing their experience of recovery increases connectedness and reduces hopelessness among support recipients, two key factors for preventing suicidal ideation. Peer support may also reduce suicide risk by decreasing stigma, increasing orientation to personal growth and recovery, and encouraging active care engagement (Bowersox et al., 2021).
The U.S. National Suicide Prevention Strategy and other guidelines have included recommendations that peer support be integrated into the care of individuals at high risk for suicide. Mutual peer support groups have a long tradition of providing support to individuals in recovery from mental health crises, and historically, these groups grew out of a desire for alternatives to psychiatric hospitalization (Bowersox et al., 2021).
Don’t Clock Out
Don’t Clock Out is an organization founded in 2022 that advocates for nurses living with mental illness and PTSD. It provides a digital crisis intervention platform to members of the nursing community who are considering suicide. It was founded following the suicide of Michael Odell, who left his shift and jumped to his death from a San Francisco Bay Area bridge. For more information about their Self Care Unit Podcast and Weekly Support Group, please click here.
Suicide prevention education programs aim to improve knowledge of suicide, specifically in relation to risk factors, protective factors, and warning signs. These programs seek to improve the way people respond to and provide support for vulnerable individuals. Multiple systematic reviews have found that education programs can make a positive contribution to suicide prevention, both for gatekeepers working across a range of settings and for specific vulnerable groups (Ferguson et al., 2018).
Education programs can contribute to favorable shifts in knowledge, attitudes, skills, and confidence, particularly in the short term. There is strong evidence to support the training of general practitioners to recognize and treat depression and anxiety as a suicide prevention strategy.
Less is known about the value of suicide-specific education programs for other health professionals, particularly the nursing profession (Ferguson et al., 2018). Suicide prevention work needs to be given greater focus both in education as well as in ongoing clinical work. Nurses need the right skills to meet suicidal patients, as it has been shown to reduce stigma in patients and make nurses pay more attention to and prioritize suicide prevention work to a greater extent (Wärdig et al., 2022).
Especially for Nurses
Suicide prevention programs need to address both institutional and individual factors associated with nurse suicide. Transitions into retirement and job loss are vulnerable times warranting psychological support (James et al., 2023).
After a suicide, nurse colleagues must continue to deliver patient care as they grieve. A standard operating procedure for how to handle the suicide of a nurse colleague does not exist, compared with what is available for physicians (Davidson, Mendis et al., 2018a).
Without a predefined process, each unit manager is left to independently develop a grief recovery plan to support staff in processing their emotions. It is common that, no one, at any level, is comfortable talking about a suicide that has occurred (Davidson, Mendis et al., 2018a).
Healer Education Assessment and Referral
A program initially designed for physicians, residents, and medical students, the Healer Education Assessment and Referral (HEAR) program provides education, assessment, and referral services to individuals who may be at risk for suicide.
The education component of the HEAR program provides information and resources to individuals and their families, including warning signs of suicide, how to identify individuals at risk, and how to access appropriate resources for help.
The assessment component involves a thorough evaluation of the at-risk individual's mental and emotional state, as well as identification of risk factors for suicide. This can include a review of an individual’s medical and mental health history, a psychological assessment, and a review of social and family support systems.
The referral component of the HEAR program involves connecting individuals and their families with appropriate resources for help, such as mental health professionals, support groups, and crisis hotlines. Healers may also provide ongoing support and follow-up care to ensure that individuals are receiving the help they need to stay safe and healthy.
The HEAR program has been piloted for nurses with promising results. The initial pilot program, conducted in 2016, yielded some surprising results. Participating nurses reported more stress and distress than previous results from physicians. Nurses reported higher rates of intense affective states than physicians (e.g., feelings of intense loneliness, hopelessness, desperation, and loss of control (Accardi et al., 2020).
Community engagement encourages involvement in a range of social activities. The goal is to improve physical health, reduce stress, and decrease depressive symptoms. Involving community members from the beginning and respecting them as experts on their own experience is critically important. Becoming familiar with the community’s history, risk and protective factors, cultural norms around language and communication, and beliefs about death are important for program organizers.
Besides educating the community about suicide warning signs and reducing stigma, community organizers and healthcare providers can work to increase:
- Knowledge of interventions (e.g., alerting emergency services)
- The intention to intervene
- Confidence to intervene
Worsteling and Keating, 2022
Additional community-based interventions such as gatekeeper training, media campaigns, and support groups can reduce the risk of suicide. Collaboration, working with community partners, schools, hospitals, and law enforcement creates a coordinated response to suicide prevention. Data collection and monitoring of suicide rates and trends help organizations develop and implement suicide prevention strategies.
The American Foundation for Suicide Prevention offers an array of community programs for suicide education and prevention. The Kentucky Chapter, founded in 2010, serves all of Kentucky and Southern Indiana (Floyd & Clark Counties). For more information about community programs available in Kentucky, please click here.
Pharmacologic treatment can be helpful in managing underlying mental disorders and address the danger of repeated or dangerous self-directed violence. If the individual is under the influence of alcohol, illicit substances, or other medications, the amount and type of medication must be carefully chosen and titrated.
All medications used by patients at risk for suicide should be reviewed. When prescribing drugs to people who are at risk for self-harm, consider the toxicity of prescribed drugs, limit the quantity dispensed or available, and identify another person who is willing to be responsible for securing access to medications (DVA/DOD, 2019).
Treatment of depression, bipolar disorder, and borderline personality disorder is essential. This can include selective serotonin uptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, lithium, or antipsychotics (Harmer et al., 2022). Individuals who have psychiatric and substance use problems should receive psychosocial interventions along with medication.
Only two evidence-based medications have been shown to lower suicidal behaviors: lithium and clozapine. However, these medications do not reach therapeutic levels immediately. Anxiolytics, sedative/hypnotics, and short-acting antipsychotic medications may be used to directly address agitation, irritability, psychic anxiety, insomnia, and acute psychosis, until such time as a behavioral health assessment can be made.