Recommended Standard Care for People With Suicide Risk

A recent survey by The Pew Charitable Trusts of accredited hospitals found that only 4% met the full criteria for implementing The Joint Commission’s recommended suicide prevention goals. One may wonder whether The Joint Commission’s suicide prevention recommendations were perhaps too expensive or burdensome for these hospitals to use? However, the exact opposite is true. Their recommendations are basic common sense suicide risk prevention approaches with supportive evidence, and are similar to recommendations issued by the National Action Alliance for Suicide Prevention (NAASP).

In 2018, the NAASP launched the “Standard Care Work Group” to develop and promote sensible recommendations for providers across outpatient, inpatient, emergency department, and primary care settings to use for effectively working with patients who are suicidal. The mission of this Work Group was to identify common sense interventions that have sufficient empirical support, would be relatively inexpensive, easy to implement, and would not require a great deal of training. The Work Group was made up of suicide prevention experts in policy (private and public sector), health care administration, and mental health care (and I was fortunate to serve as a member). The resulting document of our work was entitled, “Recommended Standard Care for People with Suicide Risk: MAKING HEALTH CARE SUICIDE SAFE” (NAASP, 2018).

Among the recommendations we promoted were: 1) routine and reliable identification and assessment of suicidal risk as a critical first step; 2) safety planning, which has become a crucial intervention for acute risk with considerable empirical support (Nuij et al., 2021); 3) identifying and reducing access to lethal means for suicide (e.g., securing a firearm or a stash of pills); and 4) brief caring communications made after clinical contact in the form of a letter, phone call, text, or postcards which are referred to as “caring contacts” and are known to decrease suicidal behaviors as shown in randomized controlled trials around the world (Luxton et al., 2012). We also proffered ideas such as routinely providing key crisis resource information (e.g., the 988 Suicide & Crisis Hotline), as well as noting the merit of “warm handoffs” to decrease suicide risk during care transitions (e.g., ensuring that inpatients make contact with outpatient providers to pursue further care post-discharge).

Given the public-private nature of the NAASP it was not altogether unexpected for our document to be embargoed for almost a year, while various reviewers critiqued the document. Neverthless, what was unexpected were the number of defenders of the “status quo,” arguing that these common sense recommendations were too extreme and could not readily used in “real world” clinical practice. Finally, after extensive vetting, the document was released online:

https://theactionalliance.org/sites/default/files/action_alliance_recom…

To be frank, the interest in our recommendations has been underwhelming. That said, it can take time—years even—for valuable practices to become a routine clinical reality. Case in point, The Joint Commission’s suicide prevention recommendations have been evolving for three decades, and we are finally seeing some progress as most healthcare settings now routinely query patients about suicide risk.

As noted at the outset, The Joint Commission engaged The Pew Charitable Trusts to conduct a survey of accredited hospitals (Chitavi et al., 2024). The survey investigated the use of “National Patient Safety Goals for Suicide Prevention” promulgated by The Joint Commission of key suicide-focused interventions (including recommendations made by the NAASP Work Group). A total of 1,148 hospitals were surveyed and 346 responded. The survey asked about the use of safety plans, warm-handoffs, lethal means safety, and caring contacts. Results showed that 61% reported using safety plans (but not necessarily with adherence), 37% reported making warm handoffs, 28% engaged in lethal means safety, and 30% reported making caring contacts. As noted early on, only 4% of hospitals surveyed met full criteria for implementing recommended suicide prevention interventions. And mind you, these are the facilities that actually responded to the survey! If data from the 70% who did not feel compelled to respond to the survey had been included, the survey findings would undoubtedly have been even more abysmal.

Clinical suicidologists are both bewildered and exasperated by such data. It feels akin to the Hans Christian Andersen short story of “The Emperor’s New Clothes” in which a vain Emperor is tricked by con men who adorn him with a magnificent (albeit invisible) new outfit. The people of his town collectively pretend to admire the Emperor's new apparel lest they be seen as stupid. The entire ruse is undone when a child blurts out that the Emperor is wearing no clothes at all! It often feels to me like the mental health care community collectively insists that practices such brief inpatient admissions or a medication-only approach to suicidal risk are more effective than they actually are. Indeed, empirical support for these routine clinical approaches is either limited, mixed, or non-existent. In sharp contrast, suicide-focused psychological interventions are largely not used despite their proven effectiveness based on extensive and replicated randomized controlled trials (Goldstein Grumet & Jobes, 2024; Jobes & Barnett, 2024).

Bottom line, if we ever aspire to decrease the suffering of 16,600,000 American adults and teens who struggle with “serious thoughts of suicide” (SAMHSA, 2023), we simply must embrace and actually use common sense clinical recommendations that are supported by empirical evidence to help save more lives from the scourge of suicide.