Mikelle Moore: Hi, I'm Mikelle Moore, senior vice president for Community Health at Intermountain. I have the pleasure of having with me today Dr. Mike Woodruff and Dr. Mark Foote, to talk about our new Zero Suicide initiative at Intermountain Healthcare. I'd love for them to introduce themselves to you. Mike?

Mike Woodruff, MD: Hi, I'm Mike Woodruff, I'm an emergency physician and I'm a senior medical director in the Office of Patient Experience here at Intermountain.

Mikelle Moore: Thank you.

Mark Foote, MD: I'm Mark Foote and I'm a practicing psychiatrist. I've been here 25 years practicing at LDS Hospital, and I'm also the medical director for the Behavioral Health Clinical Program.

Mikelle Moore: Thank you for joining me today. The reason we find ourselves as colleagues on this topic is because suicide has become such a prominent public health concern in Utah, in particular, but also in the country overall. That’s why it's been a focus as one of our community health priorities. I think it would be helpful to start with what is the nature of the problem? What do we know? What are the facts about suicide in Utah, Dr. Foote?

Mark Foote, MD: Well suicide has been around through human kind. The rates have gone up and down over time; it goes back to the ancient Greeks; it goes into the middle ages; it goes into our generation. But since about the year 2000 the rates have steadily gone up, to really an alarming point right now. As a practicing psychiatrist I see this on the frontlines and as I read through statistics in articles I see that it's going up.

Last year for instance, we lost almost 650 people in the state of Utah and almost 45,000 in the United States. It’s more than a behavioral health problem, it's a public health crisis.

Mikelle Moore: Who's dying here in Utah? We hear a lot about adolescent suicide rates. Are more children dying than other age groups?

Mark Foote, MD: Well really the main age group has been the elderly for years and years. We were always taught in medical school that it’s the old white men who died by suicide. But over the last 15 years or so we're seeing big increases in middle aged, especially middle-aged women, whose rates have almost caught up with the geriatric group. And although their rates are still the smallest, the adolescent group has increased the fastest.

And to see kids die is just so tragic. I mean it's tragic to see anybody die, but obviously when you have that loss of life in their teenage years, it is tragic.

Mikelle Moore: It really is, and I would imagine Dr. Woodruff, that you're seeing this from the perspective of an emergency medicine physician. What are the challenges you and your colleagues face?

Mike Woodruff, MD: There are a number of challenges. When a patient comes in in crisis, sometimes that's easier than when a patient comes in and doesn't tell us they're in crisis. We need to get to level of attention in time where we can say, "How are you feeling and what's going to happen with you in the next few days? Do you have the right safety net when you're at home?"

Also, reaching out to establish follow-up for these patients and applying the appropriate screening tools, which can be a challenge. From a patient safety standpoint, we often ask ourselves, “When we look at a suicide that's occurred and think about what we could have done differently to prevent this?” We’re often left scratching our heads and not knowing the answer.

I think the way forward is that we take a new approach by asking, “What can we learn from these events? How can we apply that to how we care for all our patients that contact us anywhere in the health system?”

Mikelle Moore: What are we learning about where screening should occur?

Mike Woodruff, MD: We’re learning that there are populations and groups of people at higher risk. Our task is to learn how to identify those populations. For example, patients with neurological diagnoses. Some data suggests that they're more at risk for suicide. We need to apply the right amount of resources to provide a safety net for those patients and provide the screening tools.

We're not going to screen every single patient, obviously, but also having in mind — for every caregiver and for everyone who touches the patient — just be on the lookout for the signs and symptoms of either depression or suicidal thoughts. Be open to listening to that and being able to refer the right resources, like the suicide hotlines, and providing that personal touch to get someone to the next resource.

We have a number of great stories about how our caregivers have intervened in a meaningful way with patients who weren't necessarily there for behavioral health concerns.

Mikelle Moore: I think that's really true and it seems that that's an appropriate link to the concept of Zero Harm, that you and your office lead. Tell us a little bit more about why we believe Zero Harm is the right approach and its applicability to suicide prevention?

Mike Woodruff, MD: That's a great question. Zero Harm is fundamentally about creating a culture of learning and accountability around safety and medical error and protecting our patients from harm. Through that process, it’s learning about the harms that have occurred, then thinking proactively about how our systems could fail, and then really improving them in a continuous or ongoing basis.

When we apply those techniques to suicide, at first it might seem like a daunting problem: How could we ever prevent suicide? Health systems have done this, notably the Henry Ford System. They’ve applied a set of techniques and learning principles to create a culture where everybody's on the lookout and everybody's learning about how to prevent suicide. They've achieved some fairly dramatic results in reduction in suicide for their patients.

For Intermountain, we’re on this same journey of learning and accountability around safety and creating a culture of safety. So, it’s a very natural piece to add suicide prevention to that harm prevention culture that we have.

Mikelle Moore: Dr. Foote, one thing as I've been learning about this topic is a lot of people feel uncomfortable talking about suicide and preventing suicide. What thoughts could you share? As a psychiatrist you've been trained to especially talk with people about this. As we think about working with all our caregivers to be more aware of the risks and talk more about it, do we all need to become psychiatrists? Can you share some tips that can help us all in our community?

Mark Foote, MD: I don't think we all need to become psychiatrists nor do we want to be. The first step really is awareness, just being aware that there is a problem. As a society we can solve problems. We are actually really good at solving problems when we get engaged and put our resources and put our minds behind it.

I think this is an example. Suicide is a challenge, it's a very, very uncomfortable topic for people to talk about. If someone has experienced it with a friend or a family member, they know the pain that's involved, and frankly they don't really want to relive that pain. Being aware that it's a problem and beginning to talk about it and have solutions, is an important part of what we're doing. And that's a big part of what we're doing with our Zero Suicide initiative.

We have to be aware and we have to combat stigma. That's one of the biggest things with any type of treatment and awareness of mental illness. There is a stigma that exists and it's centuries old. We're trying to beat it down. We've had some successes, but it still remains. We need to be able to just talk about it, sitting around the kitchen table talking about it, talking about it with your kids, talking about it with your friends.

Being aware of how people are doing. If they're not looking the same, if they're not acting the same, being able to say, "How are you today? You don't seem quite the same to me, is everything okay?"

Mike Woodruff, MD: Don't you think there's a misperception that talking about suicide with someone might actually plant the idea in their head and make them more at risk for suicide?

Mark Foote, MD: I think that's one of those old wives’ tales and part of this stigma. We know that talking about it’s part of prevention and bringing it up, that's part of what we're doing with this effort is to make everybody a caregiver. Make everybody aware and then to bring it up and to be able to discuss it. It helps — it doesn't hurt — to bring it up.

Mike Woodruff, MD: Yeah and I know that almost everyone I know has been touched in some way or another by suicide. I myself have had a suicide in my close family and felt that stigma and guilt. By talking about it and being open about it, I have found my way forward. I know a lot of people are in that same exact position.

Mikelle Moore: I agree. Since we launched the Zero Suicide initiative we've had several of our own caregiver community reach out and say, "I've dealt with this in my family and it's really hard." I think people are glad that we're getting involved in this work and also really want to make sure that we do it in a sensitive way. What do you think is important about the way we go forward with this Zero Suicide initiative and what will we really do?

Mark Foote, MD: We're raising awareness number one; we're starting the conversation number two. We're beginning to put into place different methods, different tools. All those things are important. We also need to put into place resources. We need behavioral health resources. We know that one of the major risk factors is having depression or having a mental illness, so we have to be able to treat, but there is a sensitivity.

Our goal has to be zero; there's no other acceptable number than zero. On the other hand, we're not naïve enough to think that we're never going to have a suicide. It's a very difficult problem and people are very complicated. People will die by suicide, but we can do better. We can help them through that critical period that most of the time is there and short-lived.

Mike Woodruff, MD: There are two other pieces in what we can do as a health system to prevent suicide. The first is putting together the culture of learning and accountability. When suicides do happen, what can we learn from them? How does that advance our ability to detect patients at risk? And that's something that Intermountain is committed to doing.

The other is limiting access to lethal means. This gets to part of the reason why I think Utah suffers from a high rate: We have a lot of access to lethal means and there’s a lot of unsecured guns out there. So, doing what we can to support locking up your guns in a safe way and keeping them out of site and very well secured, and this applies to everyone, not just Intermountain. Because you really don't know when a moment's going to happen when someone's vulnerable. When they have access to lethal means, that's how it happens.

Mikelle Moore: I believe the statistics are that about half of the attempts in our state are with a firearm, and for children usually those firearms belong to the parent. We need to be thoughtful. We have gun locks available through Intermountain and I believe KSL is distributing gun locks as well in our community. There's a lot of access for those types of prevention components at a community level.

What actions, in addition to firearms or lethal means restriction and talking about this openly, can we all do in our families and in our community to make a difference? Especially considering that Utah stands out as the fifth highest in the overall death rate by suicide.

Mark Foote, MD: We've talked about a lot of it, and we've been working on this problem in psychiatry and behavioral health for a number of years. I think we put into place a lot of the important programs, a lot of screening, but it's bigger than we are. And that's where the Zero Suicide program comes in and that's where engaging our entire healthcare system is so important.

We need everybody to be involved: primary care offices, emergency departments, inpatient units. Everybody to be aware and there to really be this culture developed throughout this system, that talks about accountability and best practices and how do we really do this right?

It takes resources, it takes people caring about it, it takes getting rid of stigma, but I think we're on the right track even though we're still seeing the statistics increase. I do think that when we put these programs into place we'll see a decrease in the rate.

Mikelle Moore: Do you feel hopeful Dr. Woodruff?

Mike Woodruff, MD: I do, I totally agree. What excites me is that seeing Intermountain partner with the state, the Department of Health, and the university and other groups, really there's power in that concerted effort. That’s what it's going to take, but we can come together, and we can deliver on these initiatives to keep our population safe and reduce suicide.

To me, it starts with realizing and really believing that suicide is preventable. Not in all cases, but it is possible to prevent suicide. Once you start thinking that way and then you realize the amount of resources that are coming together in the state to work towards this goal of Zero Suicide, to me that's very exciting.

Mikelle Moore: Yes, I agree.

Mike Woodruff, MD: I think social media plays a huge potential role here because people are sharing more than they used to, how they're feeling and when they're in crisis or when things aren't going well. So, raising the level of awareness of social networks to the point that they're doing their own monitoring, and then providing them with the access to reach out for somebody who's in need. If we can help connect those dots, then social media platforms would be really powerful I think in identifying people at risk for self-harm.

Mark Foote, MD: I will add just a couple of things that we're doing with Intermountain that are new and innovative. Our mental health integration program is intended to be in every primary care office, where we have a psychiatrist and therapist there on a regular basis to really raise awareness and to begin treatment in a primary care setting. That also helps the primary care doctors to be better and more comfortable at what they're doing.

We've also implemented a set of what we call Access Centers, which are basically mental health InstaCares throughout our system. They’re just up and coming, but they are a place where people can come in and get an urgent assessment that doesn't require them to go to the emergency department.

Those are some innovative ways that we're trying to move out along the spectrum of our treatment. I'm hoping that those will bring more access to everybody in the community.

Mikelle Moore: We know that people who die by suicide aren't just people with behavioral health diagnoses. What other kinds of issues can trigger that type of crisis for people?

Mike Woodruff, MD: We’re starting to learn more about this, but I think it's important for us to understand that it's not just people with depression. It's not just people with a history of suicide attempts, and it's not just people with substance abuse, but it can often be people who are going through a tough time in their lives mentally.

For example, people with chronic diagnoses who've gotten a new diagnosis that's really challenging them to reframe how the rest of their life is going to look. Those who’ve had to have surgery and maybe it hasn't gone exactly as they've hoped. Many things that can stress us that are related to our health that can put us at risk for self-harm for depression and for suicide.

Mikelle Moore: Utah's a pretty healthy state by many metrics and yet our suicide rate puts us fifth worst in the country. Are we an anomaly? How does Utah look compared to the rest of the country?

Mike Woodruff, MD: There's a big geographic piece here. When you look at rates throughout the country, we live in what's called the suicide belt and that is basically a north to south, down through the Rocky Mountain States. Idaho, Montana, Wyoming, Utah, Arizona all have the highest rates. And we postulate why that might be. We think easy access to guns, maybe it's the people, or a pioneering spirit.

Mark, I've heard you refer to it almost as an epidemic or I want to say public health crisis, public health emergency. Can you talk about that a little bit?

Mark Foote, MD: Well absolutely, when you start seeing the rates go up as they have and you look at the number of people who die by this, it really compares. We've lost more people by both suicide and the opioid crisis, that died at the height of the AIDS epidemic.

Mikelle Moore: Gun safes can be expensive, but gun locks are really affordable. You can order them online inexpensively or get them at any major sporting goods stores. Or there's lots of organizations giving them out for free, including the emergency department at Primary Children's Hospital.

I encourage everyone to lock up your gun, put time and distance between someone at risk of suicide and the means to complete that.

Mike Woodruff, MD: Isn't there an app too that's being developed?

Mikelle Moore: Yes, I was just thinking about that. SafeUT is an app that was built here locally and has been adopted by many schools across the state. It’s available to anyone and it's monitored 24 hours a day by the crisis line. Anyone can indicate on the app that they’re observing someone in crisis or they themselves are in crisis, through chat or phone line or email.

I know we're recommending everyone to encourage their children to download that app, if they have a phone, and link it to their school even if possible.

Mike Woodruff, MD: I'll give you another example of what's exciting about this in what Intermountain can achieve. We do a lot of work partnering with schools around sports medicine and really thinking about how we can take all those types of opportunities and weave in the suicide awareness and suicide prevention ideas and really —

Mikelle Moore: Really normalize it through a lot of our other interactions.

Mike Woodruff, MD: Normalize it, right. Making it a basic part of what we do as healthcare providers. Just as you should have proper nutrition and you sometimes have antibiotics when you have bad pneumonia, you also need to think about suicide prevention for everybody.

Mikelle Moore: I really like that. I think that those are the types of ideas we're going to realize as we begin talking and adopting Zero Suicide within Intermountain. We're going to change our lens and think about the holistic person in all our interactions. I think it will be a part of the culture change.

Thank you both. This is a difficult topic, and I know one that you both feel a personal connection to and I do as well. I think that personal commitment is something we all as Intermountain caregivers bring to our work, and that's what motivates us to be a part of finding solutions to complex issues like this. I really believe like you do, that we have hope for making a difference by working together and working with people in the community. Thank you for your time and understanding this issue.

If you or someone you know is in crisis and needs help, you can visit SuicidePreventionLifeline.org or UtahSuicidePrevention.org. There's also a 24-hour lifeline at 1-800-273-8255 and that number is available through the SafeUT app as well. Thank you.