Brief Doctor’s Orders: Using a ‘Zero Suicide’ Approach to Reduce Suicides in Health Care Systems

About half of people who die by suicide in the United States each year had a health care visit in the month preceding their deaths, according to research published in the Journal of Internal Medicine. That means there are opportunities for hospitals and health systems to help patients experiencing suicidal thoughts or behaviors.

The “Zero Suicide” framework leverages this critical period by providing a structured approach for health and behavioral health care systems to prevent suicide deaths. This model seeks to transform how care is provided to individuals with suicidal thoughts and urges, promoting a shift toward “safer and more compassionate” health care environments.

Suicide is a significant public health issue that affects thousands of American families and communities nationwide. From 2001 to 2021, suicide rates increased by approximately 36%. During this period, the suicide rate for men was three to four times higher than among women, although women were more likely to attempt suicide.

While middle-aged white men are most at risk for suicide, according to the Centers for Disease Control and Prevention (white men accounted for nearly 70% of all suicide deaths in 2022), rates of suicide are increasing more quickly in communities of color. From 2001 to 2021, suicide rates rose 14% for Black women and 3% for white women, while rates increased by 17% for American Indian Alaska Native men, 11% for Black men and 3% for white men.

Suicide is the 11th leading cause of death overall in the United States and the second leading cause of death for American teens and young adults. In 2022, about 49,000 people died by suicide in the U.S. The suicide death rate was highest in Montana, Alaska, Wyoming, New Mexico and North Dakota. Rates were lowest in New Jersey, Massachusetts, New York, Maryland and Washington, D.C.

For every suicide death, there are 11 visits to emergency departments for self-harm, 52 self-reported suicide attempts and 336 people who seriously considered suicide. The financial cost of suicide is also substantial, according to the CDC. In 2020, the combined expenses for suicide and nonfatal self-harm exceeded $500 billion in medical costs, work loss and quality-of-life impacts.

‘Zero Suicide’ Model

Zero Suicide is a comprehensive model with specific practices aimed at reducing suicide deaths within health care systems. The Zero Suicide framework is built on a "comprehensive, multi-component, system-wide" approach to suicide prevention, as no single intervention alone has been found to effectively reduce suicide rates. The emphasis in this framework is on identifying at-risk individuals during routine care, transitioning that individual into suicide prevention treatment and then retaining that individual in an ecosystem of high quality care. Seven core elements guide this framework:

1. Lead: Drive a system-wide culture shift committed to reducing suicides.
2. Train: Develop a competent, confident and caring workforce.
3. Identify: Screen and assess individuals for suicide risk.
4. Engage: Use a suicide care management plan to support at-risk individuals.
5. Treat: Address suicidal thoughts and behaviors with evidence-based therapies.
6. Transition: Ensure smooth transitions in care with warm hand-offs and supportive follow-ups.
7. Improve: Continuously refine policies and procedures through quality improvement.

Some health care systems across the U.S. have adopted the Zero Suicide framework and some are tracking their progress. For example, a Community Mental Health Center in Indiana reported a 70% reduction in suicide deaths from 2014-2018. In Massachusetts, Cambridge Health Alliance sought to increase the number of patients at risk for suicide who received safety planning before discharge by participating in a Zero Suicide learning collaborative with the Pew Charitable Trusts. In April of 2023, before joining the collaborative, only 2% of CHA patients at risk for suicide completed safety plans. By March 2024, 94% of patients experiencing suicide risk had a safety plan at discharge.

State Legislation Related to the Zero Suicide Framework

In 2016, Colorado enacted Senate Bill 147 which required the state's health department and suicide prevention coalition to work in collaboration with other stake holders, including health and behavioral health care systems and primary care providers, to develop a state suicide prevention model based on the tenets of the Zero Suicide framework.

The implementation of Zero Suicide in Colorado is outlined in a web-based resource by the Colorado Department of Public Health. It provides an overview of the zero-suicide framework along with opportunities for health systems to have discussions, access training and connect with the Office of Suicide Prevention. Hospitals that participate in the Health Quality Incentive Program are rewarded for exceeding quality measures and are provided with a guide to satisfy requirements.

In 2018, Louisiana enacted House Bill 148 which established the Suicide Prevention Act and created a program known as the Zero Suicide Initiative, providing for it to be administrated by the Office of Behavioral Health. The initiative emphasizes the Zero Suicide components of leadership development, training of health care providers, identification of risk factors, engagement of patients and health system treatment quality improvement in the zero-suicide model.

The bill tasks the Office of Behavioral Health with resource dissemination as well as analysis and coordination of data and organization of the regulations necessary to support this initiative. The bill encourages collaboration among behavioral health, criminal justice and advocacy groups to enhance statewide prevention of suicide.

Implementation of Zero Suicide in Louisiana has focused on training and education for health providers across the state. In 2023, the Louisiana Department of Health sponsored a Zero Suicide Academy which provided organizations with training and collaboration opportunities. Access Health Louisiana also offers an informative video for primary care providers outlining Zero Suicide practices and strategies for implementation.

In 2021, Montana appropriated federal grant dollars to bolster Zero Suicide efforts in the state. Montana's 2025 Suicide Prevention Strategic Plan, developed by the Montana Department of Health and Human Services, calls for the training of health care providers to ensure safer suicide care and emphasizes the need for the department to support efforts to ensure a systematic approach to suicide prevention care by partnering with health care and behavioral health programs. The strategic plan targets care providers working with high-risk Montanans, like Native Americans, people with physical disabilities, older adults and veterans/military members as being particularly important to identifying and intervening in suicide across the state.

Minnesota appropriated $137,000 in 2019 from the state general fund to support Zero Suicide efforts. That funding supported 20 behavioral and health care organizations across five years to treat individuals at risk for suicide and support those individuals across systems of care and upon discharge. The Minnesota Health Department maintains a list of health and behavioral health care providers that have worked to implement Zero Suicide models in the state.