One suicide is too many. Yet more than 47,000 Americans die each year as a result of suicide. Because suicide is the 10th leading cause of death in our nation, we at Magellan Health believe it is nothing short of a public health crisis. Thankfully many experts and organizations agree.

Recently, Magellan had the privilege to host a suicide prevention conference in Boise, Idaho. The free conference brought almost 200 local and national leaders together to exchange ideas, share successes and discuss solutions around the challenges we face together in addressing this crisis in our communities. Suicide is a topic that’s difficult, but we must talk about it and deal with it by creating an environment for genuine caring for one another. To have the greatest impact possible, this should start by encouraging those who are struggling to ask for help, and we need to remind one another to watch for signs and signals with our family, friends and colleagues.

The suicide crisis is particularly impacting the state of Idaho. In 2017, Idaho’s suicide rate was 22.9 per 100,000 residents. The state’s suicide rate is 58 percent higher than the national rate and reflects a 44 percent increase over the past 10 years.

During the conference, Dr. Michael F. Hogan, principal, Hogan Health Solutions, LLC, gave one of three keynote addresses. He spoke about opportunities to prevent suicide in all healthcare settings. As I shared in my remarks at the conference, I wholeheartedly agree with his perspective. From the examination room to the boardroom, healthcare leaders and executives play a critical role in helping solve this crisis. We must lead the charge—drawing in other key stakeholders like providers, lawmakers, teachers and family members to support efforts to make this crisis visible, reduce stigma and drive solutions.

One important place to start is by ensuring people understand the signs of suicide. First, we must increase education and awareness and promote community and statewide educational programs. We should focus on an audacious goal, a path to zero suicides, to drive the sense of urgency needed to get community-wide buy-in. In addition, we should invest in suicide training for family members and peers of those with a mental health diagnosis. Such training fosters early detection and, in the case of peer support, provides a common frame of reference, making individuals more likely to engage.

Second, we must work to break the stigma around mental health issues — and normalize the need for care. As Dr. Thomas Joiner, The Robert O. Lawton Distinguished Professor of Psychology at Florida State University, said during his keynote address, “Reach out and tell someone when you see that someone is desperate. These person to person connections as we look out for each other can have such a significant impact in reducing suicides. It is important to keep in mind that all of us hold an important role in caring for one another.” Creating opportunities for open dialogue in the community, like the workshops during our Boise conference, helps shine a light on the problem and engages more people in helping others before it’s too late.

Finally, improved access to care and early screening will go a long way toward reducing the risk of suicide. Ensuring people of all economic status and backgrounds have access to behavioral healthcare is key. However, finding specialists who are skilled in suicidology isn’t easy. One study in Maricopa County, Ariz., determined that only 30 percent of behavioral health professionals in the county believed they had the necessary skills and support to treat at-risk patients. We need increased funding for suicide training among all medical professions.

As many as 38 percent of people making a suicide attempt did so within a week of a healthcare visit. Our healthcare system must look for ways to support early detection by making depression screenings part of every primary care visit. To help identify patients with mental health conditions, Magellan Healthcare has developed SmartScreener^SM. SmartScreener is a digital application that contains standard screening tools used by behavioral health professionals like counselors, psychologists and psychiatrists. While the patient waits to be seen by the physician, he/she completes the screener. Answers are confidential and only shared with the physician, who will discuss the patient’s results during the appointment and can help with next steps.

This routine screening is making a difference in identifying patients with behavioral health concerns. In a six-month primary care SmartScreener implementation, approximately half of the patients screened positive for a behavioral health concern. About 38 percent were deemed appropriate to be referred to digital cognitive behavioral therapy (DCBT). Fifty-four percent of these appropriate patients then enrolled in DCBT, getting help for which they may otherwise never have been referred.

The path to zero suicides requires that healthcare leaders—and the nation as a whole—treat suicide as a public health crisis and that we normalize discussions about mental health, suicide and treatment. I hope everyone who attended our Boise conference left as inspired about the urgency of this issue as I did. Let’s all commit to strategies that involve our communities in suicide prevention and draw upon multiple resources for continuing education and improved access to treatment.

 For more information about suicide prevention, read our other blog articles here.

Many people who die by suicide leave loved ones behind who suffer from a range of painful emotions.

When it happens to someone you know

Losing a loved one to suicide can be overwhelmingly painful for family members and friends. Unlike a death that occurs naturally from old age or illness, a death by suicide is usually sudden, unexpected, and sometimes violent. The shock and trauma for survivors is further complicated by the social stigma of suicide, possible police investigations, media coverage, lack of privacy, and judgment of others in the community.

How many people it impacts each year

Research shows that at least six people are directly affected by the death, including immediate family members, relatives, neighbors, friends, and co-workers.

Given that more than 43,000 people take their lives each year, approximately a quarter million survivors are left behind, traumatized by the loss.¹

Many people who die by suicide suffered from clinical depression or other mental health disorder. The survivors may also be at risk for depression and anxiety.

Common responses

The emotional pain of survivors can be complicated, intense, and prolonged. People may feel a sense of guilt and responsibility and blame themselves for not seeing the warning signs. They may feel a profound sense of betrayal, rejection, and abandonment. Other common responses are:

• Feeling a need to make sense of the death and understand why the person made the decision to die. Even if the person left a note or a message, there are often unanswered questions that can persist for years.
• Replaying the events that took place before the person’s death and constantly second-guessing different outcomes.
• Experiencing symptoms of post- traumatic stress disorder such as flashbacks and anxiety, particularly if they witnessed the suicide or discovered the body.
• Shame and anger due to the stigma of suicide and mental illness, and possible negative community responses.

Some individuals experience intense grief that does not heal with time.

The bereaved person may feel empty, preoccupied with the death and unable to resume the activities of daily life. This type of grief, known as complicated grief, can affect from 10 – 20% of the survivors of suicide loss. If left untreated, complicated grief often persists, resulting in significant impairment and poor health outcomes.

How you can help

Sometimes people struggle with what to say or how to help a family who has lost a loved one by suicide. Helping the survivors means being a good listener and avoiding any criticism or judgments. Try to:

• Be present and listen attentively without feeling the need to provide answers.
• Avoid speculating on the reasons for the suicide or the person’s state of mind.
• Be sensitive about what you say. Avoid clichés such as “I know how you feel” or “time will heal all wounds.”

Helping the survivors means being a good listener and avoiding any criticism or judgments.

• Be compassionate and understanding, and remember that grieving takes time.
• Take the initiative to be helpful. Bring a meal, mow the lawn, or pick up groceries for the family.
• Be aware of support groups and offer to find one if the family is interested.

The grief of suicide survivors is unique and complicated by the circumstances of the death. You can help by being present as a caring friend and sounding board. Let the family know you’re ready to listen if and when they want to share their thoughts and emotions.

Help is available. For additional information, visit MagellanHealth.com/MYMH

1. 2014 data, released December 2015, CDC Web Based Injury Statistics Query and Reporting System (WISQARS)

Sources: American Association of Suicidology; American Foundation for Suicide Prevention; Harvard Health Publications

Common warning signs for suicide include:

• Making suicidal statements.
• Being preoccupied with death in conversation, writing, or drawing.
• Giving away belongings.
• Withdrawing from friends and family.
• Having aggressive or hostile behavior.

It is extremely important that you take all threats of suicide seriously and seek immediate treatment for your child or teenager. If you are a child or teen and have these feelings, talk with your parents, an adult friend, or your doctor right away to get some help.

Other warning signs can include:

• Neglecting personal appearance.
• Running away from home.
• Risk-taking behavior, such as reckless driving or being sexually promiscuous.
• A change in personality (such as from upbeat to quiet).

Suicidal thoughts and suicide attempts

Certain circumstances increase the chances of suicidal thoughts in children and teens. Other situations may trigger a suicide attempt.

Circumstances that increase the chances of suicidal thoughts include having:

• Depression or another mental health problem, such as bipolar disorder (manic-depressive illness) or schizophrenia.
• A parent with depression or substance abuse problems.
• Tried suicide before.
• A friend, peer, family member, or hero (such as a sports figure or musician) who recently attempted or died by suicide.
• A disruptive or abusive family life.
• A history of sexual abuse.
• A history of being bullied.

Circumstances that may trigger a suicide attempt in children and teens include:

• Possession or purchase of a weapon, pills, or other means of inflicting self-harm.
• Drug or alcohol use problems.
• Witnessing the suicide of a family member.
• Problems at school, such as falling grades, disruptive behavior, or frequent absences.
• Loss of a parent or close family member through death or divorce.
• Legal or discipline problems.
• Stress caused by physical changes related to puberty, chronic illness, and/or sexually transmitted infections.
• Withdrawing from others and keeping thoughts to themselves.
• Uncertainty surrounding sexual orientation.

Depression

Signs of depression, which can lead to suicidal behavior, include:

• Feeling sad, empty, or tearful nearly every day.
• Loss of interest in activities that were enjoyed in the past.
• Changes in eating and sleeping habits.
• Difficulty thinking and concentrating.
• Complaints of continued boredom.
• Complaints of headaches, stomachaches, or fatigue with no actual physical problems.
• Expressions of guilt and/or not allowing anyone to give him or her praise or rewards.

Take any mention of suicide seriously. If someone you know is threatening suicide, get help right away.

Help is available. For additional information, visit MagellanHealth.com/MYMH

Source: Healthwise

Myth: It’s best not to plant the idea of suicide by talking about it with someone who seems depressed.

Fact: Talking about suicide provides the opportunity for communication. Fears that are shared are more likely to diminish. The first step in encouraging a suicidal person to live comes from talking about those feelings. The first step can be the simple inquiry about whether or not the person is intending to end their life.

Myth: Only crazy people commit suicide.

Fact: Everyone has the potential for suicide. While many people who kill themselves are clinically depressed, most are in touch with reality and not psychotic.

Myth: Suicide happens more often during the holidays, such as Christmas and Thanksgiving.

Fact: Suicide rates are lowest in December and peak during the spring.

Myth: If a person is determined to commit suicide, nothing will stop them.

Fact: Suicides can be prevented. People can be helped. Suicidal crises can be relatively short-lived. Suicide is a permanent solution to what is usually a temporary problem. Most suicidal people feel ambivalent and are torn between the desire to live and the desire to die. They just want the emotional pain to stop and see no other way out.

Myth: If a person attempts suicide and survives, they will never make a further attempt.

Fact: A suicide attempt is regarded as an indicator of further attempts. It is likely that the level of danger will increase with each further suicide attempt.

Myth: Teens are the greatest risk to commit suicide.

Fact: Adults are more likely to take their own life. At particularly high risk are adults between 45 and 54, who had a suicide rate of 19.72 deaths per 100,000 people, compared with about 19 per 100,000 in people over 85, and 13 per 100,000 in the general population. Still, teenagers remain a high-risk group. The percentage of emergency room visits related to suicidal thoughts or attempts among children and teens more than doubled from 2008 to 2015. (The suicide rate for 15- to 24-year-olds is 13.15 per 100,000.)

Help is available. For additional information, visit www.magellanhealth.com/mymh

Sources: American Foundation for Suicide Prevention; CDC.gov; Nevada Division of Public and Behavioral Health Office of Suicide Prevention

Contemplating life and death is probably common when in the midst of a natural disaster. As the eye of Irma passed over me on September 10, I was thinking about suicide and suicide prevention. September is Suicide Prevention Awareness Month, and Magellan Complete Care, our health plan for individuals living with serious mental illness in Florida, had been busy preparing for summits to draw attention to and dialogue around suicide prevention to local communities. Two days before Irma hit, I was busy canceling vendors for the summits. The day before Irma, I was dealing with a surprise, last-minute mandatory evacuation order while trying to locate a friend who was experiencing homelessness and depression, and who had expressed a desire to let the storm take his life instead of seeking shelter.

As the winds howled, windows rattled, and rain pounded against the home I had evacuated to, I sat on a closet floor thinking about how much I wanted to live and how that desire to live had not always been there. There were years where, like my friend, I was lost in my own storm. Depression had flooded my soul, my thoughts were battered by negativity and I never felt safe. The aftermath, similar to a hurricane, was a life left in shambles, just wishing for normalcy.

Recent hurricanes, earthquakes and wildfires remind us of the value of life. Suicide Prevention Awareness Month provides another reminder. Every 13 minutes that the winds and rain of Irma pelted my home state, someone in this country was ending their life too soon by suicide. With a completed suicide happening in Florida every three hours , the death toll from suicide may end up being higher than that from Irma’s destruction.

Natural disasters and the realities of suicide provide the same call to action to communities. We have a responsibility to watch out for each other and take care of each other. When the power is out, you share the food and batteries you have and a reminder to hold on. When someone’s internal light is out, you share hope and support and a reminder to stay strong.

There is much work ahead to rebuild lives, homes, and communities devastated by recent natural disasters; to support communities in reducing death by suicide; and to help individuals struggling through adversity. I am living proof that a life can be rebuilt. Whatever challenge you are facing, hold on, stay strong and don’t be afraid to ask for and accept help.

As we observe National Suicide Prevention Week 2017, we sat down with Dr. Shareh Ghani, vice president and medical director at Magellan Healthcare who lead Magellan’s Driving Suicide to Zero Initiative.

Magellan Health Insights: Dr. Ghani, thank you for chatting with us today. Tell us about the work you did with the Driving Suicide to Zero Initiative
 Dr. Shareh Ghani: In some parts of the healthcare community, there is a view that suicide is something ‘that just happens’; that it is unavoidable and acceptable. The Driving Suicide to Zero Initiative sought to change that paradigm. Through our efforts in a public health program, we shifted the viewpoint to one that believes that suicide can be stopped and can be driven to zero.

MHI: You have lead a number of initiatives for Magellan, what was your interest in this particular program?

SG: I have been working in mental health since 1993. From 1993 to 1995, during my residency, I had a lot of experience with suicide prevention research, and again working in community psychiatry. There is a lot of good research on the how of suicide, but I want to understand the why.

MHI: You looked at a lot of data as a part of this initiative. Tell us about that.

SG: We were managing the behavioral health contract for Maricopa County between 2007 and 2012. At the time, Phoenix had the seventh highest suicide rate in the country. The suicide rate for those with mental health issues was even higher.

During that time, we reviewed every case of completed suicide to see what could have been done differently.

MHI: What was the Driving Suicide to Zero Initiative hoping to achieve?

SG: Of course, we were looking to significantly impact suicide rates in Maricopa County. But more than that, we were looking to develop a systematized, data-driven, reproducible model.

Part of that meant preparing the clinical workforce to confidently identify at-risk individuals and improve treatment access and engagement. It also meant incorporating family and community participation to better identify early warning signs, navigate the clinical system, and support members at risk.

Finally, there was the integration of a sustainable and replicable clinical and support model and program tools into an EMR [Electronic Medical Record] to ensure that healthcare providers can, from a single source, identify, manage and plan for zero suicides through the safe management of those at risk.

MHI: And what were the results of the initiative? Was it successful?

SG: The results were highly encouraging. Between 2007 and 2012, there was a 67 percent reduction of the suicide rate for the population. Furthermore, there was a 42 percent decrease in the suicide rate of people with serious mental illness.

MHI: You mentioned earlier that the suicide rate was much higher for those with serious mental illness?

SG: Yes, it is a fact that individuals suffering from severe mental illness are six to 12 times more likely to die from suicide than the general population.

MHI: If you could hope that people would take away one thing from the Driving Suicide to Zero Initiative what would it be?

SG: That employing a rigorous, data-driven, scalable and reproducible population health approach to address suicide prevention, and creating a sustainable ecology of support around the individual and the community, is possible.

The Magellan Driving Suicide to Zero Initiative successfully incorporated population surveillance, analytics, research, early detection, intervention and monitoring to shift the paradigm from crisis mitigation to early prevention of suicide.

When I was selected to join the National Quality Forum’s Medicaid Innovation Accelerator Project Coordinating Committee, I thought about the background and experiences I would bring with me – both personally and professionally. As a trained pediatrician, my medical training focused largely on the care and treatment of young children. According to the Centers for Medicare & Medicaid Services (CMS), more than 45.2 million children were “ever-enrolled”¹ in Medicaid and the Children’s Health Insurance Program (CHIP) during fiscal year 2015. In addition, in the time since I was in practice, I’ve worked for several national healthcare companies, with a focus on population health, clinical delivery systems delivery and improvement.

Since joining Magellan as the company’s chief medical officer, I’ve worked with my colleagues to help continually looks for ways to reinvent how care is delivered. I am passionate about supporting the volume-to-value payment transformation, and Magellan has a key role to play because of the deep expertise we bring in behavioral health. Oftentimes, we don’t realize how specialized and important that expertise is, and how it impacts the overall quality of care for a patient, particularly with comorbid conditions. Magellan is also considered a trusted partner because we are an independent company and not part of a big health plan. In addition, we also bring a breadth of experience in medical specialty, medical pharmacy and long-term services and supports (LTSS) which is not found in most other organizations.

NQF’s Medicaid Innovation Accelerator Project (IAP) Coordinating Committee is tasked with identifying and recommending measures in four priority areas to help support states’ efforts related to payment and delivery system reforms.

The four priority areas are:

• Reducing Substance Use Disorders (SUD)
• Improving Care for Medicaid Beneficiaries with Complex Care Needs and High Costs (BCN)
• Promoting Community Integration – Community-Based Long-Term Services and Supports (CI-LTSS)
• Supporting Physical and Mental Health Integration (PMH)

The challenges – and opportunities – are many. Medicaid behavioral health does not currently have standard benefit packages from state-to-state, and there are also not standard billing practices. Both of those elements make it much harder to develop metrics which are reliable, and more technical expertise is needed to ensure that the metrics selected can be broadly used. Ultimately, this committee will provide guidance on performance measures for areas which are unique to Medicaid, including patients with complex health needs, LTSS needs and those with behavioral health and substance use/opioid disorders. The states will then have a list of standardized measures for use in Medicaid performance program evaluation.

All of the committee’s meetings are open to the public. The IAP will issue its draft report in July, and its final report at the end of September. I look forward to working with my committee colleagues as we work to draft these important metrics related to state’s efforts regarding payment and delivery system reforms.

¹These enrollment data are unduplicated counts of children who were enrolled in Medicaid and CHIP at any point in FFY 2015. A child who was enrolled in more than one program (e.g., Separate CHIP and Medicaid) at different times during the FFY is only counted in the program in which he or she was last enrolled.

In late January, Magellan held its second annual Magellan Open Vision Exchange (MOVE) conference in Scottsdale, Ariz. MOVE brings together a large cast of voices from the healthcare industry to discuss the future of healthcare for patients, plans and providers. Over two days, we heard from private industry experts, government leaders, as well as other subject matter experts and thought leaders both from inside and outside the healthcare industry.

The Future of Healthcare Beyond the Affordable Care Act

Obviously, the continuing debate over the future of healthcare and the Affordable Care Act were a central topic of the conversation at this year’s MOVE. A number of speakers talked about the impact of the Trump Administration’s efforts to repeal the Affordable Care Act. Former Utah Governor Michael Leavitt, who also served as the secretary of the Department of Health and Human Services, said that while he expects repeal and replace legislation will pass, significant parts will be deferred for three or four years. Brian Coyne, VP of federal affairs at Magellan Health, said that he feared gridlock over the next couple of years.

Managing Transformation in the Healthcare World

One of the key topics discussed at this year’s event was the immediate future of the healthcare industry. After a long period of explosive innovation, there was consensus that disruptive change will continue. Magellan Healthcare CEO Sam Srivastava posited that we are currently in a tech-bubble that is about to burst. The industry is waiting to see which of the early healthcare technology entrants will survive and how technology and healthcare will continue to interface with each other.
Leavitt spoke extensively of the need to manage transformation, especially in healthcare. Leavitt stressed that systematic healthcare change takes hold over three to four decade cycle, and he believes we are less than mid-way through the current transformation. Using an analogy of a cattle herd, Leavitt made the point that you can’t drive a herd too quickly, or you risk a stampede. You also can’t push the herd too slowly or it will meander. Applied to healthcare, the idea is simple but true: If we push change too quickly there will be chaos, but if we fail to adapt and change, we will stagnate. Allowing ourselves to be “lulled into inaction” is a recipe for disaster.

Value-Based Healthcare

A critical area of discussion was the expansion of value-based care. Speakers agreed that demand for value-based care is accelerating. Leavitt said he believed this was true regardless of the Trump Administration’s plans for healthcare. Billy Millwee, President and CEO of BM&A Public Policy, cited broad bipartisan support for the value-based model and agreed that it was here to stay.

Chet Burrell, president and CEO of CareFirst BlueCross BlueShield, spoke clearly on the approach that his company was taking: “We started and ended with common sense.” He went on to explain that they had built their model with the primary care physician at the center (PCP). The PCP knows the patient best and is therefore in the best position to make decisions regarding who to refer and to whom. By taking this approach, Burrell relayed, CareFirst was able to build a patient centered medical home model that improved care while reducing costs.

Despite the level of change being experienced throughout healthcare, a common theme was one of our industry being grounded in helping people get the high-quality care they need, affordably. This is the essence of why healthcare is our chosen industry and why we are driven to innovate.

An interesting takeaway was that across the conference and speakers, there was a clear common theme: while the ultimate structure of the pay-for-value transformation is uncertain, the movement will continue. Experimentation, promoted by both public and private payer initiatives, will drive innovation and change. Some will be better prepared than others to handle this paradigm shift.