In 2009, there were 36,891 suicides in the United States, according
to the CDC. This translates to a
rate of 11.9 for every 100,000 people.
And rates among certain groups were even higher. For example, the suicide rate among veterans,
according
to the Veterans Administration, was three times higher – or 35.9 per
100,000 veterans.
Suicide is a problem that ought to command our attention.
And it does. For many
years we have used suicide data as surrogates for documenting the consequences
of serious mental illness. We all know
that the “danger to self” standard we use for determining when people with
mental illness qualify for emergency care is, in effect, a “suicide may be
imminent” standard.
As a result, for many years community mental health
organizations have also been asked to track suicides as a measure of the
effectiveness of their programming.
But there are reasons
why focusing on suicide rates too closely leads to inadequate public policy.
Suicides are just the tip of the iceberg.
Many more people consider or attempt suicide than die from
it. If you really want to be staggered
by a national statistic, CDC reported that in 2011 7.8 percent of the teenage
population had attempted suicide. That
is one thousand times as many as had died from it.
Also, the overwhelming majority of people with serious
mental illness who die early do so not because of suicide, but because they are
undertreated for other chronic conditions (such nicotine addiction, diabetes, and
cardiovascular problems). Some of these
are linked to treatments they receive for their mental illnesses.
Finally, at the community level the number of suicides is
usually so small that it is nearly impossible for any single organization to
affect the rate more than anecdotally. The
agency may be able to point to individual cases where its intervention made a
difference, but it will probably never be able to move the rate on its own.
And when the suicide rates don’t move, policy makers use
this to justify decisions to reduce or eliminate program funding.
So what does
Obamacare have to do with suicide?
Many other provisions of the law have been lost in the din
surrounding the most visible parts of the Affordable Care Act.
One of these was a mandate that the Department of Health and
Human Services focus on the quality of our health care. Since 2012, it has been doing this, along
with a number of agencies in the Department, including the Substance Abuse and
Mental Health Services Administration (SAMHSA).
SAMHSA has just invested over two years in developing a National
Behavioral Health Quality Framework (NBHQF).
When the NBHQF is finalized, it will open the door to the
use of new standard outcome indicators in determining the effectiveness of
health and behavioral healthcare in our communities.
We will be able to
add these indicators to suicide rates, giving state and local officials much
more powerful tools in judging the effectiveness of community mental health
programs.
For example, suicide risk assessments (NQF #0104) will
become a standard diagnostic tool in provider settings. Providers will also be expected to use depression
screening tools such as the PHQ-9 at six and twelve month intervals to monitor
patients consistently over time (NQF #0710-0712). And risky behavior assessment and counseling for
children under the age of 13 will become a standard of practice (NQF #1406), as
will diagnostic evaluation of children with major depressive disorder (NQF
#1364-1365).
These all focus our attention on the 999 in every 1000 who consider
and attempt suicide in addition to the one who tragically commits it.
We can also expect the integration of health and behavioral healthcare
to become more systematic.
Cardiovascular and diabetes monitoring of people who
are prescribed antipsychotics (NQF #1933-1934) will become a standard of
practice, as will management of ADHD in children in primary care settings (NQF
#0107-0108).
These indicators focus our attention on some of the other
reasons people with mental illness die so young.
We all have an
opportunity to say how we feel about these indicators.
SAMHSA has released the NBHQF
in draft form, and is accepting public
comments on it until September 17, 2013.
Comments can be submitted using an
online form, and don’t have to be formal or comprehensive.
The NBHQF will be finalized after the public comment period. Then it will begin to guide the funding and delivery
of mental health services.
But for the next week, we
all can say how we think the government should measure the quality of our behavioral
healthcare services.
Paul Gionfriddo via email: gionfriddopaul@gmail.com. Twitter: @pgionfriddo. Facebook: www.facebook.com/paul.gionfriddo. LinkedIn: www.linkedin.com/in/paulgionfriddo/
You are right, Depression is main reason of suicide, because depression is a serious medical illness that involves the brain. It's more than just a feeling of being "down in the dumps" or "blue" for a few days. If you are one of the more than 20 million people in the United States who have depression, the feelings do not go away. and attempt the suicide. Thank you for sharing.
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