This report uses New York State Office of Mental Health incident reports to present historical data and a discussion of factors hospitals identified in their root cause analyses that may have contributed to the suicides or areas that otherwise called for improved performance.
Resources
A multi-source collection of readings, tools, videos, and webinars to help you understand and implement Zero Suicide.
Jobes, D. A. (2006). Managing suicidal risk: A collaborative approach. Guilford Press.
Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive therapy for suicidal patients: Scientific and clinical applications. American Psychological Association.
Brown, G. K., & Jager-Hyman, S. (2014). Evidence-based psychotherapies for suicide prevention: future directions. American journal of preventive medicine, 47(3), S186-S194.
Weiss, A. P. (2009). Quality improvement in healthcare: the six Ps of root-cause analysis. Am J Psychiatry, 166(372).
Jayaram, G., & Triplett, P. (2008). Quality improvement of psychiatric care: challenges of emergency psychiatry. The American journal of psychiatry, 165(10), 1256-1260.
Jobes, D. A. (2012). The Collaborative Assessment and Management of Suicidality (CAMS): an evolving evidence‐based clinical approach to suicidal risk. Suicide and Life-Threatening Behavior, 42(6), 640-653.
Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., ... Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of general psychiatry, 63(7), 757-766.
Brown, G. K., Ten Have, T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005). Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. Jama, 294(5), 563-570.
This two-page, printable PDF describes the Zero Suicide approach and provides a brief history of the initiative.
Oordt, M. S., Jobes, D. A., Fonseca, V. P., & Schmidt, S. M. (2009). Training mental health professionals to assess and manage suicidal behavior: Can provider confidence and practice behaviors be altered?. Suicide and Life Threatening Behavior, 39(1), 21–32.
Schmitz, W. M., Jr, Allen, M. H., Feldman, B. N., Gutin, N. J., Jahn, D. R., Kleespies, P. M., . . . Simpson, S. (2012). Preventing suicide through improved training in suicide risk assessment and care: An American Association of Suicidology Task Force report addressing serious gaps in U.S. mental health training. Suicide and Life Threatening Behavior, 42(3), 292–304.
The New York State Office of Mental Health reviewed suicides occurring within the public mental health system over several years. This report aims to put New York State on a path toward systematically preventing suicide for people in care. It includes details of the review, a summary of findings, and a set of draft recommendations. Appendix 1 lists suicide prevention licensing standards for mental health programs in New York State.
Rudd , M., Cukrowicz, K. C., & Bryan, C. J. (2008). Core competencies in suicide risk assessment and management: Implications for supervision. Training and Education in Professional Psychology, 2(4), 219–228.
Pisani , A. R., Cross, W. F., & Gould, M. S. (2011). The assessment and management of suicide risk: State of workshop education. Suicide and Life Threatening Behavior, 41(3), 255–276.
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