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a decade ). In 2008, the program reached its
goal of zero suicides, a trend that lasted for
more than a year.
People in the suicide- prevention field took
notice. “Nobody had ever seen results like
this,” says Hogan. “This was the most effec-
tive suicide- prevention program, based on the
data, that had ever been seen in the world.”
With the Henry Ford experiment and the VA’s
suicide- prevention program, which launched
in 2007, as examples of what was possible in
health care, in 2012 HHS published a national
suicide- prevention strategy that prioritized
health care systems for the first time—and set
the goal of “zero suicides.”
The name stuck. Zero Suicide became a col-
lection of best practices for health care systems
to use to reduce suicides among people under
their care. “Over 1,000 organizations are now
using the skills and tools of the Zero Suicide
initiative,” says Goldstein Grumet, who is also
director of the Zero Suicide Institute, which
helps health care systems transform in this
way. Baked into each step is the directive to
acknowledge each patient’s pain, empower
them to make safe decisions and build hope
for recovery.
the time after a person leaves care is deli-
cate. Suicide risk rises sharply the first week
after discharge from a psychiatric facility and
remains high even years later. But there are op-
portunities to reduce suicide risk even after
treatment is over. Back in the 1970s, Dr. Jerome
Motto, a San Francisco psychiatrist, wanted to
see whether writing patients a series of short
letters to show them they weren’t alone—that
someone cared—helped keep them alive. “The
point always was, just be there for somebody,”
says Chrisula Asimos, one of Motto’s former
researchers.
Motto and his colleagues found more
than 800 people who had recently been
hospitalized because they were severely
depressed or suicidal, but who had refused
further treatment. Half were left alone, and
the others were sent a regular stream of short
letters from a staff member who had met them
in the hospital. “It has been some time since
you were here at the hospital, and we hope
things are going well for you,” one of the letters
read. “If you wish to drop us a note we would
be glad to hear from you.” They sent the letters
every so often for the next five years.
“Initially I was a little skeptical, because
working with these patients in the hospital
when they first came in, they were just acutely
depressed or suicidal,” Asimos says. “But it
became really clear when we started getting
responses back that those contact letters were
really a way to open the door.”
The group who received letters had a
lower suicide rate all five years of the study.
Many wrote back. “I was surprised to get your
letter,” read one response. “I thought that
when a patient left the hospital your concern
ended there.”
“You will never know what your little notes
mean to me,” read another.
“You are the most persistent son of a bitch
I’ve ever encountered,” read another, “so you
must really be sincere in your interest in me.”
This kind of follow-up contact for pa-
tients leaving care—which is also effective
by phone, recent research suggests—is cost-
saving and scalable through automation and
electronic health records. A 2017 study found
that follow-up letters and calls to people at
elevated risk for suicide who left emergency
departments reduced the likelihood of a new
suicide in the next year by about a third and
was cost- effective. “That’s a huge effect from
something that’s super low intensity,” says
study co-author Michael Schoenbaum, se-
nior adviser for mental- health services, epi-
demiology and economics at the National In-
stitute of Mental Health. “The holy grail in
health care is something where you get more
and pay less. And caring communications
overwhelmingly seems to be that.”
After Kristina Mossgraber left the hospital,
she slowly got better. “Recovery is the hardest
job I’ve ever had,” she says. “It’s physically and
emotionally exhausting. But it’s worth it. My
life is back to the way I’ve always wanted it to
be.” She now works as director of education
and community outreach at her local chapter
of the National Alliance on Mental Illness, talk-
ing to kids in schools about mental health and
suicide prevention. She’s also on an advisory
board at the same hospital where she was once
turned away—and later given tools, hope and
access to a better life.
“Unfortunately, the system has been one
way for so very long. And the public percep-
tion of mental health and suicide has been one
way for so very long,” she says. “It’s going to
take a while. But I’m encouraged. I really think
things are changing.” □If you or someone you know may be contem-
plating suicide, call the National Suicide Pre-
vention Lifeline at 800-273-8255 or text HOME
to 741741 to reach the Crisis Text Line. In emer-
gencies, call 911 or seek care from a local hospi-
tal or mental-health provider.‘
Thosecontactletters werereally a wayto opent he do or.