Over the last two decades, the suicide rate in America has increased by 30%. During that time, suicide prevention measures like gun safety bills have failed to gain political traction at a national level, and cuts to Medicaid funding have threatened access to mental health care. But in recent years, an approach known as “Zero Suicide,” which focuses on using the health care system as a first line of defense, has gained financial and empirical support.
More than 50% of Americans who die by suicide visit a health care provider within a month of their death, and over 90% do so within a year, according to a study published in 2019. Such research has helped experts identify a population particularly well-positioned to intervene with people in crisis: doctors.
While some people who die by suicide have a history of prior attempts, many have no documented suicidal thoughts or psychiatric conditions associated with suicide risk. Often, suicidal ideation stays hidden because trusted individuals, including clinicians, don’t know to ask about it.
“For a long time, suicide was the type of issue that people thought they couldn’t do anything about, or that talking about it would make it worse,” said Kristen Mizzi Angelone, project director of the suicide risk reduction project at The Pew Charitable Trusts. “People feel uncomfortable bringing it up in conversation, but research is continuing to show that reducing that stigma is the first step to ensuring that people receive the care that they need.”
Many experts have now coalesced around the Zero Suicide framework, which aims to equip health care providers with the tools and training they need to ask patients about suicide directly and ensure they get treatment. It focuses specifically on making suicide screening a routine part of medical care, regardless of a clinician’s speciality.
“You never know who’s going to be the person who identifies this risk and you don’t know who a person might feel comfortable talking to,” said Edwin Boudreaux, director of the Center for Accelerating Practices to End Suicide at the University of Massachusetts Chan Medical School. “It could be that the front desk staff has a good relationship with a patient. This is the whole system’s responsibility, and optimally, you train every single person who works in the health system at whatever level is appropriate.”
Researchers first recognized the health care setting as central to suicide prevention in 2001. That year, the National Academy of Medicine (then known as the Institute of Medicine) released a report that called for a fundamental redesign of the U.S. health care system to address quality gaps. In response, clinicians at Detroit’s Henry Ford Health sought to define what perfect depression care would look like. But they had one problem: They couldn’t think of a measurable outcome.
“Health system leads, patients, and clinicians all got together to discuss what the perfect goal would look like,” said Brian Ahmedani, the director of the Center for Health Policy and Health Services Research at Henry Ford. “And a nurse said, ‘you know, if we want a perfect outcome for depression, then no one would die by suicide.’”
From there, clinicians at Henry Ford tested new models of depression care and suicide prevention, including universal screening for all behavioral health patients, comprehensive risk assessment, safety planning, and consistent provider follow-up. By the first year that the initiative was fully implemented, it had already produced an 80% reduction in suicide deaths compared to previous years at Henry Ford Health.
Despite the success, it took over a decade of research and advocacy for the findings in Detroit to reach health systems nationwide. A lack of funding contributed to the delay: Suicide prevention research receives less than one-third of the funding allocated to other leading causes of death.
Beginning in 2010, members of the Clinical Care and Intervention Task Force, a national group of suicide prevention and public health experts, developed and launched what would become the official Zero Suicide model. Their work influenced the 2012 update of the National Strategy for Suicide Prevention, which called for suicide prevention to become a “core component” of health care for the first time. Soon after, the Education Development Center launched a series of training resources for providers. But health systems only started implementing Zero Suicide in earnest in the last five years, largely in response to an increase in the suicide rate between 2020 and 2022.
“Coming out of Covid was the first time we had real, widespread awareness of the impact of mental health and how much people were really struggling,” Ahmedani said.
As with other public health issues like heart disease and lung cancer, doctors with the proper training can screen for suicide risk during routine check-ups, in the emergency room, or in other specialized settings.
“Not everybody who has a heart attack has high cholesterol, but if you do have a high cholesterol score, we do something about it,” Ahmedani said. “In the same sense here, the negative screen doesn’t mean that somebody’s not at risk, but if they screen positive, their risk is exponentially higher.”
Still, screening for suicide is more complex than simply asking patients whether they are smoking or eating well. When doctors explain to their patients why the questions are being asked and show genuine care, patients are much more likely to be honest, said Boudreaux of UMass Chan.
Training doctors how to ask those questions and what to do when a patient screens positive is the focus of government funding and legislation. At the federal level, both the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration have been providing grants to states that help health care organizations adopt and implement the Zero Suicide model. Since January, the Trump administration has ground much of SAMHSA’s work to a halt through layoffs and funding cuts, which could compromise future grants from the agency. The department of Health and Human Services’ proposed 2026 budget, however, designates $28 million for the National Strategy for Suicide Prevention, in line with this year’s allocation.
Vermont, one of 24 recipients of funding from the CDC’s Comprehensive Suicide Prevention Program, used its grant to create the Vermont Emergency Department Suicide Prevention Quality Improvement Initiative, which focuses on improving the quality of care for patients at risk for suicide in the state’s 14 emergency departments. Since the project began in 2022, the state has experienced a drop in both the number and rate of suicide deaths.
“When we came out of Covid, emergency departments were interested in becoming more skilled because they had become a default place for people experiencing some kind of mental health crisis,” said Nick Nichols, the suicide prevention program coordinator at the Vermont Department of Health.
Oregon, meanwhile, used a SAMHSA grant it received in 2021 to create infrastructure for suicide prevention training in health care systems in six counties. In 2022, the state allocated $5 million a year of its general fund to suicide prevention, which has helped the Oregon Health Authority focus on a comprehensive approach that includes prevention efforts in schools and programs that help restrict access to lethal means for those in crisis. While it’s difficult to connect the new programs to suicide deaths directly, Oregon’s suicide rate has remained below its 2019 peak for four consecutive years, according to CDC data.
“Movement happens when there’s been a tragedy and, for better or worse, much of our legislation and funding is attached to a personal story somewhere along the line,” said Jill Baker, the manager of Oregon’s Youth Suicide Intervention and Prevention Plan. “Suicide loves living in secret. By putting it out in the open, that shifts the power back to away from suicide’s power, to the person’s choice for life.”
Health systems have also received funding for suicide prevention. At UMass Chan, the Center for Accelerating Practices to End Suicide received $17 million from the National Institute of Mental Health to bring best practices into clinical care across emergency departments, inpatient units, outpatient settings, and more.
Despite the promise of the health care system as a central player in prevention, Boudreaux noted that policymakers, clinicians, and researchers shouldn’t lose sight of people at risk who don’t visit the doctor’s office regularly. Efforts to restrict access to lethal means, crisis hotlines like 988, and initiatives to address the major risk factors associated with suicide — anxiety, depression, chronic pain, and substance use — also play a significant role in reducing suicide deaths.
Still, experts like Ahmedani see the health care system as the core of the solution, because it’s often the only place people can get the treatment they need. Calling a hotline or removing a gun from a household may prevent short-term harm, but can’t help manage any underlying psychiatric conditions.
“Ultimately, you can screen somebody for suicide in any setting, but if they’re really at risk, they have to go to the health care system,” Ahmedani said. “This is the first time in my career — in my life — that I can remember people being so motivated to prevent suicide. It’s one of the few things everyone can agree on.”
If you or someone you know may be considering suicide, contact the 988 Suicide & Crisis Lifeline: Call or text 988 or chat 988lifeline.org. For TTY users: Use your preferred relay service or dial 711 then 988.
