RICHMOND – It has been 35 years since the popular TV version of MASH went off the air on prime time, although the show has continued as a perennial rerun favorite on cable channels.

The theme song to the series and the original movie, “Suicide Is Painless,” still remains a familiar refrain, recognizable as the melody from the life-affirming TV show despite the paradoxical song title, in which doctors and nurses in a mobile surgical hospital attempted to save lives of soldiers wounded during the Korean War – and in turn dealt with many of the human traumas and stigmas afflicting their own lives.

The music for the theme song, written by Johnny Mandel, with the lyrics written by film director Robert Altman’s 14-year-old son, Michael Altman, came with the instruction from the director: “It’s got to be the stupidest song ever written,” according to Mandel in a 2008 interview, with the intention to serve as a song with a strong anti-suicide message.

Suicide is still very much a taboo subject in our world, often enveloped in stigma. In Rhode Island, there were 126 suicides in 2016, based upon data from the Center for Disease Control and Prevention. The rate was 11.09 per 100,000, compared to the national rate of 13.42 per 100,000.

It is one of the diseases of despair – deaths from alcohol, suicide and drugs – that have plagued both Rhode Island and the nation.

Troubled waters
The state’s annual suicide total is more than four times the homicide total,” according to the R.I. Department of Health. And, suicide is the second leading cause of death for Rhode Islanders ages 15 to 34.

In 2017, 15.9 percent of surveyed Rhode Island high school students said they had considered suicide and 10.5 percent said they had attempted suicide, according to a recent self-reporting survey.

Washington County in Rhode Island has the highest suicide rate in the state, at 13.9 persons per 100,000, according to 2015 statistics. The 13.9 rate represented a 20 percent increase from the rate of 11.5 persons per 100,000 in 2013, two years earlier.

To help remedy that, Sue Orban, the director of Healthy Children, Healthy Lives, a health equity zone collaborative, and Lou Giancola, the president and CEO at South County Health, in partnership with Westerly Hospital, applied for and won a $2 million federal grant over five years to implement a suicide prevention initiative, Zero Suicide.

A news conference, scheduled for Monday, Sept. 10, at Harvest Acres Farm in Richmond, featuring Sen. Sheldon Whitehouse, Sen. Jack Reed, Rep. Jim Langevin and Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, will officially announce the new Zero Suicide initiative.

The new initiative is based upon a Zero Suicide program instituted at Henry Ford Health System in Detroit, which was able to reduce suicides by 80 percent in its first two years of operation, according to Dr. Robert Harrison, the Zero Suicide project director.

Unlike the program in Detroit, which was part of one large health system, the new South County Zero Suicide initiative is a collaboration, involving two hospitals, Westerly and South County, the Thundermist, Wood River and Rhode University health centers, in partnership with Health Bodies, Healthy Minds, one of nine operating Health Equity Zones in Rhode Island. It also includes the Narragansett Indian tribe as a collaborator.

“What is different about our approach,” Orban explained, “is that Zero Suicide is typically implemented within one organization – one hospital system or one health center takes it on.”

Instead, Orban continued, “We are taking a population health approach and implementing [the program] in multiple health care settings in an effort to bring down our countywide suicide rate.”

“We are going to make changes not in one hospital system,” Orban said, “But in two, Westerly [owned by Yale-New Haven] and South County, as well as in various health centers, [including] Thundermist, Wood River and the URI health center, as well as implementing the changes in South County Health and South County Medical Group.”

Here is the ConvergenceRI interview with Sue Orban, director of Healthy Bodies, Healthy Minds, and Dr. Robert Harrison, the Zero Suicide project director, talking about the implementation strategies for the new initiative.

ConvergenceRI: In a recent conversation with Lou Giancola, president and CEO of South County Health, he said that Washington County had the highest suicide rate in Rhode Island Is that accurate?
HARRISON: Yes it is.

ORBAN: Yes, we have the highest rate.

ConvergenceRI: Is the focus on the new initiative on children and teens, or is it on everyone?
ORBAN: Out focus is on people ages 25 and up.

ConvergenceRI: Syracuse University sociologist Shannon Monnat’s research, looking at what she called the diseases of despair, found that Rhode Island had the highest rate of deaths from suicide, alcohol and drugs in 2010-2014, for male and female white adults between the ages of 25-34, at 59.8 percent.
As part of the Zero Suicide initiative, will you be looking to factor in such research?
ORBAN: We are aware of that work, and this initiative will definitely link to the work already going on with alcohol and substance use.

But the focus of this grant implementing Zero Suicide involves a very specific quality improvement program that we are replicating. It got its start at the Henry Ford Health System in Detroit, and has been used in health care systems throughout the country.

HARRISON: Henry Ford is a huge health system where the Zero Suicide effort began about four years ago. The results have been remarkable: over a period of two years, they have reduced the suicide rate among their patients by 80 percent.

ConvergenceRI: The funding for the program is for $2 million over five years. Is that correct?
HARRISON: Yes, $400,000 a year for five years.

ConvergenceRI: Can you describe what the specific uses of the money will be targeted?
HARRISON: About 65 percent of the money will be spent on patients who don’t have insurance that covers their mental health or behavioral health treatments, or they are under-insured, so that their insurance will not pay for it.

ORBAN: Zero Suicide is an effort that works to identify folks [through health organizations] that may be suffering from depression or have suicide ideation.

A big part of what we will be doing is training people and implementing standard protocols for screening, identification and follow up.

[Some of] the funding will go toward training folks and helping health care organizations set up systems for tracking patients and supporting patients. Part of that effort will be making adjustments to their electronic medical records so that they will be systematically screened and provided with follow up.

It will help us keep track of the progress we are making so that we work to improve the outcomes.

ConvergenceRI: Is this work part of the local Health Equity Zone collaboration?
ORBAN: It is part of the HEZ collaboration. When this grant opportunity came up, we knew that suicide was a very significant health issue in our community, so we gathered our partners together to apply.

We are taking a population health approach and implementing the program in multiple health care settings across the county.

In the first year, we are targeting emergency rooms at both Westerly Hospital and South County Hospital. We expect that we will learn along the way as go forward.

ConvergenceRI: How will the practice of trauma-informed care be integrated into the Zero Suicide program?
ORBAN: Trauma informed care is certainly considered a best practice. Folks who have experienced trauma in their lives, the research has shown, and as you know from you work around awareness about Adverse Childhood Experiences [toxic stress], there is a strong correlation between trauma and mental health issues.

[The connection] is something that definitely gets talked about in mental health first aid training, which is an evidence-based training that we will be part of this initiative.

Part of the reason why we received this grant is because we have such strong collaboration and we’re doing a lot of this work around community awareness and community training.

HARRISON: Part of the example of how trauma plays into this effort is the fact that first responders have a six-times higher suicide rate than other occupations, primarily because of the PTSD and trauma they experience. That is a significant causal area for us.

ORBAN: I have also heard you talk about the high suicide rate among physicians as well.

HARRISON: About 450 physicians take their own lives every year.

ORBAN: Part of the strategy and big part of what we have been doing already is to conduct trainings, educating people about the risks of suicide, and having these difficult conversations with folks about their mental health status, not only with patients but with their family members and colleagues.

That effort is critical to our ability to create a more compassionate community and to really be able to move the needle on this issue.

HARRISON: Stigma is a huge problem for people who have mental health problems in seeking help. All of our training programs try to address that: changing the language, changing the approaches about how to reduce the stigma, so that conversations around mental health suicide ideation become more acceptable for people to talk about.

ConvergenceRI: What other kinds of collaboration do you anticipate as you implement the new Zero Suicide initiative?
ORBAN: My office is co-located with the Community Health Team that is funded by the Care Transformation Collaboration, so we have regular interactions with Liz Fortin who oversees the work here in South County.

As part of the Zero Suicide program, we will be hiring a peer recovery specialist to help support patients who would benefit from support with treatment after an attempt or after a hospitalization. The peer recovery specialist will become part of the Community Health Team.

ConvergenceRI: One of the ongoing conversations around the work to prevent and intervene around drug overdose deaths is whether new metrics are needed rather than just measuring how many people died from drug overdoses, which is considered by some a perverse metric that doesn’t capture many of the successful outcomes.
As you move forward with implementing Zero Suicide, will you also be considering different metrics other than how many people committed suicide?
HARRISON: Some of the measurements we will be tracking are: how many people are screened, how many people have been screened positive, and how many people are followed up with [care], which should be 100 percent.

All the numbers will be followed, analyzed and evaluated by professional analysts from Yale-New Haven.

ORBAN: Yale-New Haven will be providing the evaluation of our grant performance. The other piece we are going to implement is PHQ9, which is a standard screening tool that asks about depression and thoughts of suicide.

It is a comprehensive screening to identify patients that may not be suicidal but are experiencing depression, so that we can hook them with treatment as well.

HARRISON: About 65 percent of the people who have mental health problems are also substance abusing – people who have diagnosable mental health problems are self-medicating and abusing substances.

Some research has suggested that between 20-30 percent of drug overdose deaths are actually suicides, but that is hard number to pin down.

ConvergenceRI: What are the takeaways you hope that people get at the news conference?
ORBAN: First, the phenomenal collaboration that we have, that we have all of these health care institutions coming together, making a commitment to go after this really audacious goal of Zero Suicide in our community. I am so proud of that.

Second, that this effort is really about system change and culture change, and it’s going to be a long process. [Our goal is] to transform health care institutions, to be really thinking about, and working to make it part of what they do every day, to focus on the risk of suicide with every single patient.

People are going to be screened, and those that get identified, it’s not just going to be giving them a phone number to call, there are going to be warm hand-offs, so that folks are going to get the follow-up care and treatment they need.

Health care systems are among our biggest employers in the region. They are going to become real leaders in helping to understand stigma around mental health issues.

HARRISON: The overall answer is going to come from the community to reduce the stigma. Imagine if one in every 10 adults were trained in mental health first aid and in suicide prevention, with people being identified very early to be at risk and encouraged to get help.