Zero Suicide Model Implementation and Suicide Attempt Rates in Outpatient Mental Health Care
Authors: Brian K. Ahmedani, Robert B. Penfold, Cathrine Frank, Julie E. Richards, Christine Stewart, Jennifer M. Boggs, Karen J. Coleman, Stacy Sterling, Bobbi Jo H. Yarborough, Gregory Clarke, Michael Schoenbaum, Erika M. Aguirre-Miyamoto, Lee J. Barton, Hsueh-Han Yeh, Joslyn Westphal, Sarah McDonald, Arne Beck, Rinad S. Beidas, Laura Richardson, Jacqueline M. Ryan, Edward T. Buckingham, Stuart Buttlaire, Cambria Bruschke, Jean Flores, Gregory E. Simon
Journal: JAMA Network Open (2025)

Importance Suicide is a major public health concern, and as most individuals have contact with health care practitioners before suicide, health systems are essential for suicide prevention. The Zero Suicide (ZS) model is the recommended approach for suicide prevention in health systems, but more evidence is needed to support its widespread adoption. Objective To examine suicide attempt rates associated with implementation of the ZS model in outpatient mental health care within 6 US health systems. Design, Setting, and Participants This quality improvement study with an interrupted time series design used data collected from January 2012 through December 2019, from patients aged 13 years or older who received mental health care at outpatient mental health specialty settings within 6 US health systems located in 5 states: California, Oregon, Washington, Colorado, and Michigan. Analyses were conducted from January through December 2024. Exposure The ZS model was implemented in 4 health systems at different points during the observation period (2012-2019) and compared with health systems that implemented the model before the observation period (postimplementation). Implementation included suicide risk screening, assessment, brief intervention (safety plan, means safety protocol), and behavioral health treatment. Main Outcomes and Measures The primary outcome was a measure of standardized monthly suicide attempt rates captured using health system records and government mortality records. Suicide death rates were also measured as a secondary outcome. Results There was a median of 309 107 (range, 55 354-451 837) unique patients per month. In 2017, there were 317 939 eligible individuals (63.2% female). Baseline suicide attempt rates were at least 30 to 40 per 100 000 individuals at each implementation site and decreased to less than 30 per 100 000 individuals at 3 sites by 2019. Decreases in suicide attempt rates were observed at 3 intervention health systems after site-specific implementation: health systems A and B had decreases of 0.7 per 100 000 individuals per month and C, 0.1 per 100 000 individuals per month. System D evidenced a similar suicide attempt rate after implementation (before implementation: median rate: 35.0 [range, 11.0-50.3] per 100 000 patients per month; after implementation: median rate: 34.3 [range, 18.5-42.0] per 100 000 patients per month). The 2 postimplementation health systems maintained low or declining suicide attempt rates throughout the observation period. The rate at system Y decreased by 0.3 per 100 000 individuals per month across the observation period. The rate at system Z began at 11 per 100 000 individuals per month and declined by 0.03 per 100 000 individuals per month during the observation period. Two systems evidenced reductions in the suicide death rate after implementation: system B declined by 0.2 per 100 000 individuals per month and system C by 0.1 per 100 000 individuals per month. Conclusions and Relevance In this quality improvement study, ZS model implementation was associated with a reduction in suicide attempt rates among patients accessing outpatient mental health care at most study sites, which supports widespread efforts to implement the ZS model in these settings within US health systems.