On an ordinary morning in 2010, a man in his 50s arrived at a Henry Ford Medical Group office in Detroit for a psychiatry appointment. He too was ordinary—middle class, married, two kids. He hunted in his spare time. Lots of Michiganders do.
But in the last few years he’d had several hospitalizations for depression, and he had once attempted suicide. He was there for a checkup. His wife was with him.
“Do you have any guns in the home?” his psychiatrist when taking a history.
“Yes, a rifle. I like to hunt,” the man replied.
The psychiatrist explained the risks, including that once you’ve had three major depressive episodes—as this man had—your risk of having another is around 90%, and that firearms account for more than half of all suicides in the U.S.
“I’m hoping we can get the gun out of your home,” the psychiatrist said. “Do you have anyone you can give it to?”
“Yes, I have a brother. He works in law enforcement,” the man said, and he promised to take care of it.
Soon after, the psychiatrist called the man’s wife to confirm that the gun was no longer in their home. She confirmed it wasn’t.
Over the next several years, the man continued in treatment and improved significantly through a combination of psychotherapy and medication, and his depression went into remission. His psychiatrist set his checkups for every six months.
“If you notice any problems,” the psychiatrist told the man and his wife, “give me a call.”
Then one evening, the man’s wife came home and found him cleaning his gun. Hunting season was coming up, so she didn't think much of it. She put herself to bed. Shortly after, she was awakened by a gunshot. He had killed himself.
“He had been doing well for a couple of years,” his wife later told the psychiatrist. “We didn't think the gun mattered anymore, so we gave it back to him.”
A goal of zero
By then, stories like this were vanishingly rare in Henry Ford’s behavioral health patient population. In fact, in the previous year, not a single mental health patient had died of suicide.
This wasn’t accidental or just a blip in outcomes. Zero suicides was the top-level goal when the behavioral health services division imagined its Perfect Depression Care initiative, in 1999. It grew out of a challenge from a grantor: Create a program that would demonstrate “perfect health care.”
“Our psychiatry team had a long debate about what they could do for patients diagnosed with depression and what they could do about suicide specifically,” says Cathrine Frank, MD, chair of Henry Ford’s psychiatry/behavioral health service line and one of the architects of the zero suicides concept. “One of the questions they asked themselves was, ‘What’s the acceptable number of suicides in the population we’re managing?’ They decided the only perfect outcome would be zero suicides, so we designed a program to try to eliminate it entirely.”
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Read this story in its entirety as featured in the fall issue of AMA Moving Medicine.
