Zero Suicide Initiative – A model for reducing suicide in United States behavioral healthcare

Suicide is a serious public health concern in the US, especially for those served in outpatient behavioral health. Over the past decade, there has been a dramatic increase in US suicide rates, and a significant proportion of those dying by or attempting suicide were treated in outpatient behavioral healthcare within the prior year. In response, the US Action Alliance released the National Strategy for Suicide Prevention in 2012, a key tenet of which is the “Zero Suicide” (ZS) model. ZS provides resources for administrators and providers to create a systematic approach to quality improvement for suicide prevention in healthcare systems via seven essential elements (Lead, Train, Identify, Engage, Treat, Transition, Improve). In this paper, we describe the ZS model, as well as our operationalization of the model in an NIMH-funded study in ~170 free-standing New York State outpatient behavioral health clinics, serving >80,000 patients. This study is the largest implementation and evaluation of the ZS approach ever conducted in outpatient behavioral health. Evaluation of ZS implementation in “real-world” clinical settings will provide crucial insight regarding broader dissemination and inform how to best adopt empirically-supported care for suicidal patients in outpatient behavioral health, thereby reducing tragic and preventable loss of life.

ZS is a key component of the National Strategy for Suicide Prevention and priority of the National Action Alliance that aims to bridge gaps in practice. ZS is a strategic framework for creating a systematic approach to suicide prevention and quality improvement in the healthcare system with the aspirational goal of “zero suicides.” The foundational belief of ZS is that suicide deaths for individuals receiving care within health and behavioral health systems are preventable.1 The few healthcare systems that have implemented and evaluated ZS-like approaches demonstrated notable reductions in suicide deaths. It must be noted these studies were correlational and preliminary; it is extremely challenging to prove that a reduction of suicides is causally related to a specific suicide prevention effort, and only large-scale, controlled evaluations of ZS procedures will establish their effectiveness. However, reductions of greater than 70% in the year after unveiling ZS interventions are certainly promising. The ZS model provides guidance on how to best implement “best practices” in “real-world” settings. ZS is comprised of seven essential elements for an effective, coordinated system for suicide care; four of these elements focus on how the patient should be treated and the remaining three relate to implementation factors.

Suicide is an enormous public health concern, and ZS has been promoted as a way to reduce suicides for those receiving services. Our study is the largest implementation and evaluation of the ZS approach in outpatient clinics ever conducted. Results from this study will provide crucial insight regarding how to best adopt and disseminate empirically-supported suicide-safe care, thereby reducing preventable loss of life.

Population: Everyone


  • Read the full journal article ““Zero Suicide” – A model for reducing suicide in United States behavioral healthcare“.
  • Learn more about the Zero Suicide Initiative.
  • Access the Zero Suicide Initiative Toolkit.
  • Access the Zero Suicide Initiative Resource Library.

Date: 2020