Addressing Suicide Prevention Among a High-Risk Population

Members of NCHATS, including representation from stakeholders, institutions, and investigators, at their first in-person meeting.

Suicide is a leading cause of death in the United States, with one suicide reported every 11 minutes. As with other serious public health challenges, suicide does not discriminate, and people of all genders, ages, and ethnicities can be at risk. According to the National Institute of Mental Health (NIMH), however, certain identifiers can determine populations at an increased risk.

Among the groups with a higher risk: Individuals coming into contact with the criminal legal system.

Jennifer Johnson, a C.S. Mott Endowed Professor of Public Health with Michigan State University's College of Human Medicine, is working to prevent suicides in this population through community-based research and transdisciplinary collaboration.

"The idea is that involvement with the criminal legal system, which can include anything from initial 911 calls, arrests, police contacts, and even parole and probation, is an indicator for suicide risk in the general population," Johnson said.

Johnson and her partners, Brian Ahmedani, from Henry Ford Health, and Lauren Weinstock, from Brown University, established the National Center for Health and Justice Integration for Suicide Prevention, or NCHATS. Funded by a $15 million grant from NIMH, the center focuses on suicide prevention research and combines the expertise of stakeholders, investigators, and institutions. The goal of NCHATS is to implement scalable, sustainable, and effective suicide prevention strategies between justice and health care systems to identify individuals at a high risk of suicide and connect them to community care resources.

Bridging the Justice and Community Health Systems

"One of the challenges with suicide prevention research is finding at-risk individuals the moment they're at risk," Johnson said. "Justice-involved individuals have high rates of suicide risk factors, including substance use and mental health challenges, and having contact with the criminal legal system is an indicator that things are not going well."

From 2016-2020, Johnson and Weinstock conducted a randomized trial of suicide prevention with people briefly involved with the justice system — jailed for a few days, then released — and focused on the year immediately following their release. Their findings revealed a greatly elevated risk for suicide among this population.

Forthcoming research conducted by Johnson's team suggests that more than one fifth of U.S. adults who die by suicide have spent at least one night in jail in the past year.

"A lot of people who are brought into jails are under the influence of drugs/alcohol, or experiencing psychosis or manic episodes," Johnson said. "The priority for jail staff is to keep these individuals alive, and most are released back to the community within days."

This leaves little time, resources, and bandwidth for jail staff to initiate a warm handoff to community health providers following the individual's release. Conversely, community health organizations are often uninformed about whether someone receiving their services has been temporarily detained in jail, potentially indicating worsening symptoms.

"While there have been attempts to connect the two systems, the connection has long been dependent on someone from a community health care organization going to the jails and looking through booking and release data for names they recognize, which is labor-intensive. It just isn't a scalable way to identify individuals who need to be connected back to community services," Johnson said.

Coordinating Care

Counties, which typically run jails, probation, and parole services, as well as many community mental health and substance use treatment systems, bear the brunt of care for the vast majority of justice-involved individuals. They also struggle with overuse of incarceration for those with mental health challenges and substance use disorders and lack of health care services for current justice-involved individuals in the community.

There are more than 3,000 county and local jails across the U.S. with differing access to electronic health systems. What access they do have may not be compatible with other systems. Making the connection between multiple systems to reconnect high-risk, justice-involved individuals to community behavioral health services would take an immense level of IT support.

To find more scalable ways to coordinate care between health care and justice systems, Johnson connected with a Medicaid managed-care organization in Ohio called CareSource.

"They've done something really clever," Johnson said. "As the Medicaid payer, they have access to claims data that is protected under confidentiality laws. On the other hand, most jail booking and release data are publicly available. With advances in biomedical informatics, computer programs are now able to search text data to identify names, allowing health care organizations to crosswalk their patient lists against publicly available jail records to identify who has recently been admitted or released from jail."

This approach solves the linking problem between the two systems, she said. By searching names from inside the managed-care organization, high-risk individuals can be flagged, letting providers know that someone who receives their services was recently booked into or released from jail and may need additional suicide prevention, mental health, or substance use care.

"When I came across this I thought, 'This is the answer we've been looking for,'" Johnson said.

Exploring Suicide Prevention Strategies

NCHATS is currently using CareSource's model to help health systems identify when their patients come into contact with police or jails in order to implement effective suicide prevention interventions across multiple projects in multiple states.

"NCHATS has four projects being conducted right now, each exploring a different prevention strategy," Johnson said. "But they all nudge health systems to scan data about contact with police, jail, etc., and apply evidence-based suicide prevention interventions."

One intervention strategy NCHATS is assessing is the use of "Caring Contact" cards. In this project, cards will be sent to 43,000 Medicaid subscribers per year in Ohio who have been flagged as recently released from jail.

"The cards are simple and cost-effective, while letting the individual know that people are available and ready to help them," Johnson said. "Letting them know that someone cares really matters."

NCHATS is researching another approach using claims data that identifies people who have recently been released from jail and seen their behavioral health or substance use provider within the past six months.

"We'll reach out and let the health care provider know that an individual receiving services from their organization went through jail, and they may be at an elevated risk for suicide," Johnson said. "We'll ask providers to do a suicide risk assessment, and, if needed, we'll provide evidence-based training to better equip them to assist these individuals. From there, we rely on the expertise of clinicians from the individual organizations to follow up."

NCHATS consortium partner panel

Working Together to Solve a Common Problem

MSU was named as the fiduciary of the grant, but Johnson shares responsibilities overseeing NCHATS with two other principal investigators:

• Brian Ahmedani, Ph.D., director of the Center for Health Policy and Health Services Research and Psychiatric Research at Henry Ford Health in Detroit, and
• Lauren Weinstock, Ph.D., professor of psychiatry and human behavior at Brown University in Providence, Rhode Island.

Johnson, Ahmedani, and Weinstock, along with their respective institutions, bring their own expertise to NCHATS while also relying on the varied skill sets and knowledge bases of investigators from 15 organizations and a large set of local, state, and national community partners. Partners represent jails, courts, health systems, and individuals with lived experience.

One institution NCHATS has partnered with is the Addiction Policy Forum (APF), a nationwide nonprofit organization dedicated to individuals and families struggling with the disease of addiction.

Jessica Hulsey, founder and CEO of APF, has spent her career looking at the intersection between criminal justice involvement and behavioral health conditions such as addiction and mental health challenges.

She and Johnson first met through a research partnership at George Mason University looking at principles of stakeholder engagement.

Hulsey said Johnson had a vision for community participation in NCHATS from the start, so once they connected and began talking, APF was happy to be involved in the groundbreaking efforts to address suicide and suicide prevention.

"We're excited to provide engagement from a diverse set of stakeholders to enhance the work of NCHATS," Hulsey said. "Finding solutions to complicated problems that are often overlooked or ignored is what our partners do, and we can learn so much from building a big table where listening to our peers is encouraged."

Next Steps

NCHATS is in its first year of a five-year grant and will continue assessing suicide prevention strategies and demonstrating scalable ways to prevent suicide among high-risk, justice-involved individuals across the U.S. Center research projects will include data from more than 100,000 individuals in four states to evaluate intervention effectiveness.

Johnson said the research explicitly includes implementation science to encourage policy change, with the goal to make the center's intervention approaches and strategies standard practice.

Looking forward, Johnson said the approach NCHATS is using could prove beneficial in addressing other serious public health challenges that are over-represented in those coming into contact with 911, police, jails, etc., including substance use disorders, mental health problems, partner violence, and many infectious diseases.

"For a variety of reasons, people who are marginalized and people with heavy burden of many diseases are more likely to come across police than health care providers," Johnson said. "What this approach allows us to do is connect them back to health care providers at scale. This is a huge public health win because the health systems can have a hard time reaching many of our most vulnerable people."

By sharing data between the justice and health care systems and applying effective suicide prevention intervention strategies, the leaders of NCHATS hope to expand and enhance the public health response to suicide prevention, especially for people not well-connected to care.

Learn more about NCHATS