In this episode of the Purpose in Practice podcast, ACU’s Rick Brown speaks with national suicide prevention expert Dr. Virna Little, Co-Founder and Special Advisor for Advocacy & Research at Concert Health and the Co-Founder and Chief Operating Officer of Zero Overdose, about the overall scope of suicide as a public health crisis, the role of healthcare providers and staff in suicide prevention, ACU’s Suicide Safer Care program, and more.

Are you having suicidal thoughts? You’re not alone, and help is available: Call or text 988 for 24/7, confidential help from the Suicide & Crisis Lifeline, or chat online.

Full Transcript

Rick Brown: If there was just one myth that you could dispel about suicide, what would it be?

Dr. Little: That suicide is not preventable, that there are people who are just heck bent on dying by suicide, and there’s nothing we can do about it. When I was trained, I was told, oh, you’re going into behavioral health field, like you’re just going to lose some people to suicide, and we now know that those are preventable deaths. And so that to me would be one of the biggest myths—that these deaths are not preventable. They are preventable.

Rick Brown: Hello, my name is Rick Brown and I am the Associate Director of Communications and Membership with the Association of Clinicians for the Underserved. I’m here today with Dr. Virna Little co-founder and special advisor for advocacy and research at Concert Health. She’s also the Chief Operations Officer and co-founder of Zero Overdose, as well as a member of the Association of Clinicians for the Underserved’s Advisory Council. She’s a nationally known suicide prevention expert. It’s a pleasure to have you with us, Dr. Little.

Dr. Little: Thank you. I’m really glad to be here.

Rick Brown: I wonder if we could start by having you tell us a little bit about yourself and your professional background.

Dr. Little: Sure. I’m a psychologist and social worker by trade, and I’ve been working in primary care healthcare, particularly federally qualified community health centers for many, many years now. And that’s actually how I started doing some of the suicide prevention work is I was running behavioral health services for a large FQHC network, and I started to notice that we were having more suicides and more suicide attempts, and so I really started to think about what could we do to try to put some systems in place to identify and support those patients.

Rick Brown: I’m curious about how that journey evolved over the years.

Dr. Little: So, I think it evolved a lot. One of the things that we really started to think about was how do we know how many people are at risk for suicide in our organization and how do we train staff and who do we train and what needs to happen differently in primary care and behavioral health visits? And I started to realize that even though we had behavioral health and primary care services, many of the people who were dying by suicide were actually only seeing our primary care providers and hadn’t even been connected to behavioral health. I started to think about what we could do differently in our school-based health centers. We unfortunately had a 12-year-old die by suicide, and I started to think, how could we identify those kids that might be at risk and what could we do differently in our primary care and behavioral health services in the school-based health centers? And so that’s how it really evolved over time.

Rick Brown: For those who may not be familiar, what is the scope of the crisis of suicide in the United States?

Dr. Little: I mean, when I think about the fact that we’re going to lose over 50,000 people this year to suicide, and those are just the people that we know about, we know that many deaths don’t go classified as suicides as an example. So to me, that’s an incredible number of lives lost, and we know that those are preventable deaths. When I think about the number of geriatric patients and how about 18% of those deaths are actually seniors who never get connected to behavioral health services. And when I think about the number of youth and that a little more than 10% of the youth in this country and high schools are going to try to die by suicide, so, not think about suicide, but actually have an attempt. And I think those numbers are just continuing to increase, and I think most people don’t know what a dire situation it has become.

Rick Brown: I think when you illustrate it in those numbers, I think the truly staggering impact becomes very, very clear. I’m wondering too, oftentimes we’ll see suicide sort of viewed popularly as the outcome of mental illness or of depression alone. I’ve seen you note before that suicide rarely stems from a single cause or from behavioral conditions. What plays a role here?

Dr. Little: So one of the things that we’ve learned is that many people who die by suicide don’t have a mental illness at the time of death. They’re not people who have been known to their community mental health center as an example. And so we’ve learned that what really plays a role are the social determinants, the housing, the finances, the employment. All of those play a huge role in placing somebody at risk for suicide. And oftentimes when we’re thinking about suicide, we automatically think depression, but in actuality, anxiety is a huge risk factor for suicide. And so really changing the way we think about who’s at risk for suicide is going to be important.

Rick Brown: Absolutely. Oftentimes we’ll see suicide prevention portrayed really as sort of the province of behavioral conditions, but you’ve always argued for a holistic approach. I’m curious why is suicide prevention important for the entire healthcare field especially and including primary care?

Dr. Little: There’s a couple of reasons. It’s really important to focus on primary care. Firstly, what we know is that many of the people who die by suicide saw their primary care provider in the month of death. The other thing that we’ve learned is individuals who are not connected to care, so not primary care, mental health, even dental, they actually resurface in the month of death into primary care. We also know that many times, like for adolescents as an example, or children, they see their primary care provider and may not have exposure to other systems. And so primary care becomes a really important piece in identifying and caring for individuals who are at risk for suicide.

Rick Brown: That makes a lot of sense. I’m curious, just to build on that too. You recently authored an article with others in health care scholar on the prevalence of suicide risk and a sample of people who were referred from primary care subpopulations. I’m just curious to learn, what did you find in that study?

Dr. Little: The purpose of that article was to really raise the flag and to let primary care providers know this is what we’re seeing in the patients that you’re referring for behavioral health. And when we say 10 to 14% of those patients are at risk for suicide, really meant to say many of them that you’re referring for behavioral health needs, you’re not referring for suicide risk. And yet we’re finding that 10 to 14% of them are actually at risk for suicide. So this is how many people in your practice that are at risk for suicide, and these are just the ones that you’ve identified. And so really trying to say to providers and to provider organizations, you have an increasingly growing number of individuals at risk for suicide, and we really want you to pay attention because maybe you’re not aware of how many people you actually may have in your system that are at risk or your practice that are at risk.

Rick Brown: I’m wondering, the need is clear, but how can primary care clinicians and organizations get started in terms of playing a role, playing a necessary role in suicide prevention?

Dr. Little: The first is to really ask about suicide. And one of the things we know is we’re not going to give anyone any ideas. Like I often hear from pediatric providers, we’re afraid to ask because we don’t want to give kids any ideas. And the reality is kids already know about suicide, and the research overwhelmingly says if we ask about suicide, we’re not giving someone an idea. And so to ask about suicide and ask very directly, many of my patients who are struggling like you are, think about suicide. I’m wondering if you are thinking about suicide. So that we’re asked very clearly. There’s also some tools out there like the ASQ or the Columbia Scale, the C-SSRS that actually can be used in primary care. There are five or six questions they can be used in primary care across populations to ask very specifically about suicide. So screening and asking directly about suicide is one of the best things that you can do. And then the second is to learn what to do when somebody says yes, so that you have a response, thank you for telling me or thinking about suicide, that you have the ability to understand risk and to make sure people get the appropriate care that they need.

Rick Brown: On an organizational level, too, I’m curious, does this start with a commitment? Does it start with an idea of seeing suicide prevention as a clinical priority?

Dr. Little: It absolutely stems from seeing suicide prevention as a clinical priority. And I think that comes from understanding the prevalence. When you think about adolescents or high school students, what other chronic illness or health concerns do those adolescents have where more than 10% of them are actually affected in some life-threatening way? And so really thinking about when we think about it that way, then it really needs to be a clinical priority. We need to be asking about it, addressing it, and putting some clinical pathways in place to care for individuals and not just to identify them, but what happens when that person comes back for care? Do we ask them if they’re safe? Do we have suicide on the problem list so that we know that they’re at risk?

Rick Brown: That makes complete sense. I’m wondering as well, what can individual clinicians do? And honestly, just thinking more broadly, do staff have to be clinicians to be able to play a role?

Dr. Little: No, absolutely not. We know that one thing that saves lives or what saves lives more than anything else is giving someone hope. And anyone can give someone hope. Anyone can ask someone if they’re safe. Anyone can ask someone if they’re thinking about suicide. So that should be brought across the entire organization. And what individual clinicians can do, primary care, behavioral health is they can put suicide risk on the problem list so that they know how many people in their practice, on their panel, in their organization are at risk. It’s a quality issue so that someone else can ask them if they’re safe, make different decisions. So it’s really important that we get that suicide risk on the active diagnosis or problem list.

Rick Brown: You mentioned a little bit about resources like the ASQ that can be of assistance. Are there any other resources that can be helpful?

Dr. Little: Yeah, I think one of the things that is helpful for particularly primary care providers is to be able to give individuals 988, to have them actually put 988 in their phone. 911 is a little more baked in for people than 988. So I actually have them put it in their phone. So if they’re struggling, they have it right there. Most of the calls to 988 actually get resolved on the first call. It’s been shown to be helpful for individuals at risk. So that’s a really important evidence-based resource that is available 24 hours a day for people. I would also say the NowMattersNow website, pull it up on their phones, save the spot, another evidence-based resource right at somebody’s fingertips. So giving people those two resources is incredibly helpful.

Rick Brown: Thank you for sharing this. I’m interested as well, just thinking more broadly. We’ve all heard too about the endemic stress, the burnout, and the moral injury that the healthcare workforce is facing. Does the risk of suicide impact play a role with clinicians themselves as well?

Dr. Little: It sure does. We know that nurses, particularly female nurses, have a much higher prevalence of death by suicide than the general population. We know that we lose about a physician a day to suicide. So healthcare workers are especially impacted by suicide and suicide risk. And so when we think about doing education and training, we really do it to not only impact how organizations care for patients, but how they can ask each other about suicide or know what to do if someone in the lunchroom or on social media makes a suicidal statement or sends a suicide risk message.

Rick Brown: I’m wondering too, are there any other steps that organizations can take in terms of suicide prevention for staff or simply wellness for staff?

Dr. Little: I think part of it is training so that we talk about suicide, we talk about behavioral health. When we think about information that we might give new employees at a new hire orientation information on 988 or NowMattersNow. Letting them know what their behavioral health benefits are and how much it might cost, letting them know that that information won’t be shared with the organization or with their employer, that seeking care or treatment won’t impact their ability to be promoted or to advance their careers. And also for individuals who maybe where there’s a copay and they’re not able to afford the copay, what are some other resources like 988 or other free resources in the community that individuals might take advantage of.

Rick Brown: For the past few years as well I’ve really been glad to be able to work with you on the Suicide Safer Care program, and I’m wondering for those who may not be familiar with it, could you describe a bit about the origin of the program and what it hopes to accomplish?

Dr. Little: Yeah. I’ve been really proud to be a part of the National Zero Suicide Initiative and part of the faculty in training organizational leaders and clinicians to be zero suicide. And it’s been an incredibly impactful initiative. But one of the things sort of working in primary care my whole career is, I would be there with healthcare organizations and realize that I wasn’t convinced that it was going to change what was happening in a primary care visit for people who might be at risk for suicide. And so the Suicide Safer Care Initiative and training developed with ACU was meant to be a really informational piece on what primary care providers can do during the course of a 15-minute primary care visit. So what can I actually do to identify and care for someone at risk during a standard visit? And that’s been incredibly successful. And I think now you and I together have trained over 4,000 primary care providers and their teams in 32 states.

Rick Brown: It’s a little hard to believe, honestly.

Dr. Little: I know. It’s been fun though. It’s been fun.

Rick Brown: Thinking just more broadly in terms of practice transformation, I’m just wondering, would you have any thoughts or insights on how just healthcare and as a whole can work to advance suicide prevention?

Dr. Little: I think it needs to be part of training. I know as a behavioral health provider, one of the things that we learned, right, was that behavioral health providers in the health centers where we were training, 44% of them said, I don’t feel comfortable or competent to care for someone at risk for suicide. And that’s incredibly stressful for those providers and risky for patients. And so when I think about what needs to happen is training really as part of training schooling. So for me as a behavioral health provider, I was never trained in my master’s in social work, my doctorate in psychology. Nobody ever really trained me to identify and treat someone at risk for suicide. And I worked in emergency rooms and hospitals in community health centers. And so I think we really need to bake it into the curriculum for nursing, for primary care providers of all disciplines, behavioral health providers of all disciplines. To me, that’s an absolutely critical next step.

Rick Brown: If there’s one thing you wish people did know about suicide or prevention, what would it be?

Dr. Little: That regardless of your role, your background or your training, that you’re able to give someone hope and you’re able to save lives. And so your ability to ask someone whether or not they’re at risk for suicide, to share the lifeline, to share some resources, those are all things and activities that give someone hope and can save lives. So I really strongly encourage you practice at the dinner table, at the staff meeting in the car with your family, talk about suicide. What would we say to someone who told us they were thinking about suicide? And so that everyone knows.

Rick Brown: I think that truly encapsulates it, that everyone can play a role.

Dr. Little: Absolutely, yes.

Rick Brown: In closing, we’ve spoken about quite a few different things and covered a lot of ground. I’m wondering, would you have anything that you’d like to add?

Dr. Little: I think it’s to really think about, particularly in your practice, how can we build in suicide safer care? How can we increase the number of people that we’re screening? What does that look like? How can we develop a clinical pathway so that we can take excellent care of someone at risk for suicide? How can we be thoughtful about our responses? How can we create an organization where patients and team members feel safe and feel comfortable to talk to us about their thoughts of suicide?

Rick Brown: Thank you so much for joining us today, Dr. Little. Honestly, I think suicide prevention has never been more important. I think some of the staggering figures and insights I think that you provided really illustrate that. So thank you so much again for taking time to speak with us.

Dr. Little: Thank you. It’s a pleasure. As always.

Outro: Thanks for listening to this episode of ACU’s Purpose in Practice podcast. We hope you enjoyed our conversation. You can access all our episodes, including show notes and links as well as learn more about ACU on our website at