The origins of the Zero Suicide Framework

The two programmes that provide the basis for the ZSF are the US Air Force Suicide Prevention Program (‘US Air Force Program’), which ran from 1996 to 2002,^{Reference Knox, Litts, Talcott, Feig and Caine3} and the Perfect Depression Care initiative by Henry Ford Behavioural Health Services (HFBH), which was initiated in 2001.^{Reference Coffey4} However, there is limited evidence regarding the effectiveness of both these programmes.²

Aspiring towards zero suicides: Australian case study

In 1997, a formal evaluation of Australia’s national mental health policy recommended the introduction of effectiveness markers to assess the impact of the policy, including reduced suicide prevalence. Accordingly, in 1998, the Second National Mental Health Plan included suicide reduction as a key outcome for measurement and, in 2003, the third National Mental Health Plan made an explicit link between mental illness and suicide.¹⁶

More recently, interventions based on the ZSF have served as a guiding post for mental health policy and planning. The Queensland State Government has explicitly adopted the ZSF¹⁷ while other states, such as New South Wales,¹⁸ Victoria¹⁹ and South Australia,²⁰ have implemented strategies with similar aspirations to work towards zero suicides. In March 2022, the Australian Federal Government allocated 46 million dollars of the 2022–2023 budget to associated initiatives, noting that, ‘as we work towards our goal of zero suicides, we are building upon our record investment in suicide prevention’.²¹ To date, however, the evidence for these interventions is sparse.

Stapelberg et al^{Reference Stapelberg, Sveticic, Hughes, Almeida-Crasto, Gaee-Atefi and Gill15} evaluated the efficacy of a clinical suicide prevention pathway (SPP) based on the ZSF in a Queensland mental health service in a total of 604 persons with 737 suicide attempt presentations between 1 July and 31 December 2017. They compared the rates of consecutive hospital presentations or re-presentations for those on the SPP to those who were not because of a non-specific and broad range of individual and clinician factors. The SPP lasted, on average, for 16 days and was found to be most efficacious in the first 14 days, with higher rates of repeated suicide attempts at 90 days in both groups. Notably, this study did not demonstrate evidence of decrease in actual suicides, only decreased re-presentations with suicide attempts to the hospital emergency department, as one would arguably expect when receiving face-to-face follow-up care following an attempt. A further evaluation of the SPP was conducted through analysis of cumulative rates of suicides in the 4 years before (2013–2016) and 3 years after the implementation of the SPP (2017–2019).^{Reference Turner, Sveticic, Almeida-Crasto, Gaee-Atefi, Green and Grice22} This demonstrated a reduction of 23.3% in the rate of mental health consumers who died by suicide since its implementation. However, like the previously mentioned Perfect Depression Care study, a graph illustrated this impressive decrease, but no absolute numbers were provided.^{Reference Turner, Sveticic, Almeida-Crasto, Gaee-Atefi, Green and Grice22} To our knowledge, no follow-up studies have been published to investigate the effect on re-presentations or actual suicides in the long term.

Potential consequences of the Zero Suicide Framework

There is some evidence for developing mental health services with elements similar to the ZSF. As exemplified in England and Wales and evaluated by While et al,^{Reference While, Bickley, Roscoe, Windfuhr, Rahman and Shaw23} developing such services can lead to laudable outcomes even if this may not have a significant impact on suicide rates in the general population. This highlights that using suicide as an end-point indicator of health system functioning may be misleading.

The ZSF advocates for assigning suicide a special status as a major marker of a healthcare system’s performance. Suicide is a rare and complex phenomenon with multiple socioeconomic-environmental confounders that extend beyond the remit of psychiatry or even healthcare.^{Reference O’Connor and Nock24} The analysis of suicide trends requires long historical data, adequate sample sizes that allow adjustments by age, gender and other population characteristics, complex approaches to data analytics, including interrupted time series,^{Reference Alvarez-Galvez, Salinas-Perez, Rodero-Cosano and Salvador-Carulla25,Reference Pirkis, Gunnell, Shin, Del Pozo-Banos, Arya and Aguilar26} and the adoption of a health ecosystem approach^{Reference Furst, Bagheri and Salvador-Carulla27} that could explain variations across regions, local areas and over time.^{Reference Caine28} While suicide is a sentinel event that could be used as an indicator of flaws in the care system, this metric must be considered with caution and with reference to multiple integrated markers within the local context.

When suicide is selected as an end-point driver of mental health care reform, there are many potential adverse consequences that we must consider. First, given the broad objective of suicide prevention, there is a risk of surrogation effect in which concrete metrics of suicide rates, suicide attempts and suicidal thoughts replace the ultimate goal of suicide prevention, particularly where healthcare systems readily accept such substitution.^{Reference Rosen, Rock and Salvador-Carulla29} This would then misguide the direction of mental healthcare provision and reforms. For instance, where suicidal ideation or attempts are designated as key items that drive access to acute care and complex services, patients who are not suicidal but equally require specialist mental health support (e.g. those with severe anxiety or depression) are likely to experience barriers in accessing care. This may have the paradoxical effect of exacerbating mental ill health, a risk factor for suicide.^{Reference Zalsman, Hawton, Wasserman, van Heeringen, Arensman and Sarchiapone30}

Where mental health services focus on suicide elimination as a target, it leads to an overemphasis on acute over chronic and/or preventive care, undermining the strength and scope of community models of mental health care.^{Reference Rosen, Gill and Salvador-Carulla31,Reference Thornicroft and Tansella32} It may also disincentivise the balanced provision of care across different mental health conditions and target populations. While the ZSF champions tailored care, the opposite may occur at the clinical coalface as the focus on assessing suicide risk is likely to divert resources from a comprehensive psychiatric formulation towards more defensive, algorithmic medical practice. The aspirational goals must be translatable into an actionable strategic plan that accounts for such potential consequences; otherwise, a detachment between mission and planning is likely to result.^{Reference Lega, Longo and Rotolo33}

Towards broader, multifaceted evidence-based strategies

Suicide prevention requires more than healthcare solutions. The narrow focus on preventing suicide through healthcare alone is a major limitation that hampers the ability of the ZSF to adequately address the complex challenges associated with suicide prevention. Suicide prevention efforts must be multifaceted and involve a whole-of-government and whole-of-community approach given the important social determinants of mental ill health and suicide.^{Reference Shand, Yip, Tye and Darwin34} These are the factors that affect social, economic and physical environments; for example, poverty, unemployment, homelessness, substance use and domestic violence. Thus, strategies must engage all levels of the health ecosystem^{Reference Rosen, Gill and Salvador-Carulla31} and non-health sectors, including media regulations, means restriction, drug and alcohol laws and gatekeeper training.

In contrast to the ZSF, which operates only in healthcare settings, multi-component approaches to suicide prevention, such as the LifeSpan and the European Alliance Against Depression (EAAD), include essential community-based interventions at the population level adapted to the local context.^{Reference Baker, Nicholas, Shand, Green and Christensen14} The LifeSpan approach combines nine evidence-based suicide prevention strategies for simultaneous implementation within a community-led framework with local-level governance for a tailored, coordinated approach. Programme components include universal prevention strategies such as means restriction and public awareness raising campaigns; selective prevention strategies such as training to upskill frontline responders to support individuals with suicidal ideation or self-harming behaviours and capacity-building of general practitioners (GPs) in suicide detection; and indicated strategies such as the establishment of aftercare services in areas of need.^{Reference Shand, Torok, Cockayne, Batterham, Calear and Mackinnon35} There is a paucity of evidence regarding the effectiveness of this approach.

Similarly, the EEAD is a broad, community-based, multi-faceted approach that simultaneously targets depression and suicidal behaviour and includes early clinical interventions and community and population health interventions.^{Reference Hegerl, Maxwell, Harris, Koburger, Mergl and Székely36} Its four-level intervention strategy targets (a) GPs with capacity-building in diagnosis and treatment of depression and suicidality, (b) the general public with public awareness campaigns, (c) community facilitators with training to improve the health literacy of target groups, such as priests, policemen, pharmacists and journalists, and (d) at-risk individuals and their next-of-kin with interventions to improve knowledge, promote self-help activities and facilitate help-seeking behaviour.^{Reference Hegerl, Maxwell, Harris, Koburger, Mergl and Székely36} A recent systematic review of population and community-based interventions to prevent suicide found promising evidence for the EEAD relative to other interventions^{Reference Linskens, Venables, Gustavson, Sayer, Murdoch and MacDonald37}; however, the results of the EAAD study itself were equivocal.^{Reference Hegerl, Maxwell, Harris, Koburger, Mergl and Székely36}

While the heterogeneity of suicide prevention strategies and outcome measures continues to limit conclusions about the effectiveness of specific suicide prevention strategies,^{Reference Zalsman, Hawton, Wasserman, van Heeringen, Arensman and Sarchiapone30} broader strategies like the EEAD and LifeSpan are more likely to be effective than narrow ones like the ZSF, particularly as the specific target of zero suicides in the latter is more likely to distort optimal resource allocation.^{Reference Rosen, Rock and Salvador-Carulla29} Indeed, the dramatic decline in suicide rates in countries such as Denmark and Finland has been attributed to intentional, broad strategies with collective alignment of local, regional and national priorities from a socio-ecological perspective, rather than one based exclusively in health systems.^{Reference Caine28}

Using suicide prevention as a key indicator of mental health system performance may distract from broader, more impactful opportunities for mental health reform; for instance, earlier intervention and community-based rather than healthcare-focused settings. One such zero suicide approach, the ZSF, has inspired suicide prevention polices in mental health care settings in a number of countries. However, as we have highlighted, the seminal studies that provide the foundation of the ZSF have limited evidence of efficacy in mental health settings. Twenty years after its release, and despite wide endorsement, funding and implementation, there is a dearth of published evidence demonstrating success for the ZSF in achieving the stated aim of suicide reduction anywhere in the world. Importantly, the narrow focus on suicide prevention within healthcare settings neglects appreciation of the complex socioeconomic-environmental phenomena that underlie suicidality.

The ZSF is an arguably vague framework with a scant evidence base, particularly for application in healthcare settings. Despite this, the concrete goal championed by the ZSF, that of ‘zero suicides’, is appealing and has been widely promulgated in mental health services, ahead of evidence for the same. It is wise to consider if we may be diverting resources from core mental health care and public health investments that may be more effective in tackling mental ill health and, in doing so, preventing suicides.