The State of Oklahoma began an initiative in 2016 to provide a system of care to the people of Oklahoma that would more rapidly and successfully deal with the growing problem of death by suicide.
William Morris, the Program Field Representative at the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS), said that before this initiative, “many clinicians didn’t know how to treat suicidal patients and were not capable of meeting suicidal ideation head on because they were uncomfortable talking about this topic.” Any person who had attempted suicide or who had a plan to kill themselves was immediately hospitalized and these hospitalizations included very little in the way of suicide-specific treatment. An imminent suicide risk was averted, but the suicidality was not treated and thereby remained a future threat. In lieu of being involuntarily hospitalized, some clinicians asked patients to sign suicide “no harm” contracts, a practice that has since been proven to be ineffective within clinical trials.
Implementing CAMS into Oklahoma’s System of Care
In 2014, Jackie Shipp, Senior Director of Treatment and Recovery at ODMHSAS, met Dr. David Jobes, the creator of the Collaborative Assessment and Management of Suicidality (CAMS), at the American Association of Suicidology (AAS) conference. Jackie recognized that CAMS would be a solution for the Oklahoma program to meet the goal of keeping suicidal patients out of hospital except in the most extreme cases and providing high quality care and treatment in outpatient clinics. The ODMHSAS began contracting with Dr. Jobes to provide CAMS training in Oklahoma. Within the first few years, CAMS trainings were required for those with mobile crisis service contracts. Success with this partnership formed the foundation for Oklahoma’s Zero Suicide Initiative in 2016.
“The CAMS model stresses the importance of identification and continued contact with patients at risk, at all levels—from hospitals to doctors’ offices to community health care centers,” says the Interim Commissioner, Carrie Slatton-Hodges. “These are critical components of the Zero Suicide framework.”
Oklahoma’s clinical workgroup developed a standardized protocol agreed upon by all state-run and contracted community mental health centers (CMHCs), which provide services statewide. Oklahoma has 77 counties and there is at least one CAMS trained clinician in each county and in every CMHC.
All persons served are administered a short screen for suicidality, a PHQ-9, and a C-SRSS. If there is recent suicidal ideation with a plan, CAMS treatment is offered immediately. In addition, these screenings are administered at the state-run crisis centers and psychiatric inpatient units. If possible, CAMS is initiated while inpatient, and if not possible, a warm hand off to a CMHC for CAMS treatment takes place.
ODMHSAS has built a system of care designed to allow a suicidal person to be seen immediately with no waiting period. All CMHCs provide 24/7 crisis stabilization services either through 23-hour/59-minute urgent care, a 24/7 crisis center, and/or a 24/7 mobile crisis team. Law enforcement in many areas may reach a CMHC clinician for an evaluation 24/7 via tablet.
In addition, select law enforcement officers around the state have been trained in crisis intervention through ODMHSAS efforts. These Crisis Intervention Team (CIT) Officers receive special training in how to deal with suicidal crisis as well as the mentally ill. The State is working to increase the number of CIT Officers and to educate them about the system of care used to help citizens.
Following the interview by a CAMS-trained clinician, if the client is deemed not safe to themselves or others, they will be admitted for a three-day crisis center or hospital stay. However, CAMS is not routinely initiated in hospital settings and most suicidal patients are seen by a CAMS clinician in an outpatient setting. Until the availability of CAMS in crisis center and hospital settings can be increased, connection to CMHCs is emphasized, with expectation that engagement will happen as soon as possible after discharge.
It is important to the program directors at ODMHSAS that there is a consistent treatment methodology used across the entire system. Every CMHC must maintain CAMS-trained mental health providers.
ODMHSAS has consistently held multiple CAMS role play trainings in various locations across the State over the last six years to train clinicians in CAMS and the use of the Suicide Status Form to guide and document treatment. The Department has provided clinicians with access to all four elements of CAMS training:
- The book, Managing Suicidal Risk, 2nd Edition; a Collaborative Approach by Dr. Jobes
- The 3-hour foundational video demonstrating 12 sessions of CAMS with a patient
- A full day of Role Play training with techniques for using CAMS and the Suicide Status Form; and
- up to 8 one-hour consultation calls with a CAMS Consultant to answer questions about the use of CAMS and the Suicide Status Form when working with clients in the field.
Challenges and Planned Improvements
Of course, as with any system, there are issues to work through and improvements to make. While Oklahoma has trained hundreds of clinicians, every location has a slightly a different way that they deliver CAMS and use the Suicide Status Form. ODMHSAS is working with these clinicians to build a more consistent approach. ODMHSAS also plans to work toward increasing the availability of CAMS in crisis center and hospital settings.
Another difficulty is the challenge in determining whether CAMS is being used in every case, since the billing system used by clinics does not provide a specialized code for the clinician to indicate CAMS as the treatment method. Ideally, CAMS would be a standalone billable service code within every mental health center so program managers can see when and how CAMS is being used within the system.
Finally, there is always more work to be done to raise awareness of the services that the ODMHSAS system of care has to offer and to reduce the stigma around seeking mental health care. While the State works hard to treat as many clients with suicidality as possible, there are still many Oklahomans that do not seek help.
In 2016, 822 people killed themselves in Oklahoma, according to the U.S. Centers for Disease Control and Prevention. That equated to an age-adjusted rate of 21 suicides per 100,000 population, ranking Oklahoma 8th highest in the nation. In 2018, 790 people killed themselves, which equates to 20 suicides per 100,000, ranking Oklahoma 15th highest in the nation. However, during that time frame, the average age-adjusted suicide rate in the United States increased from 13.5 to 14.2 so not only is Oklahoma’s suicide rate decreasing, it is counter to the national trend.
While the overall suicide rate in the State remains high, leadership is vocal about their goal to reduce suicide deaths. In 2015, there were 58 deaths by suicide recorded in the state managed facilities. In 2016 there were 45; a 22% reduction. ODMHSAS has built a system of care using evidenced-based treatment that is making a difference for Oklahomans.