As suicide rates continue to rise, only 61% of U.S. outpatient mental health facilities have a comprehensive suicide prevention program, and facilities treating low-income patients are especially likely to lack these services, according to an analysis of federal government data.

The study, published March 4 in Psychiatric Services, found that while nearly 70% of facilities accepting private insurance provided such a program, only 61% of facilities accepting uninsured or Medicaid patients did. While facilities may have had some prevention services, this study looked at whether they had a multiprong, evidence-based, comprehensive program. 

Over 40,000 people die by suicide in the U.S. each year, and suicidal patients are left even more vulnerable by a lack of regulation, the researchers argue. 

The suicide rate has increased from 10.2 deaths per 100,000 people in 1999 to 14.2 deaths per 100,000 people in 2018, according to the National Institute of Mental Health. And yet there are no consistent suicide program requirements for outpatient mental health care facilities; as a result, each one is more or less left to decide independently — and for-profit facilities are the least likely to implement these costly services, said lead author Peiyin Hung.

"For-profit facilities would tend to minimize the uncertainties for profits," said Hung, an assistant professor at the University of South Carolina. "This is basically the economic theory. We know their mission and vision is not really to reflect community needs. ... If we see substantial differences across facilities with different ownership having different scopes of suicide prevention services, that's a signal that markets are having a failure, and there is a need for intervention."

In Hung's analysis of 7,597 facilities logged by the Substance Abuse and Mental Health Services Administration, she found that public facilities were the most likely to have a program, with 65.7% reporting that they provided these services. Among nonprofits, 58.7% offered these suicide prevention services, while merely 51% of for-profit facilities did. 

Regulations, however, clearly got results: Over 95% of facilities affiliated with the U.S. Department of Veterans Affairs, which are more robustly regulated by the federal government, had comprehensive suicide prevention programs. 

"Evidence-based treatments for suicidality have emphasized the importance of outpatient mental health treatments using suicide-specific intensive psychological care, which helps replace or eliminate suicidal thoughts," the study's authors wrote. "Yet, as our data showed, this care is not universally available in outpatient mental health care facilities."

Native communities in particular stood out: In ZIP codes with a population that was 71% to 97% American Indian/Alaska Native, 66.1% of facilities had a comprehensive program.

According to Hung, this is the first study of where suicide prevention programs are located. 

"I think the next step would be to use this data to really identify how this distribution affects local suicide rates, and see if residents at risk of suicide living in communities without these comprehensive suicide prevention programs would have reduced rates of suicide," Hung said. 

With more information about how prevention programs are working, providers could "try to really identify how to tailor it," she added. "Tailor it to the community needs; tailor interventions for different types of patients."

The researchers looked at outpatient facilities specifically because those are more accessible to patients. Previous research has shown that 26% of people who die of suicide seek help from such a place within one year of their death, though many others do receive life-saving treatment. 

But, if people aren't getting the comprehensive services currently accepted as best practice, Hung said, then those people are slipping through the cracks. Those contacts at outpatient facilities, she said, are opportunities to save lives — and too many facilities are missing the opportunities.

The study, "Suicide Prevention Programs Across U.S. Outpatient Mental Health Care Settings: Differences by Facility Ownership," published March 4 in Psychiatric Services, was authored by Peiyin Hung, Yi-Wen Shih, Monique J. Brown and Elizabeth Crouch, University of South Carolina.

​Correction: A previously published version of this article misidentified the institution with which Elizabeth Crouch is affiliated. The error has been corrected.