Ch.22 Suicide Prevention (Screening, Assessment, and Intervention)

Interventions for Imminent, Intermediate, and Long-Term Suicide Prevention

-Interventions for those at imminent risk -Ensuring patient safety -Inpatient safety considerations -Interventions for intermediate and long-term risk

Social Distress

-A lack of social connection contributes to suicide ideation, attempts, and deaths across the age span -Among adults, those who are single, never married, separated, widowed, living alone, and those reporting loneliness, alienation, and a lack of belongingness, are also more likely to engage in suicidal behavior -Being socially connected, however, does not in itself reduce risk -Interpersonal conflict, sexual underrepresented groups, and being a victim of bullying can contribute to suicidal behavior, especially in adolescents and young adults

Suicide Attempt

-A nonfatal, self-inflicted destructive act with explicit or implicit intent to die -In 2018, an estimated 1.4 million Americans attempted suicide, with adult females reporting an attempt 1.4 times more often than males

Parasuicide

-A voluntary, apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death (e.g., taking a sublethal drug) -Parasuicidal behavior varies by intent -Some people truly wish to die, but others simply wish to feel nothing for a while -Still others want to send a message about their emotional state -Parasuicide behavior is never normal and should always be taken seriously

Adolescents Sexuality and Suicide

-Adolescents in sexual underrepresented groups are often stigmatized and discriminated against -They have more suicidal ideation, more suicide attempts, and are more at risk for completed suicides than their heterosexual peers -Individuals are more at risk for suicide when they experience conflict with family or friends because of their sexual identity, threat of violence, abuse, bullying, isolation, and other high risk behaviors -A nationwide study of youth health behaviors and experiences reported a significantly higher percentage of lesbian, gay, or bisexual students (48%) seriously contemplated suicide, as compared with 13% of heterosexual students, and 23% of lesbian, gay, or bisexual students attempted suicide, as compared to 5% of heterosexual students

Assessing Risk

-After suicidal ideation has been established, the next step is to determine the risk for a suicide attempt -Suicide risk assessment is difficult and whenever possible should proceed only with the assistance of other members of the interdisciplinary treatment team -Assessing for risk includes determining the seriousness of the suicidal ideation, degree of hopelessness, disorders, previous attempt, suicide planning and implementation, and availability and lethality of suicide method -Risk assessment also includes the patient's resources, including coping skills and social supports, that can be used to counter suicidal impulses -The greatest predictor of a future suicide attempt is a previous attempt, partly because the individual already has broken the "taboo" around suicidal behavior -Repeated episodes of self-harm with or without suicidal intent also increase immediate risk because they increase an individual's capacity to complete suicide -Other important signs of high risk are the presence of suicide planning behaviors (detailed plan, availability of means, opportunity, and capability) and engaging in final acts, such as giving away prized possessions and saying goodbye to loved ones -Although the presence of a specific psychiatric disorder, such as depression, is an important consideration in risk assessment, anxiety, agitation, alcohol use, and impulsivity may be better indicators of immediate risk -However, support from important others, religious prohibitions, responsibility for young children, and employment may provide protection from suicidal impulses -Ideally, an interdisciplinary team conducts suicide risk assessment in an emergency department or outpatient facility with multiple supports -Nurses practicing in more isolated situations should keep a list of contacts in settings that routinely conduct suicide risk assessments so the contacts may be consulted if a seriously suicidal individual appears in the nurse's setting

Treatment and Nursing Care for Suicide Prevention

-Interdisciplinary treatment and recovery -Clinical judgment -Priority care issues: preventing suicide and promoting mental health -Evaluation and treatment outcomes -Continuum of care -Documentation and reporting

Severity of Ideation

-How often do you have these thoughts? -How long do they last? -How much do the thoughts distress you? -Can you dismiss them or do they tend to return? -Are they increasing in intensity and frequency?

Assessment of Suicidal Episode

-Intent to die -Severity of ideation -Degree of planning

Social Theories

-Before the turn of the 20th century, Emile Durkheim (1951\[1897\]) linked suicide to the social conditions in which people live -Both a lack of social connectedness and social conditions contribute to suicidal behavior -People who are socially connected are less likely to engage in suicidal behavior -When an individual has others they can depend on, suicide can be prevented, even among those at significant risk -Even among people with social bonds, however, lack of community and social resources can interact with physiologic and psychological risk to increase the likelihood of suicide

Nurses' Reflection

-Caring for suicidal patients is highly stressful and can lead to secondary trauma for the nurse -Nurses who care for suicidal patients must regularly share their experiences and feelings with one another -Talking about how the situations or actions of patients make them feel will help alleviate symptoms of stress -Some nurses find outpatient therapy helpful because it enhances their understanding of what situations are most likely to trigger secondary trauma -By demonstrating how to effectively manage the stressors in their own lives, nurses can be powerful role models for their patients

Assessment

-Case finding -Assessing risk

Psychological Theories

-Cognitive theories -Emotional and personality factors -Ideation to action theories

Biologic Theories

-Depression and severe childhood trauma are linked to suicide -Those who complete suicide often have extremely low levels of the neurotransmitter serotonin -Impairments in the serotonergic system contribute to suicidal behavior -Additionally, dysregulation in the hypothalamic-pituitary-adrenal axis, abnormalities of neurotrophins and neurotrophin receptors, and abnormalities of neuroimmune functions may be associated with suicide risk

Electroconvulsive Therapy

-Electroconvulsive therapy (ECT) has been used in both inpatient and outpatient settings to alleviate severe depression, especially in medically compromised groups, such as older adults, who may not tolerate conventional pharmacotherapy for depression -Rapid reduction in depression often leads to a decreased suicide drive -More research is needed to determine the role ECT may play in managing suicidal behavior -At this time, ECT is among several strategies used to decrease suicidal behavior over the long term

Emotional and Personality Factors

-Emotional factors and personality traits also play a role in suicidal behavior by enhancing perceptions of helplessness and hopelessness, contributing to poor self-esteem, and interfering with coping efforts -Shame, guilt, despair, and emotion-focused coping have been linked to suicidal behavior -Loss and grief are also important considerations -Emotional distress often is potentiated by personality traits that contribute to poor self-esteem, impulsivity, and suicidal behavior

Suicide in Hispanics

-Even though the suicide rate for Hispanics is less than half of the overall US rate, in 2017 suicide was the second leading cause of death for Hispanics, aged 15 to 34 -Among Hispanic populations, suicide rates remain somewhat consistent across the lifespan, and the death rate for Hispanic men is four times the rate of Hispanic women -Suicide attempts for Hispanic adolescents were 40% greater than non-Hispanic White adolescents

Three-Step Theory (3ST)

-Explains progression from ideation to action in three steps -First, emotional pain and hopelessness cause the suicide ideation -Second, thoughts of suicide become strong as the emotional pain exceeds connectedness -The third step involves the actual attempt when the person has the knowledge and capacity to carry out the suicide -In this model, suicide prevention focuses on reducing pain, increasing hope, improving connections, and reducing capacity to carry out the suicide

Suicide in African Americans

-Family cohesion and social support in African American families contribute to the lower rates of suicide in this group -In 2018, the suicide rate among African American females was the lowest among men and women of all ethnicities -Although the overall suicide rate for African American individuals is low, young African American men take their lives at a rate considerably above that of other age groups -Higher rates of suicide in younger men may be associated with disparities in mental health treatment and social factors disproportionally affecting Black adolescents

Suicide Risk Factors

-Family history of suicide -Family history of child maltreatment -Previous suicide attempt(s) -History of mental disorders, particularly clinical depression -History of alcohol and substance abuse -Feelings of hopelessness -Impulsive or aggressive tendencies -Cultural and religious beliefs (e.g., belief that suicide is noble resolution of personal dilemma) -Local epidemics of suicide -Isolation, a feeling of being cut off from other people -Barriers to accessing mental health treatment -Loss (relational, social, work, or financial) -Physical illness -Easy access to lethal methods -Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts

Intent to Die

-Have you been thinking about hurting or killing yourself? -How seriously do you want to die? -Have you attempted suicide before? -Are there people or things in your life who might keep you from killing yourself?

Degree of Planning

-Have you made any plans to kill yourself? If yes, what are they? -Do you have access to the materials (e.g., gun, poison, pills) that you plan to use to kill yourself? -How likely is it that you could actually carry out the plan? -Have you done anything to put the plan into action? -Could you stop yourself from killing yourself?

Ensuring Patient Safety

-Helping patients develop strategies for making safer choices when distressed is an important goal -Nurses caring for patients who are emerging from the initial hours and days of a suicide attempt can support the patient and focus on managing suicidal urges and developing protective strategies -As the nurse connects with the patient, together they can create a list of personal and professional resources that can be used when the individual is in crisis -With the nurse's help, the patient can visualize "emotional spaces that are safe places to go" when distressed -For years, the no-suicide contract was a staple of psychiatric nursing practice and widely used across disciplines as a means of preventing suicide among those at risk -No-suicide contracts are verbal and written "contracts" between the individual at imminent risk for suicide and a health care provider that contain an agreement that the patient will not commit suicide during a specific time period -Careful evaluation of this practice has not established its efficacy in preventing suicidal behavior and suicide deaths -As a consequence, the nurse should avoid engaging in a no-suicide contract with a patient

Suicide

-Is one of the major health problems in the United States, accounting for more than 48,000 deaths in 2018 -Suicide rates have steadily increased in the past 20 years, with a 35% increase in the total suicide rate from 1999 to 2018 -The public health problem of suicidal behavior is so important that several goals stated in Healthy People 2020 and retained in Healthy People 2030 directly target the reduction of deaths by suicide -This behavioral definition of suicide is limited and does not consider the complexity of potential underlying mental illness, personal motivations, and situational and family factors that provoke the suicide act -Except for the very young, suicide occurs in all age groups, social classes, and cultures -Suicide is ranked as the tenth leading cause of death and accounts for 14.2 deaths per 100,000 population -On average, 132 Americans die by suicide each day, with a suicide occurring every 11 minutes in the United States: a rate of 132 completed successful suicides per day -Mountain regions have the highest rate of suicide -Its overall prevalence may be underestimated because suicide can be disguised as vehicular accidents or homicide, especially in young people

Males and Suicide

-Males have a suicide completion rate nearly four times that of females -White males account for 70% of completed suicides, with middle-aged (ages 45 to 65 years) White men having the highest rate -Men are more likely to use means that have a higher rate of success, with 56% of their suicide deaths by firearms -Men living in rural areas have a much higher risk of suicide than those in urban areas, and that gap is widening, perhaps attributable to the higher rates of gun ownership in rural areas -Substance abuse, aggression, hopelessness, emotion-focused coping, social isolation, and feeling little purpose in life have been associated with suicidal behavior in men

Facts about Suicide

-Many individuals with mental illness are not affected by suicidal thoughts, and not all people who attempt or die by suicide have mental illness -Warning signs, verbally or behaviorally, precede most suicides -Typically, people do not die by suicide because they do not want to live -People die by suicide because they want to end their suffering -Active suicidal ideation is often short term and situation specific -While suicidal thoughts can return, they are not permanent -Talking about suicide not only reduces the stigma but also allows individuals to seek help, rethink their opinions, and share their story with others

Medication Management

-Medication management focuses on treating the underlying psychiatric disorder -Currently, clozapine is the only U.S. Food and Drug Administration-approved medication for suicide risk in individuals with schizophrenia -Studies showing reduced suicide risk in patients with bipolar disorder or major depression taking lithium are not conclusive -For depression, a nonlethal antidepressant, such as a selective serotonin reuptake inhibitor, usually will be prescribed

Cognitive Theories

-Most evidences on the psychological contributions to suicidal behavior point to cognitive, affective, behavioral, and personality factors that intensify the experience of hopelessness and disconnection from others -Aaron Beck first identified the cognitive triad of hopelessness, helplessness, and worthlessness as integral to the experience of depression -Since then, a significant evidence base has been established linking hopelessness, loneliness, and other cognitive symptoms to suicide ideation -Depressed persons who are hopeless are more likely to consider suicide than those who are depressed but hopeful about the future -Furthermore, it appears that lack of positive thoughts about the future is more likely to predict suicidal behavior than negative thoughts even though both contribute to hopelessness

Observation

-Observation is not, in itself, therapeutic -An observation becomes therapeutic when interaction occurs with the patient -Psychiatric intensive care of this kind and restriction of freedom can be very upsetting to the patient who is withdrawn and isolated -Nurses can help patients reestablish personal control by including them in decisions about their care and restricting their behavior only as necessary -Nurses can also reduce the patient's stress while ensuring the patient's safety by intruding as little as possible on the person's exercise of free will -Observational periods can be used to help patients express a broad range of feelings and strengthen their belief in their own abilities to keep themselves safe -During observation, the nurse can help the patient describe feelings and identify ways to manage safety needs

Commitment to Treatment

-Patients are usually ambivalent about wanting to die -The commitment to treatment statement (CTS) directly addresses ambivalence about treatment by asking the patient to engage in treatment by making a commitment to try new approaches -Different from the no-suicide contract, the CTS does not restrict the patient's rights regarding the option of suicide -Instead, the patient agrees to engage in treatment and access emergency service if needed -Underlying the CTS is the expectation that the patient will communicate openly and honestly about all aspects of treatment, including suicide -This commitment is written and signed by the patient -The efficacy of this approach has yet to be established by systematic research -Whether using the CTS or other means, be observant for lapses in the patient's participation in treatment and discuss them with the patient and other members of the interdisciplinary team

Interventions for Intermediate and Long-Term Risk

-Patients who are suicidal may need ongoing preventive interventions -The risk varies with the genetic, psychiatric, and psychological profile of the patient and the extent of their social support -Discouragement and hopelessness often persist long past the suicidal episode -Episodes of hopelessness should be anticipated and planned for in the patient's care -Patients should be taught to expect setbacks and times when they are unable to see much of a future for themselves -They should be encouraged to think of times in their lives when they were not so hopeless and consider how they may feel similarly in the future -Helping patients review the goals they already have achieved and at the same time set goals that can be achieved in the immediate future can help them manage periods of discouragement and hopelessness

Interventions for the Biologic Domain

-Patients who have survived a suicide attempt often need physical care of their self-inflicted injury -Overdose, gunshot wounds, and skin wounds are common -There will be biologic interventions for the underlying psychiatric disorder

Interventions for the Social Domain

-Poor social skills may interfere with the patient's ability to engage others -The nurse should assess the patient's social capability early in treatment and make necessary provisions for social skills training -The interpersonal relationship with the nurse is an ideal place to begin shaping social behaviors that will help the patient to establish a social network that will sustain them during periods of discouragement or crisis -Participation in support networks, such as recovery groups, clubhouses, drop-in centers, self-help groups, or other therapeutic social engagement, will help the patient become connected to others -Patients need to anticipate that even some of the people closest to them will feel uncomfortable with their suicidal behavior -Helping the patient to anticipate the stigmatizing behavior of others and how to manage it will go far in reintegrating the patient into a supportive social community -The nurse can also explore the patient's participation in specific social activities such as attending church or community activities

Economic Disadvantage

-Poverty and economic disadvantage are associated with depression, suicide ideation, and suicide mortality -Individuals who are not employed, not married, and with low education and low income have a higher risk of suicide -Suicide risk is greater for adults in socially and materially deprived areas -Adolescents from impoverished neighborhoods have more suicidal ideation and attempts, and suicides increase as the percentage of boarded-up buildings in a neighborhood increases, particularly if the individuals have a mental disorder -In impoverished communities, particularly rural America, lack of good schools and employment opportunities leads to unemployment and loss of meaningful social roles -Access to health care is limited in these communities, and there is an increased exposure to others exhibiting suicidal behavior that enhances suicide risk

Developing New Coping Strategies

-Preventing suicidal behavior requires that patients develop crisis management strategies, generate solutions to difficult life circumstances other than suicide, engage in effective interpersonal interactions, and maintain hope -The nurse can help the patient develop a written plan that can be used as a blueprint for action when the patient feels that they are losing control -The plan should include strategies that the patient can use to self-soothe; friends and family members that could be called, including multiple phone numbers where they can be reached; self-help groups and services such as suicide hotlines; and professional resources, including emergency departments and outpatient emergency psychiatric services

Integrated Motivational Volitional Model

-Proposes that motivational factors, such as defeat and entrapment, cause suicide ideation -The progression from suicide ideation to suicide attempt is explained by volitional factors, such as acquired capability, access to lethal means, planning, and impulsivity -In a study differentiating between those thinking about suicide and those attempting suicide, those reporting a suicide attempt were found to have greater acquired capability, mental imagery about death, and impulsivity, and were more likely to know a friend who had made a previous attempt

Protective Factors

-Protective factors buffer individuals from suicidal thoughts and behavior -Although identifying and understanding protective factors is very important, they have not been studied as extensively as risk factors

Psychological Risk Factors

-Psychological pain, internal distress, low self-esteem, and interpersonal distress have long been associated with suicide -Childhood physical and sexual abuse is linked to suicide, suicide ideation, and parasuicide -Cognitive risk factors include problem-solving deficits, impulsivity, rumination, and hopelessness -Impulsivity, anger, and reduced inhibition increase the risk of suicide -Recent purchase of a handgun increases the risk of self-harm

Case Finding

-Refers to identifying people who are at risk for suicide so proper treatment can be initiated -People who are contemplating suicide often do not share their ideation -This lack of disclosure often means that family, friends, and health professionals are unable to intervene until the suicidal ideation and planning have progressed -Yet early identification of suicidal ideation may reduce suicide deaths -Nurses can play important roles in suicide prevention by recognizing the warning signs -The Columbia Suicide Severity Rating Scale (C-SSRS) is a commonly used evidence-supported suicide risk assessment that measures severity of suicidal ideation, intensity of ideation, suicidal behavior, and lethality -Requires careful and concerned questioning and listening that make the patient feel valued and cared about -Most standardized health questionnaires have questions about suicide thoughts -Many nurses are concerned that asking patients about their suicidal thoughts will provoke a suicide attempt (this belief simply is not true) -The patient expressing suicidal ideation often has had these thoughts for some time and may feel more socially connected when another recognizes the seriousness of the situation -Under no circumstances should a patient be promised secrecy about suicidal thoughts, plans, or acts -Instead, tell patients that disclosure of suicidal intent will be shared with other interdisciplinary team members so the safety of the patient can be ensured

Lethality

-Refers to the probability that a person will successfully complete suicide -Is determined by the seriousness of the person's intent and the likelihood that the planned method of death will succeed -A plan to use an accessible firearm to commit suicide has greater lethality than a suicide plan that involves superficial cuts of the wrist

Suicide Contagion

-Social exposure to suicide is associated with an increased personal risk for suicidal behavior, particularly among adolescents -Suicidal behavior that occurs after the suicide death of a known other is called suicide contagion or cluster suicide -Suicide contagion seems to work through modeling and is more likely to occur when the individual contemplating suicide is of the same age, gender, and background as the person who died -Contagion can be prompted by the suicide of a friend, an acquaintance, online social networking, or an idolized celebrity -Actions of peer groups, media reports of suicide, and even billboards with content about suicide can trigger suicide behavior among adolescents -In the case of a celebrity suicide, the number of "copycat suicides" is proportional to the amount, duration, and prominence of media coverage -Evidence suggests that adolescents can also be influenced by simple individual and community suicide prevention efforts

Social Risk Factors

-Social isolation is a primary risk factor for suicide -Social distress leads to despair and can be caused by family discord, parental neglect, abuse, parental suicide, and divorce -Social distress can prevent the patient from accessing the support necessary to prevent suicidal acts -Other social factors associated with suicide risk include economic deprivation, unemployment, poverty, knowing someone who has died by suicide (especially if this person was a family member), and lack of access to behavioral health care

Epidemiology

-Suicidal behavior is complex, and there can be many contributing factors -Mental illness is an important factor contributing to suicide in adults -Mood disorders, particularly recurrent depression, are associated with higher risk of suicide -Substance use disorder and personality disorders are also found to influence suicide risk in young adults -Auditory hallucinations increase the risk for suicide because of the possibility of individuals impulsively responding to "voices" directing them to hurt themselves -Substance abuse increases the likelihood that suicidal ideation will result in both parasuicidal and suicidal behaviors -Medical illness contributes to functional disability and also increases the likelihood of chronic depression, which, in turn, contributes to the increased suicide rate of those over the age of 65 -Additionally, symptoms of comorbid illnesses often are similar to depressive disorder, making recognition of depressive disorder by primary care providers difficult -Patients are often reticent to disclose their suicidal thoughts, further complicating detection

Priority Care Issues: Preventing Suicide and Promoting Mental Health

-Suicidal ideation, planning, and acts are not easily predicted and, therefore, are difficult to study -As a result, few evidence-based treatments exist that are known to prevent suicide and manage suicidal behavior -There is growing consensus that the suicidal act is part of a continuum of behaviors that extend long before and after a specific suicide behavioral incident -The beginning evidence points to four steps in preventing suicide and promoting long-term mental health: identification of those thinking about suicide (case finding), assessment to determine an imminent suicidal threat, intervening to change suicidal behavior associated with a specific suicidal threat, and institution of effective interventions to prevent future episodes of suicidal behavior

Suicide Assessment

-Suicide assessment is always considered a priority -Practice by asking patients about suicidal thoughts and plans -Develop a plan with a suicidal patient that focuses on resisting the suicidal impulse -Apply the assessment process that delineates the (1) intent to die, (2) severity of ideation, (3) availability of means, and (4) degree of planning

Suicide and the Military

-Suicide disproportionally affects those who have served in the military, with suicide rates for Veterans 1.5 times the rate for non-Veterans -An estimated 18 veterans die by suicide per day -Depression, Post Traumatic Stress Disorder (PTSD), and combat exposure are some of the leading contributing factors to suicide for both men and women military members -Other related factors include alcohol or substance dependence, intimate partner problems, legal/administrative stressors, and financial strain -For women, military sexual trauma also contributes to suicide ideational and attempts

Family Response to Suicide

-Suicide has devastating effects on everyone it touches, especially family and close friends -One suicide is estimated to leave at least six survivors who are significantly impacted by the loss -In the aftermath of a family member's suicide, survivors experience more grief, anxiety and depression, guilt, shame, self-blame, and dysfunction than families whose loss was because of other reasons and the personal and familial disruption often lasts for years -Although recovery from a loved one's suicide is an ongoing task, survivors who are emotionally healthy before the suicide act and who have social support are able to manage the psychological trauma associated with suicide -Still, the intensity and duration of the postsuicide grief process for many survivors has led to the development of family intervention programs -Although the evidence base for these interventions is still small, strategies that support a positive sense of self, enhance problem-solving, promote the formation of a suicide story, encourage social reintegration, reduce stigma, use journaling, or permit the survivor to debrief may be effective in reducing subjective distress and to resolve grief -These strategies may be most effectively delivered in survivor peer help groups

Ideation to Action Theories

-Suicide ideation does not necessarily lead to suicide attempts -Most people who think of suicide do not act on the idea, but the suicide thoughts of those who do take lethal actions are often indistinguishable from those who do not -Ideation-to-action theories examine factors that identify those who are most likely to attempt suicide -These emerging theories, which are supported by research, provide a basis for discriminating between those who are only thinking about suicide versus those who are likely to engage in suicidal acts

Suicide in Adults and Older Adults

-Suicide is a major contributor to premature death in adults, ranking the fourth leading cause of death among adults aged 35 to 54 -Suicide rates peak during middle age, and a second peak occurs in those aged 75 years and older -Physical illness, pain, loss, loneliness, social isolation, and disconnectedness are important precipitants to suicide in older adults

Stigma and Suicide

-Suicide is so rejected in contemporary society that people with strong suicidal thoughts do not seek treatment for fear of being stigmatized by others -Reports and portrayals of suicide in the popular media and television further stigmatize those who consider or attempt suicide -Society's unwillingness to talk openly about suicide also contributes to the common misperceptions resulting in many myths regarding suicide

Suicide in Children, Adolescents, and Young Adults

-Suicide is the second leading cause of death among those aged 10 to 34 -Mental disorders can lead to poor performance in school, alcohol or other drug abuse, family discord, violence, and suicide -The most recent Youth Risk and Behavior Survey found that in the preceding year among high school students, 18.8% seriously considered attempting suicide, 15.7% made a suicidal plan, 8.9% attempted suicide, and 2.5% were seriously injured in a suicide attempt -Female students were more likely to attempt suicide (11.0%) than male students (6.6%), though males were more likely to die by suicide than females

Myths about Suicide

-Suicide only affects individuals with a mental health condition -Most suicides happen suddenly without warning -People who die by suicide are selfish and take the easy way out -When people become suicidal, they will always be suicidal -Talking about suicide will lead to and encourage suicide

Suicide in American Indians and Alaska Natives

-Suicide rates among American Indian and Alaska Native (AI/AN) populations are the highest of any racial/ ethnic group in the United States -Rates peak during adolescence and young adulthood, then decline -AI/AN populations engaged in suicidal behavior are more likely to have been exposed to suicide by a family member or friend and more likely to report substance use -For these reasons, community level prevention strategies focusing on survivor support and substance use treatment are critical

Genetic Factors

-Suicide runs in families -First-degree relatives of individuals who have completed suicide have a two to eight times higher risk for suicide than do individuals in the general population -Suicide of a first-degree relative is highly predictive of a serious attempt in another first-degree relative -Children of depressed and suicidal parents have higher rates of suicidal behavior themselves -The genetic link to suicide is evident in twin studies -Suicidal behavior has a 50% concordance for completed suicide -There also appears to be a gene/environment connection between early childhood sexual abuse and suicidality -Early childhood adverse experiences appear to lead to genetic changes that modify the expression of the neurologic system, impacting the biologic and psychological development -As a result, there is a propensity to react to stressors, increasing the likelihood of suicidal behavior

Health Care and Suicide

-Suicides are preventable deaths when immediate friends and family and health care providers identify symptoms and use effective interventions -All practicing nurses will come into contact with patients who are thinking about suicide and often can prevent suicides by identifying and intervening with those at risk -Through individual and public education, nurses also can do much to demystify suicide and reduce stigma for those at risk -To reduce the devastating public impact of suicide on those at risk and their families, nurses must be knowledgeable about suicide and be able to implement effective preventive interventions

Challenging the Suicidal Mindset

-Teaching patients to distract themselves when thinking about suicide or engaging in negative self-evaluation can help to diminish suicidal ideation, dysfunctional thinking, and emotional reactivity -Simple distracting techniques such as reminding oneself to think of other things or engaging in other activities such as talking on the telephone, reading, or watching a movie are excellent temporary means of distracting the patient from negative cognitive states -Validating the patient and teaching the patient to self-validate are powerful means of reducing suicidal thinking -Patients can learn that everyone experiences emotional distress and can begin to recognize it as a routine event -To manage emotional distress and increase tolerance for it, patients can be taught simple anxiety management strategies such as relaxation and visualization -The patient can be encouraged to write about their emotional experiences -When negative thoughts and emotions coexist, they reinforce each other and contribute to suicidal ideation -Individuals who are suicidal often believe they are a burden to their family, who would be better off without them and do not feel connected to others -Nurses can challenge negative beliefs, especially the patient's idea that they are a burden to others -Ask the patient to describe the events that led to specific suicidal behavior so the patient can be engaged in developing alternative solutions -For each event, work with the patient to identify specific strategies that could be used to manage their distress, sense of disconnection, extreme focus on suicidal ideas, and other experiences that led the person to believe they had no option other than to die

Interdisciplinary Treatment and Recovery

-The challenges of preventing suicides and promoting healthy coping belong to all disciplines -An interdisciplinary treatment or recovery approach along with peer support is needed for managing the threats of suicide -A true psychiatric emergency exists when an individual presents with one or more symptoms associated with imminent risk for suicidal behavior -Immediate and focused action is needed to prevent the patient's death

Etiology

-The convergence of biologic, psychological, and social factors can be directly linked to suicidal behavior -In genetically and physiologically vulnerable individuals, thoughts, feelings, and personality factors can interfere with personal problem-solving, promote impulsivity, and support suicidal behavior -Poverty, unemployment, and social conflict also contribute to suicidal behavior in those at risk for suicide

Clinical Judgment

-The first priority is to provide for the patient's safety while initiating the least restrictive care possible -In contrast, an example of the most restrictive care is an outpatient who is admitted to a locked unit with one staff member who is assigned to observe the person at all times -Hospitalization should be reserved for those whose safety cannot be ensured in an outpatient environment

Interventions for the Psychological Domain

-The goals of treatment in the psychological domain include reducing the capacity for suicidal behavior, increasing tolerance for distress, expanding coping abilities, and developing effective crisis management strategies -During the early part of a hospitalization, the most important way to reduce stress is to help the patient feel more secure and hopeful -As patients become more comfortable in their environment, the nurse can provide education about emotions, help patients explore and link presuicidal beliefs to a positive and hopeful future, support the application of new skills in managing negative thoughts, and help develop effective problem-solving skills

Sexuality and Suicide

-The lesbian, gay, bisexual, transgender, queer, questioning, and intersexed (LGBTQI) community is at increased risk for suicide -An estimated 1.8 million LGBTQI young people seriously consider suicide each year, with LGBTQI youth nearly five times as likely to attempt suicide compared with heterosexual youth -In lesbian, gay, and bisexual older adults, there are high levels of inadequate general health disability

Evaluation and Treatment Outcomes

-The most desirable treatment outcome is the patient's recovery with no future suicide attempts -Short-term outcomes include maintaining the patient's safety, averting suicide, and mobilizing the patient's resources -Whether the patient is hospitalized or cared for in the community, their emotional distress must be reduced -Long-term outcomes must focus on maintaining the patient in psychiatric treatment, enabling the patient and family to identify and manage suicidal crises effectively, and widening the patient's support network

Documentation and Reporting

-The nurse must thoroughly document encounters with patients who are suicidal -This action is for the patient's ongoing treatment and the nurse's protection -Lawsuits for malpractice in psychiatric settings often involve completed suicides -The medical record must reflect that the nurse took every reasonable action to provide for the patient's safety -The record should describe the patient's history, assessment, and interventions agreed upon by the patient and nurse -The nurse should document the presence or absence of suicidal thoughts, intent, plan, and available means to illustrate the patient's current and ongoing suicide risk -If the patient denies any suicidal ideation, it is important that the denial is documented -Documentation must include any use of drugs, alcohol, or prescription medications by the patient during 6 hours before the assessment -It should include the use of antidepressants that are especially lethal (e.g., tricyclics), as well as any medication that might impair the patient's judgment (e.g., a sleep medication) -Notes should reflect the level of the patient's judgment and ability to be a partner in treatment -The documentation should reflect if any medications were prescribed, the dosages, and the number of pills dispensed -Notes should reflect the plan for ongoing treatment, including the time of the next appointment with the provider, instructions given to the patient about obtaining emergency care if needed, and the names of family members and friends who will act as supports if the patient needs them

Suicide in White People

-The rate of suicides among White people has steadily increased since 1999 -Suicide rates are higher in males than in females in all age groups, with a rate of 22.8 (males) and 6.2 (females) per 100,000 -Completed suicides are highest for White individuals between the ages of 35 and 64 -Suicide rates among those older than 75 years are also high -The use of firearms is by far the most prominent method of suicide among White people -Access to firearms contributes to the risk of completed suicides -Firearm ownership is more prevalent in the United States than in any other country, with an estimated 120 firearms per 100 people

Definition of Suicide

-The voluntary act of killing oneself -It is a fatal, self-inflicted destructive act with explicit or inferred intent to die -Sometimes called suicide completion

Transgender and Suicide

-There are alarming rates of suicide ideation and suicide rates among transgender individuals -In a national study, 40% of transgender adults reported a suicide attempt, with 92% of these individuals making their attempt before the age of 25 -Gender-based victimization, discrimination, bullying, violence, rejection by family, friends, and communities are risk factors associated with suicidal behavior

Interventions for Those at Imminent Risk

-There are three urgent priorities for care of a person who is at imminent risk for suicide: reconnecting the patient to other people and instilling hope, restoring emotional stability, and reducing suicidal behavior, and ensuring safety -Reconnecting the patient interpersonally includes listening intently, and without judgment, to the patient's thoughts and feelings and validating their experience and suffering -This intervention directly challenges the patient's belief that no one cares -Using cognitive interventions can help the client regain hope and establish goals for the future

Race and Ethnicity

-There is considerable variation in the profile of suicide rates across racial groups, including the age when rates are at their peak and the duration of high rates across several age groups -Rates of suicide among American Indian/Alaska Native people and White people are highest, at 22.1 and 18.0 per 100,000 respectively -Lower suicide rates are found among Asian/Pacific Island individuals (7.0 per 100,000), Hispanics (7.4 per 100,000), and Black (7.2 per 100,000) populations

Suicidal Ideation

-Thinking about and planning one's own death -In 2019, 4.8% of adults aged 18 and older had serious thoughts of suicide, with the highest prevalence among young adults aged 18 to 25 (11.8%) -Population studies show that suicidal ideation varies depending on characteristics of the participants and the way suicidal ideation is measured -Although suicidal ideation often does not progress, having recurrent suicidal ideation is associated with poor mental health

Inpatient Safety Considerations

-When hospitalization is considered the best option to ensure the safety of the patient, the nurse has responsibility for providing a safe, therapeutic environment in which human connection, instilling hope, and changing suicidal behavior can occur -There are no evidence-based guidelines for preventing suicides in hospitals. Inpatient suicides do occur -One study reported an average of 50 to 65 hospital inpatient suicides occurring per year in the United States -The vast majority of inpatient suicides take place in psychiatric facilities, and the method used in 70% of these events is hanging -Removal of dangerous items and environmental hazards, continuous or intermittent observation of at-risk patients by hospital personnel trained in observation methods, and limitation of outpatient passes are the mainstays of hospital interventions -Observation procedures vary from facility to facility -For patients who require constant supervision, a staff member will be assigned only to the high-risk patient -For less risky patients, observation may entail close or intermittent observations

Continuum of Care

-Whether the suicide prevention plan is instituted in the hospital or in an outpatient setting, the patient cannot be released to home until a workable plan of care is in place -The care plan includes scheduling an appointment for outpatient treatment, providing for continuing somatic treatments until the first outpatient treatment visit, ensuring postrelease contact between the patient and significant other, providing for access to emergency psychiatric care, and arranging the patient's environment so it provides both structure and safety -At the first follow-up visit, the patient and health care provider can establish a plan of care that specifies the intensity of outpatient care -Very unstable patients may need frequent supervision (e.g., telephone or face-to-face meetings or both) in the early days after hospitalization to maintain the patient's safety in the community -These contacts often can be short; their purpose is to convey the ongoing concern and caring of professionals involved in the patient's care -In arranging outpatient care, be certain to refer the patient to a provider who can provide the intensity of care the patient may need -The patient's outpatient environment should be made as safe as possible before discharge -The nurse must share the care plan with family members so they can remove any objects in the patient's environment that could be used to engage in self-harm -The nurse should explain this measure to the patient to reinforce their sense of self-control -It is important to be reasonable in deciding what to remove from the environment -Patients who are truly determined to kill themselves after discharge will succeed in doing so, using whatever means are available

Pandemic Impact on Suicide

-While the full extent of the impact of coronavirus disease 2019 (COVID-19) on mental health will not be fully realized for quite some time, evidence of mental health challenges related to COVID-19-associated morbidity, mortality, and mitigation activities (including physical distancing and mandated stay-at-home orders) were noted within months of the outbreak in the United States -A national survey of adults in June 2020 found that 41% of respondents reported at least one adverse mental or behavioral health condition related to COVID-19 -Symptoms reported included anxiety or depression (31%), trauma/stress (26%), and having started or increased substance use (13%) -Nearly 11% of respondents reported having seriously considered suicide in the previous month -In particular, younger adults, members of underrepresented racial/ethnic groups (Hispanic and Black persons), essential workers, and unpaid caregivers for adults were more likely to report disproportionately worse mental health outcomes, increased substance use, and increased suicidal ideation -Distress, anxiety, depression, fear of contagion, uncertainty, chronic stress, isolation, and economic hardship all contribute to a person being more vulnerable to negative impact

Suicide in Asian Individuals or Pacific Islanders

-While the suicide rate for Asian individuals or Pacific Island populations is approximately half of the overall suicide rate in the United States, the scant literature on suicide among Asian populations shows that suicide ideation, plans, and attempts may be more common than popularly believed and vary within Asian ethnic groups -In 2017, suicide was the leading cause of death for Asian American individuals aged 15 to 24 -The suicide death rate for men is double that of women -Unlike that of the overall US population, in Asian or Pacific Islander populations, suicide rates peak later in life, in those over the age of 85 -A study of racial/ethnic differences in youth having died by suicide found that Asian American/Pacific Islander youth had significantly lower rates of mental health treatment compared to White youth, consistent with research demonstrating disparities in mental health service utilization

Women and Suicide

-Women across age, racial, and ethnic groups are less likely to die from suicide than are men but are more likely to attempt suicide -Women make three attempts to every attempt by men -Adolescent girls and women aged 10 to 44 years have the highest rate of suicide attempts -Women are less likely to complete a suicide, partly because they are more likely to choose less lethal methods -Women with current or previous exposure to domestic violence are at an increased risk for suicidal behavior

The Interpersonal Psychological Theory of Suicidal Behavior (IPTS)

-introduced by Thomas Joiner in 2005, proposes that three interacting factors indicate a high risk of suicide—"thwarted belongingness", perceived burdensomeness, and acquired capability -The term thwarted belongingness is used to describe alienation from social relationships or experiences; the human need to belong is not being met -It refers to an individual's feelings of loneliness and isolation, as well as a lack of reciprocal, caring, and meaningful relationships -Perceived burdensomeness is the perception that the individual is a burden to others -Acquired capability for suicide, which develops over time, involves a heightened sense of fearlessness and a high pain threshold -IPTS views the act of suicide as being very difficult to carry out -When thwarted belongingness, perceived burdensomeness, and acquired capability come together in one person, these beliefs lead to the misperception that others would be better off without them and the idea that sacrificing themselves is the appropriate action to take -Researchers are testing the theory in a variety of clinical situations

Warning Signs for Suicide

I—Ideation: Talking or writing about death, dying, or suicide -Threatening or talking of wanting to hurt or kill self -Looking for ways to kill self: seeking access to firearms, available pills, or other means S—Substance abuse: Increased substance (alcohol or drug) use P—Purposelessness: No perceived reason for living; no sense of purpose in life A—Anxiety: Anxiety, agitation, unable to sleep, or sleeping all the time T—Trapped: Feeling trapped (like there is no way out) H—Hopelessness W—Withdrawal: Withdrawal from friends, family, and society A—Anger: Rage, uncontrolled anger, seeking revenge R—Recklessness: Acting reckless or engaging in risky activities, seemingly without thinking M—Mood change: Dramatic mood changes

Suicidality

Refers to all suicide-related behaviors and thoughts of attempting or completing suicide and suicidal ideation

Hopelessness

The pervasive belief that undesirable events are likely to occur, coupled with the belief that one's situation is unlikely to improve

-Biologic theories -Psychological theories -Social theories

What are examples of etiology for suicide?

-The Interpersonal Psychological Theory of Suicidal Behavior (IPTS) -Integrated Motivational Volitional Model -Three-Step Theory (3ST)

What are examples of ideation to action theories?

-Medication management -Electroconvulsive therapy

What are examples of interventions for the biologic domain?

-Challenging the suicidal mindset -Developing new coping strategies -Commitment to treatment

What are examples of interventions for the psychological domain?

-Assessment -Interventions for imminent, intermediate, and long-term suicide prevention -Interventions for the biologic domain -Interventions for the social domain

What are examples of preventing suicide and promoting mental health?

-Psychological risk factors -Social risk factors -Gender -Sexuality -Race and ethnicity -Pandemic impact

What are examples of risk factors for suicide?

-Social distress -Suicide contagion -Economic disadvantage

What are examples of social theories?

Suicidal ideation, previous psychiatric hospitalization, and a previous attempt

What are significant predictors of a completed suicide?

-Effective clinical care for mental, physical, and substance abuse disorders -Easy access to a variety of clinical interventions and support for help seeking -Family and community support (connectedness) -Support from ongoing medical and mental health care relationships -Skills in problem-solving, conflict resolution, and nonviolent ways of handling disputes -Cultural and religious beliefs that discourage suicide and support instincts for self-preservation

What does the CDC identify as protective factors?

Genetic factors

What is an example of biologic theories?

Suicide Prevention

When teaching the patient and family about suicide and its prevention, be sure to address the following topics: -Importance of emotional connections to family and friends -Importance of instilling hope -Discouraging suicidal ideation, rumination, self-harming behaviors -Self-validation -Emotional distress management -Finding alternatives to suicidal behavior -Establishing and using a crisis management plan -Reestablishing the social network of the patient -Information about treatment of underlying psychiatric disorders