Mental Health Chapter 12- Suicide Prevention

Assessment: Analysis of the Suicidal Crisis:

-Precipitating stressor -Relevant history -Life-stage issues -Psychiatric /medical/family history

Assessment:

-Presenting Symptoms: Medical- psychiatric diagnosis -Suicidal ideas or acts: Seriousness of intent, Plan, Means, Verbal and behavioral clues. -Interpersonal support system -identify and distinguish ideas (thoughts), plans (intentions), and attempts (behavior) -level of risk -istinguish between suicidal self-injury and nonsuicidal self-injury -The following items should be considered when conducting a suicidal assessment: demographics; presenting symptoms and medical-psychiatric diagnosis; suicidal ideas or acts; interpersonal support system; analysis of the suicidal crisis; psychiatric, medical, and family history; and coping strategies.

Planning/Outcome- Short term:

-Remain safe -Has experienced no physical harm to self. -Sets realistic goals for self. -Expresses some optimism and hope for the future.

Diagnosis- Nursing diagnoses for the suicidal client may include:

-Risk for suicide -Hopelessness

Nursing diagnoses for the suicidal client may include the following:

-Risk for suicide related to feelings of hopelessness and desperation. -Hopelessness related to absence of support systems and perception of worthlessness.

Age

-Suicide risk and age are, in general, positively correlated, particularly with men. -in 2013, the highest rate of suicide occurred in the 45- to 64-year-old age group (with men at particular risk), and the second-highest rate was for those 85 or older (AFSP, 2015). A consistent high rate of suicide in both age groups was shown for the period 2000 to 2013, but the 45 to 64 age group showed a steady incline in suicide rates over the same period.

Interventions- Information for family and friends of the suicidal client:

-Take any hint of suicide seriously. -Do not keep secrets. -Be a good listener. -Express feelings of personal worth to the client. -Important to stress that the person's life is important to you and to others. -Express concern for individuals who express thoughts about committing suicide. -Know about suicide intervention resources. -Restrict access to firearms or other means of self-harm. -Acknowledge and accept the person's feelings. -Provide a feeling of hopefulness. -Do not leave him or her alone. -Show love and encouragement. -Seek professional help. -Remove children from the home. -Do not judge or show anger toward the person or provoke guilt in him or her.

Outcome Criteria

-include short- and long-term goals -Has experienced no physical harm to self. -Sets realistic goals for self. -Expresses some optimism and hope for the future.

Suicide

-is not a diagnosis or a disorder; it is a behavior -In the field of psychiatry, suicide is considered an irrational act associated with mental illness and most commonly, but not exclusively, with depression. -More than 90 percent of all persons who commit or attempt suicide have a diagnosed mental disorder

Demographics- Gender:

Males are at higher risk for successful suicide than females, but females attempt suicide more frequently.

Presenting Symptoms and Medical-Psychiatric Diagnosis

Mood disorders (major depression and bipolar disorders) are the most common disorders that precede suicide. Individuals with substance use disorders are also at high risk. Other psychiatric disorders in which suicide risks have been identified include anxiety disorders, schizophrenia, bipolar disorders, substance use disorders, anorexia nervosa, and borderline and antisocial personality disorders. Other chronic and terminal physical illnesses have also precipitated suicidal acts.

Epidemiological Factors

More than 41,000 people committed suicide in 2013, the most recent year for which statistics have been recorded. This is the highest rate of suicide in 15 years. These recent statistics have established suicide as the second-leading cause of death (behind unintentional injuries) among young Americans ages 15 to 34 years, the fourth-leading cause of death for ages 35 to 44, the fifth-leading cause of death for individuals age 45 to 64, and the tenth-leading cause of death overall.

Gender

More women than men attempt suicide, but men succeed more often. Successful suicides number about 70 percent for men and 30 percent for women. This success rate has to do with the lethality of the means. Women tend to overdose; men use more lethal means, such as firearms. -Transgender individuals are also a high-risk population for suicide with an alarming 41 percent lifetime prevalence.

Demographics- Marital status:

Single, divorced, and widowed individuals are at higher risk for suicide than are married people.

Shame and Humiliation

Some individuals have viewed suicide as a "face-saving" mechanism—a way to prevent public humiliation following a social defeat such as a sudden loss of status or income. Often, these individuals are too embarrassed to seek treatment or other support systems.

Demographics- Military history:

Suicide rates among military personnel now exceed those of the general population.

Demographics Ethnicity/race:

The CDC reports highest rates of suicide among Caucasians followed by American Indians

Life-stage issues:

The ability to tolerate losses and disappointments is often compromised if those losses and disappointments occur during various stages of life in which the individual struggles with developmental issues (e.g., adolescence, midlife).

Demographics- Method:

The lethality of the method identified by an individual with suicide ideation or by one who has already made an attempt provides meaningful information about the client's intent to die. Use of firearms, for example, is considered a highly lethal method.

Marital Status

The suicide rate for single, never married persons is twice that for married persons, and divorce increases risk for suicide particularly among men, who are three times more likely to take their own lives than are divorced women.

Genetics

Twin studies have shown a much higher concordance rate for monozygotic twins than for dizygotic twins. Some studies with people who have attempted suicide have focused on the genotypic variations in the gene for tryptophan hydroxylase, with results indicating significant association to suicidality. Tryptophan hydroxylase is an enzyme associated with the synthesis of serotonin, and diminished serotonin has implications for both depression and suicidal behavior. These findings suggest the potential for genetic predisposition toward suicidal behavior.

Ethnicity

With regard to ethnicity, statistics show that whites are at highest risk for suicide, followed by Native Americans, African Americans, Hispanic Americans, and Asian Americans

Anomic suicide

occurs in response to changes in an individual's life (e.g., divorce, loss of job) that disrupt feelings of relatedness to the group. An interruption in the customary norms of behavior instills feelings of "separateness" and fears of being without support from the formerly cohesive group.

Suicidal Ideas or Acts

-MUST ASK -Individuals may provide both behavioral and verbal clues as to the intent of their act. -Verbal clues may be both direct and indirect. -determining whether the individual has a plan, and if so, whether he or she has the means to carry out that plan

Risk factors

-Marital status -Gender -Age -Ethnicity -Socioeconomic status -Religion -Psychiatric illness -Severe insomnia -Other

Evalution

-Ongoing reassessment -Ensure Follow-up -Ensure the client knows who to call if feeling suicidal -continuous reassessment of the client as well as determination of goal achievement -A suicidal person feels worthless and hopeless

Other Risk Factors

- Although suicide is often thought of as strictly related to depression, there is also a recognized risk of suicide among people with schizophrenia, bipolar disorders, personality disorders, eating disorders, anxiety disorders, and substance use disorders. -Severe insomnia is associated with increased suicide risk even in the absence of depression. -Use of alcohol, and particularly a combination of alcohol and barbiturates, increases the risk of suicide. Withdrawal from stimulants increases suicide risk as the person begins to "crash." Psychosis, especially with command hallucinations (hearing voices telling one to harm or kill oneself), poses a higher risk. Affliction with a chronic painful or disabling illness also increases the risk of suicide. -Suicide risk may increase early during treatment with antidepressants. -higher risk factor for suicide among gay men and lesbian women: increased risk may be a function of the social stigma and discrimination associated with being part of a marginalized group. -Higher risk is also associated with a family history of suicide, especially in a same-gender parent. Persons who have made prior suicide attempts are at higher risk for suicide. -Being bullied via the Internet or e-mail (called cyberbullying) has also been associated with increased risk of depression and suicidal behavior among young people.

Fleener (2013) offers the following suggestions for interacting with people who are suicidal:

-Acknowledge and accept their feelings and be an active listener. -Try to give them hope, and remind them that what they are feeling is temporary. -Stay with them. Do not leave them alone. Go to where they are, if necessary. -Show love and encouragement. Hold them, hug them, touch them. Allow them to cry and express anger. -Help them seek professional help. -Remove any items from the home with which the person may harm himself or herself. -If there are children present, try to remove them from the home. Perhaps friends or relatives can assist by taking the children to their home. This type of situation can be extremely traumatic for children. -DO NOT judge suicidal people, show anger toward them, provoke guilt in them, discount their feelings, or tell them to "snap out of it." This is a very real and serious situation to suicidal individuals. They are in real pain. They feel the situation is hopeless and that there is no other way to resolve it aside from taking their own life.

Nursing Process: Assessment: Demographics:

-Age -Gender -Ethnicity -Occupation -Socioeconomic status -Marital status -Lethality and availability of method -Religion -Family history of suicide

Theories of Suicide: Psychological

-Anger turned inward -Hopelessness -Desperation and guilt -History of aggresion and violence -Shame and humiliation

Planning/Outcome- Long term:

-Develop and maintain a more positive self-concept. -Learn more effective ways to express feelings to others. -Achieve successful interpersonal relationships. -Feel accepted by others and achieve a sense of belonging.

Interventions- Guidelines for treatment of the suicidal client on an outpatient basis:

-Do not leave the person alone. -Establish a no-suicide contract with the client. -Enlist the help of family or friends. -Schedule frequent appointments. -Establish rapport and promote a trusting relationship. -Be direct and talk matter-of-factly about suicide. -Discuss the current crisis situation in the client's life. -Identify areas of self-control. -Give antidepressant medications. -Psychological interventions

Theories of Suicide: Sociological- Durkheim's three social categories of suicide:

-Egoistic suicide -Altruistic suicide -Anomic suicide

Interventions- Interventions with family and friends of suicide victims:

-Encourage him or her to talk about the suicide. -Discourage blaming and scapegoating. -Listen to feelings of guilt and self-persecution. -Talk about personal relationships with the victim. -Recognize differences in styles of grieving. -Assist with development of adaptive coping strategies. -Identify resources that provide support.

Theories of Suicide: Biological

-Genetics -Neurochemical

IS PATH WARM?

-I: Ideation -S: Substance Abuse -P: Purposelessness -A: Anger -T: Trapped -H: Hopelessness -W: Withdrawal -A: Anxiety -R: Recklessness -M: Mood

Historical Perspectives

-In ancient Greece, suicide was an offense against the state, and individuals who committed suicide were denied burial in community sites . -In the culture of the imperial Roman army, individuals sometimes resorted to suicide to escape humiliation or abuse. -In the Middle Ages, suicide was viewed as a selfish or criminal act. Individuals who committed suicide were often denied cemetery burial and their property was confiscated and shared by the crown and the courts. -The issue of suicide changed during the Renaissance period. Although condemnation was still expected, the view became more philosophical, and intellectuals could discuss the issue more freely. -Most philosophers of the 17th and 18th centuries condemned suicide, but some writers recognized a connection between suicide and melancholy or other severe mental disturbances. -Suicide was illegal in England until 1961, and only in 1993 was it decriminalized in Ireland. -Most religions consider suicide as a sin against God. Judaism, Christianity, Islam, Hinduism, and Buddhism all condemn suicide. -In 1995, Pope John II restated Church opposition to suicide, euthanasia, and abortion as crimes against life, not unlike homicide and genocide.

Socioeconomic Status

-Individuals in the very highest and lowest social classes have higher suicide rates than those in the middle classes

Demographics- Family history:

A family history of suicide increases an individual's risk for suicide.

History of Aggression and Violence

A history of violent behavior or impulsive acts has been associated with increased risk for suicide, although recent evidence suggests that impulsive traits are higher in individuals with suicide ideation but not necessarily associated with more attempts.

Neurochemical Factors

A number of studies have revealed a deficiency of serotonin (measured as a decrease in the levels of 5-hydroxyindole acetic acid [5-HIAA] in the cerebrospinal fluid) in depressed clients who attempted suicide. These studies, as well as postmortem studies, have supported the hypothesis that deficiencies in central nervous system (CNS) serotonin are associated with suicide.

Demographics- Age:

Adolescents and the elderly have been generally identified as high-risk groups, but recent statistics demonstrating the highest incidence in the 45- to 64-years age group suggests that nurses should pay close attention to assessing for suicide risk in all of these age groups.

The precipitating stressor

Adverse life events in combination with other risk factors, such as depression, may lead to suicide. Life stresses accompanied by an increase in emotional disturbance include the loss of a loved person either by death or by divorce, problems in major relationships, changes in roles, or serious physical illness.

Interpersonal Support System

Does the individual have support persons on whom he or she can rely during a crisis situation? Lack of a meaningful network of satisfactory relationships may implicate an individual as a high risk for suicide during an emotional crisis.

Recklessness

Engages in reckless or risky activities with little thought of consequences

Anxiety

Expresses anxiety, agitation, and/or changes in sleep patterns

Withdrawal

Expresses desire to withdraw from others or has begun withdrawing

Mood

Expresses dramatic mood shifts

Hopelessness

Expresses lack of hope and perceives little chance of positive change

Trapped

Expresses the belief that there is no way out of the current situation

Purposelessness

Expresses thoughts that there is no reason to continue living

Anger

Expresses uncontrolled anger or feelings of rage

Anger turned inward

Freud (1957) believed that suicide was a response to the intense self-hatred that an individual possessed. The anger had originated toward a love object but was ultimately turned inward against the self. Freud believed that suicide occurred as a result of an earlier repressed desire to kill someone else. He interpreted suicide to be an aggressive act toward the self that often was really directed toward others.

Substance abuse

Has current and/or excessive use of alcohol or other mood-altering drugs

Ideation

Has suicide ideas that are current and active, especially with an identified plan

Relevant history

Has the individual experienced numerous failures or rejections that would increase his or her vulnerability for a dysfunctional response to the current situation?

Durkheim 1951

He believed that the more cohesive the society and the more that the individual felt an integrated part of society, the less likely he or she was to commit suicide.

Demographics- Occupation:

Health-care professionals (especially physicians), law enforcement officers, dentists, artists, mechanics, lawyers, and insurance agents have all been identified as occupational groups incurring greater risks for suicide.

Hopelessness and Other Symptoms of Depression

Hopelessness has long been identified as a symptom of depression and as an underlying factor in the predisposition to suicide.

Demographics- Socioeconomic status:

Individuals in the highest and lowest socioeconomic classes are at higher risk than those in the middle classes.

Demographics- Religion:

People with a close religious affiliation may be at less risk for attempting suicide if they believe, for example, that suicide is an unforgivable sin or that within their religious affiliation suicide is strictly forbidden. Conversely, people without close affiliations that impose restrictions about suicide may be at greater risk.

Psychiatric, Medical, and Family History

The individual should be assessed with regard to previous psychiatric treatment for depression, alcoholism, or previous suicide attempts. Medical history should be obtained to determine the presence of chronic, debilitating, or terminal illness.

Altruistic suicide

is the opposite of egoistic suicide. The individual who is prone to altruistic suicide is excessively integrated into the group. The group is often governed by cultural, religious, or political ties, and allegiance is so strong that the individual will sacrifice his or her life for the group.

Egoistic suicide

is the response of the individual who feels separate and apart from the mainstream of society. Integration is lacking, and the individual does not feel a part of any cohesive group (such as a family or a church).

Religion

men and women who consider themselves affiliated with a religion are less likely than their nonreligious counterparts to attempt suicide

Socioeconomic Status- Occupation

suicide rates are higher among physicians, artists, dentists, law enforcement officers, lawyers, and insurance agents. There are more suicides among the unemployed than among the employed, and suicide rates increase during economic recessions and depressions.