Suicide and Non-Suicidal Self-Injury
Guidelines for action with the SAD PERSONS scale
5 to 6- Strongly consider hospitalization, depending on confidence in the follow-up arrangement; 7 to 10- Hospitalize or commit
Secondary intervention
treatment of the actual suicidal crisis
Recent theories
combination of suicidal fantasies and significant loss, rage or guilt, or copycat suicide
Professionals are more likely to
commit suicide than non-professionals
Counseling:
crisis techniques, problem solving are necessary. Staff should be warm, sensitive, interested, and consistent. Some counselors use a no-suicide contract
Third leading cause of death in
15 to 24 age group
Fourth leading cause of death in
25 to 44 age group
Menninger
3 parts of suicidal hostility- Wish to kill; Wish to be killed; Wish to die
Eighth leading cause of death in
45 to 64 age group
Suicide protective factors
Effective and accessible mental health care; Strong connections to others; Problem solving and conflict resolution skills; Contact with providers
Societal Factors
Increase in social isolation!!!
Suicide
Intentional act of killing oneself by any means; Tenth leading cause of death; Fourth leading cause of death among children 10 to 14 years of age
Psychosocial interventions
Key element: ESTABLISHING A THERAPEUTIC RELATIONSHIP!!!!; What does this include? How do you do this?; Patient safety plan; Be warm, sensitive, interested, and consistent
A person with which psychiatric problem is most likely to complete suicide?
Major depression
Protective factors: African Americans
Religion, role of the extended family
Diagnosis
Risk for suicide
Protective factors: Hispanic Americans
Roman Catholic religion and importance of extended family
Assessment: Obtain a history from the patient regarding self-injury
Types of self-injury; Triggers for the behavior; Frequency of the behavior; What has helped in the past to stop the behavior; Assess the wounds; Self-assessment
Assessment
Verbal and nonverbal clues; Lethality of suicide plan; Assessment tools: Columbia-Suicide Severity Rating Scale, SADPERSONS scale; Self assessment
Patient safety plan includes:
Warning signs that a problem is developing, internal coping strategies, people and social settings that provide distractions, people the person can call for help, professionals or agencies to contact during a crisis, and making the environment safe.
Oregon's Death with Dignity Act of 1994
terminally ill patients allowed physician-assisted suicide
As you plan care for someone who is suicidal, you base care on
risk and protective factors. Consider comorbid problems, the support systems of the person to decrease the person's sense of isolation which leads to hopelessness.
50% of those who commit suicide have
some medical/physical illness.
Lethality:
specific plan? How lethal is the plan? Do they have the means to carry out the plan?
Being married reduces the risk of
suicide and if there are small children, even better. Divorced men commit suicide more often than divorced women
Primary care takes place in
the community, in primary care, in churches...etc
Consider the pain of being a survivor of someone who committed suicide:
they are your patient, not the deceased. Pain doesn't go away quickly...talk about the person, use open ended questions, recommend support groups.
Suicide precautions:
watch suicidal person continuously, include affect as you describe the person's behavior. Suicide is highest in the first few days following admission and during staff rotation.
Suicidal behavior tends to run in
families
Interventions
Pharmacological interventions; Alternative somatic treatment: ECT; Milieu therapy; Health teaching and health promotion; Case management; Post-vention for survivors of completed suicide
Suicide Risk factors
Previous Suicide attempt; History of suicide in the family; Mood disorders; Alcohol or substance use disorders; Access to lethal means; Losses and other events; History of trauma or abuse; Chronic physical illness; Exposure to the suicidal behavior of others
50% of people who have completed suicide have
alcohol in their system.
Male:
although women attempt suicide more frequently; Males...rates peak after 45 and for women...rates peak after 55; White males commit 2 out of 3 suicides in the US
Switzerland
assisted suicide legal since 1918
Protective factors: Asian Americans
Adherence to religions that tend to emphasize interdependence between the individual and society
Self-Injury Comorbidity:
depression, non-heterosexual orientation, personality disorders, anxiety, substance use disorders
Always remember: suicidal behavior is the result of
interpersonal turmoil!
Overt statements:
"I can't take it anymore"
Covert statements:
"I won't be a problem much longer"
Interventions for self-harm
Caring for the wounds; Establish a therapeutic relationship (This provides support; Will serve as an alternative to self-injury when anxiety increases); Teach coping skills to replace the behavior
Meds:
SSRIs, watch for cheeking of meds and saving for suicide attempt, assess for side effects. Lithium may help decrease suicidal ideation, second generation antipsychotics may help with agitated/psychosis. And ECT may be treatment of choice for one who is actively suicidal.
SAD PERSONS scale
Sex: 1 if male; 0 if female; (more females attempt, more males succeed); Age: 1 if < 20 or > 44; Depression: 1 if depression is present; Previous attempt: 1 if present; Ethanol abuse: 1 if present; Rational thinking loss: 1 if present; Social Supports Lacking: 1 if present; Organized Plan: 1 if plan is made and lethal; No Spouse: 1 if divorced, widowed, separated, or single; Sickness: 1 if chronic, debilitating, and severe
Outcomes identification
Suicide self-restraint
Suicide Warning factors
Talking or writing about death; Making hopeless, helpless, or worthless comments; Increased alcohol and/or drug misuse; Withdrawal from friends, family, and community; Reckless behavior or more risky activities; Dramatic mood changes; Talking about feeling trapped or like a burden to others
A patient is hospitalized with major depression and suicidal ideation. He has a history of several suicide attempts. For the first 2 days of hospitalization, the patient eats 20% of meals and stays in his room between groups. By the fourth day, the nurse observes that the patient is more sociable, is eating meals, and has a bright affect. Which factor should the nurse consider?
The patient may have decided to commit suicide; the nurse should reassess suicidality.
Nonsuicidal Self-Injury
This is deliberate and direct attempts to cause bodily harm that does not result in death...cutting, burning, scratching, biting, hitting; Prevalence is 13% to 23% in adolescents.
Primary intervention
activities that provide support, information, and education to prevent suicide
A history of suicide attempts puts a person at a high risk of
actually completing the suicide in the future.
Freud
aggression turned inward
Aaron Beck
central emotional factor is hopelessness
Religiosity is associated with
decreased rates of suicide and Roman Catholics have lower rates than protestants and jews
Low serotonin levels are related to
depressed mood
Secondary care takes place
in clinics, hospitals, jails, and telephone hotlines
Tertiary intervention
interventions with a circle of survivors left by individuals who completed suicide to reduce the traumatic aftereffects
Netherlands
nonterminal cases of "lasting and unbearable" suffering
Belgium
nonterminal cases when suffering is "constant and cannot be alleviated"
Suicide is possible when
pain and hopelessness are present.
Washington state
physicians can prescribe lethal medication
Health teaching includes information about
psychiatric diagnosis, medications, complementary therapies, and developmental crisis
90% of people who completed suicide had a
psychiatric disorder...depression, bipolar disorder, schizophrenia. There is pain, hopelessness, guilt, self-loathing as well as the belief that there is no solution and that things will not get better. Provide HOPE