Chpt 16-Suicide prevention
Assess 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. On the other hand, 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. 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.
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 manage effectively the stressors in their own lives, nurses can be powerful role models for their patients.
Assessment
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 mnemonic IS PATH WARM can serve as a useful memory aide for these signs. 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.
Psychological Theories
Cognitive Theories Most evidence 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 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 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
Intervention Psychological Domain
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 like he or she is 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. 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.
Treatment for Suicide Prevention
EMERGENCY CARE ALERT ! 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. 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. 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.
Assessment for Suicide
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? 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? 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?
Suicide Prevention Address
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
Family response to suicide
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 post-suicide 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 Protective factors Protective factors buffer individuals from suicidal thoughts and behavior. Although identifying and understanding risk factors is very important, they have not been studied as extensively as risk factors. The Centers for Disease Control and Prevention identifies the following protective factors 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
Interventions
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 roughly 50 to 65 hospital inpatient suicides occurring per year in the United States, a rate that continues to present challenges for the inpatient nursing staff. The vast majority of inpatient suicides takes 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. 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. 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 his or her 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
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 his or her experience and suffering. This intervention directly challenges the patient's belief that no one cares. Using cognitive interventions can help the client to regain hope These actions help reestablish links between the patient's presuicidal past and helps the patient begin establishing goals for the future 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. Until recently, 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
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
Epidemiology and Risk factors
Mental illness is an important factor contributing to suicide in adults. Many young adults who die by suicide also have a depressive disorder, and many others have personality disorders. Adolescents who have panic attacks are particularly at risk for suicide. Auditory hallucinations increase the risk for suicide because of the possibility of individuals impulsively responding to "voices" directing them to kill 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 older than the age of 65 years Additionally, symptoms of comorbid illnesses often are similar to those of depressive disorder, making recognition of depressive disorder by primary care providers difficult. Patients are often reticent to disclose their suicidal thoughts, further complicating detection.
Myths and Facts
Myth: People who talk about suicide do not complete suicide. Fact: Many people who die by suicide have given definite warnings of their intentions. Always take any comment about suicide seriously. Myth: Suicide happens without warning. Fact: Most suicidal people give many clues and warning signs regarding their suicidal intention. Myth: Suicidal people are fully intent on dying. Fact: Most suicidal people are undecided about living or dying. A part of them wants to live; however, death seems like the only way out of their pain or situation. They may allow themselves to "gamble" with death, leaving it up to others to save them. Myth: When people become suicidal, they will always be suicidal. Fact: Most people are suicidal for a limited time, though these feelings could recur at a later time. Myth: You should never ask people if they are thinking about suicide, because doing so may put the idea in their heads. Fact: Asking about suicide does not give people the idea for suicide. It is important to ask the question so that you understand people's thoughts and intentions. Myth: When people who are suicidal feel better, they are no longer at risk. Fact: Sometimes suicidal people feel better because they have made a decision to die, and they may feel a sense of relief that their pain is ending.
Interventions for 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. For both groups, there will be biologic interventions for the underlying psychiatric disorder Medication Management Medication management focuses on treating the underlying psychiatric disorder. In schizophrenia and schizoaffective disorder, evidence suggests that antipsychotic use is related to decreased mortality compared with those not taking an antipsychotic, but currently clozapine is the only FDA-approved medication for suicide risk reduction in individuals with schizophrenia. Studies showing reduced suicide risk in patients with bipolar disorder or major depression taking lithium are not conclusive Electroconvulsive Therapy Electroconvulsive therapy (ECT) has been used in both inpatient and outpatient settings to alleviate severe depression, especially in medically compromised groups such 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
Intervention for 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 him or her 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.
Epidemiology
Psychological Risk Factors Psychological pain, internal distress, low self-esteem, and interpersonal distress have long been associated with suicide. Childhood physical and sexual abuse are linked to suicide, suicidal 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 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 that person was a family member), and lack of access to behavioral health care Gender Males have a suicide completion rate nearly four times more than females. White males account for 78% of completed suicides, with middle-aged 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 Rural men have a much higher risk of suicide than urban men, 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. Women across age and 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 ages 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 Sexuality The lesbian, gay, bisexual, and transgender (LGBT) population is at increased risk for suicide Other risk factors include early disclosure of their sexual orientation and early onset of sexual activity. A cross-national study meta-analysis showed that lifetime suicidal ideation was more common among gay men (40% to 55%) compared with heterosexual men (18% to 30%) as were lifetime suicide attempts Adolescents in sexual minority groups are often stigmatized and discriminated against. They have more suicidal ideation, more suicide attempts, and are more at risk for completed suicides than heterosexual adolescents (Yildiz, 2018). Individuals are more at risk for suicide when they experience conflict with family or friends because of their sexual identify, threat of violence, abuse, bullying, isolation, and other high-risk behaviors A nationwide study of youth health behaviors and experiences reported that a significantly higher percentage of lesbian, gay, or bisexual students (48%) seriously contemplated suicide as compared to 13% of heterosexual students, and 23% of lesbian, gay, or bisexual students attempted suicide as compared to 5% of heterosexual students There are alarming rates of suicidal ideation and suicide rates among transgender people. The suicide attempt rate among transgender persons ranges from 32% to 50%. Gender-based victimization, discrimination, bullying, violence, and rejection by family, friends, and communities are risk factors associated with suicidal behavior 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 Indians/Alaska Natives and whites are highest The rate of suicides among Caucasians has steadily increased since 1999. Suicide rates are higher in males than in females for all groups, with a rate of 24.79 (males) and 7.16 (women) per 100,000. Completed suicides are highest for Caucasians between the ages of 40 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 Caucasians. Access to firearms contributes to the risk of completed suicides Family cohesion and social support in African-American families contribute to the lower rates of suicide in this group. In 2016, the suicide rate among African-American females was the lowest among men and women of all ethnicities. Although the overall suicide rate for African Americans 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 is associated with being in foster care, early aggressive behavior, depression, and dissatisfaction with life Even though the suicide rate for Hispanics (Latinos) is less than half of the overall US rate, suicide is the 12th leading cause of death for Hispanics of all ages and third leading cause of death for Hispanic males ages 15 to 34. Among Hispanic ethnic subgroups in the United States, Puerto Rican adults have the highest rates of suicide attempts. Hispanics born in the United States have higher rates of suicidal ideation and attempts than Hispanic immigrants Suicide is the eighth leading cause of death for American Indians/Alaska Natives of all ages and the second leading cause of death among youth ages 10 to 24. Men and women ages 35 to 64 had a greater percentage increase in suicide rates between 1999 and 2013 than any other racial/ethnic group. Lifetime rates of having attempted suicide reported by adolescents ranged from 15.8% in girls to 11.8% in boys. Adolescent suicide attempts are significantly higher among youth (both sexes) raised on reservations (17.6%) compared to youth raised in urban areas (14.3%). Whereas exposure to suicide and access to alcohol and drugs contribute to suicide rates for Native Americans, family support and cultural and tribal orientation are protective The scant literature on suicide among Asian populations shows that suicidal ideation, plans, and attempts are more common than popularly believed and vary within Asian ethnic groups. For example, Native Hawaiians living in Hawaii who were between the ages of 15 and 44 had a significantly higher suicide death rate than other racial/ethnic groups, but those over 45 had a much lower rate than Whites, the same rate as Japanese, and a higher rate than Filipinos. Asians who immigrated to the United States as children have higher rates of suicidal ideation and suicide attempts than US-born Asians. Cultural identification with the Asian culture (sense of belonging and affiliation with spiritual, material, intellectual, and emotional features) is associated with a 69% reduction in the risk of suicide attempt
Ideation to Action Theories
Suicidal ideation does not necessarily lead to suicide attempts. Most people who think of suicide do not act on the idea, but the suicidal thoughts of those who do take lethal action 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. 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 that is, the human need to belong is not being met. It refers to an individual's feelings of loneliness and isolation, as well as 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 The Integrated Motivational Volitional (IMV) model proposes that motivational factors such as defeat and entrapment cause suicidal ideation. The progression from suicidal 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 suicide attempt The Three-Step Theory (3ST) explains progression from ideation to action in three steps. First, emotional pain and hopelessness cause the suicidal 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 Suicide prevention focuses on reducing pain, increasing hope, improving connections, and reducing capacity to carry out the suicide. Social Theories Emile Durkheim-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 he or she 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. Social Distress A lack of social connection contributes to suicidal ideation, attempts, and deaths across the life span. Among adults, those who are single, never married, separated, widowed, or 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 and being a victim of bullying can contribute to suicidal behavior, especially in adolescents and young adults
Social theories
Suicide Contagion Social exposure to suicide is associated with an increased personal risk for suicidal behavior, particularly among adolescents. Suicide 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 also can be influenced by simple individual and community suicide prevention efforts Economic Disadvantage Poverty and economic disadvantage are associated with depression, suicidal 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, a 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
Keypoints
Suicide is a common and major public health problem. Suicide completion is more common in white men, especially older men. Parasuicide is more common among women than men. People who attempt suicide and fail are likely to try again without treatment. Suicidal behavior has genetic and biologic origins. A suicide assessment focuses on the intention to die, hopelessness, available means, previous attempts and self-harm behavior, and degree of planning. Patients who are in crisis, depressed, or use substances are at risk for suicide. The major objectives of brief hospital care are to maintain the patient's safety, reestablish the patient's biologic equilibrium, help the patient reconnect to others, instill hope, strengthen the patient's cognitive coping skills, and develop an outpatient support system. The nurse who cares for suicidal patients is vulnerable to secondary trauma and must take steps to maintain personal mental health.
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 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. This chapter contains tools that can be used to reduce the broad effects of suicide and provide appropriate care for suicidal patients.
Suicide across lifespan
Suicide is the second leading cause of death among those 10 to 34 years old Mental disorders can lead to worse performance in school, alcohol or other drug abuse, family discord, violence, and suicide. Approximately 20% of US children and adolescents have mental disorders in their lifetime. The most recent Youth Risk and Behavior Survey found that in the preceding year among high school students: 17.2% seriously considered attempting suicide, 13.6% made a suicide plan, 7.4% attempted suicide, and 2.4% were injured in a suicide attempt. Female students were more likely to attempt suicide (9.3%) than male students (5.1%), though males were more likely to die by suicide than females. Suicide attempts vary according to racial and ethnic groups. Black students reported the highest rate of attempt (9.8%), whereas white students reported the fewest attempts (6.1%)
Suicide and attempts
Suicide is the voluntary act of killing oneself. It is a fatal, self-inflicted destructive act with explicit or inferred intent to die. It is sometimes called suicide completion. This behavioral definition of suicide is limited and does not consider the complexity of a 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 The term suicidality refers to all suicide-related behaviors and thoughts of attempting or completing suicide and suicidal ideation. Suicidal ideation is thinking about and planning one's own death. 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 thoughts is associated with poor mental health A suicide attempt is a nonfatal, self-inflicted destructive act with explicit or implicit intent to die. Only recently have data on suicide attempts been compiled. In 2017 in the United States, an estimated 1.4 million adults attempted suicide, with adult females reporting an attempt 1.4 times more often than males (American Foundation for Suicide Prevention [AFSP], 2017). Suicidal ideation, previous psychiatric hospitalization, and a previous attempt are significant predictors of a completed suicide Parasuicide is 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. Parasuicide occurs frequently in younger age groups but declines after the age of 44 years. Lethality refers to the probability that a person will successfully complete suicide. Lethality 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 is ranked as the 10th leading cause of death and accounts for 14 deaths per 100,000 individuals. A suicide occurs approximately every 12 minutes in the United States, resulting in an average of 129 completed suicides per day. The suicide rate in the United States has been stable for several years despite a significant increase in the rate of suicide attempts. Mountain regions have the highest rate of suicide
Adults and OA
Suicide rates peak during middle age, and a second peak occurs in those age 75 years and older. Alienation, loss, a sense of disconnectedness, physical illness, and financial difficulties are important precipitants to suicide in older adults The suicide rate for veterans is estimated at 20 per day. There is considerable debate whether combat exposure or deployment is directly or indirectly responsible for this increase. As is the case with civilian suicide, suicide in the military seems to be related to mental health problems, intimate partner problems, alcohol or substance abuse problems, recent crises, and job problems However, combat and deployment are associated with PTSD and depression, which are associated with suicide Combat exposure is one of the leading factors for both men and women military members. For women, military sexual trauma also contributes to suicidal ideation and attempts
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. 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 (HPA) axis, abnormalities of neurotrophins and neurotrophin receptors, and abnormalities of neuroimmune functions may be associated with suicide risk 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 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
Interventions for 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 pre-suicidal beliefs to a positive and hopeful future, support the application of new skills in managing negative thoughts, and help develop effective problem-solving skills. 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 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 his or her 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. Nurses can challenge negative beliefs, especially the patient's idea that he or she is 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 his or her distress, sense of disconnection, extreme focus on suicidal ideas, and other experiences that led the person to believe he or she had no option other than to die.
Evaluation and Treatment
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, his or her 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. 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 post-release 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 his or her 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
Documentation and Reporting
The nurse must thoroughly document encounters with suicidal patients. 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 the 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.
Factors that enhance suicide risk
VULNERABILITY Primary family member who has completed suicide Psychiatric disorder Previous attempt by the patient Loss (e.g., death of significant other, divorce, job loss) Unrelenting physical illness RISK White or Native American man Older man Adolescent non-Hispanic white or Native American male Gay, lesbian, or bisexual orientation Access to firearms Middle-aged woman INTENT Suicide plan and means of executing it Inability to commit to treatment DISINHIBITION Impulsivity Isolation Psychotic thoughts Drug or alcohol use
