J: Chapter 17: Mood Disorders and Suicide
When a woman in the last weeks of her pregnancy expresses concern over experiencing postpartum depression (PPD) after the birth of her baby, which response by the nurse indicates the use of therapeutic communication?
"What makes you feel that you'll get depressed after your baby's birth?" Explanation: Although it is important to provide information and probability statistics about PPD to a pregnant client who is concerned about developing this mental health condition, the nurse best demonstrates therapeutic communication by using exploring to learn more about the client's concerns. A female client who has experienced PPD in the past is more likely to experience this with proceeding births. The statistics offered are not accurate, 1 out of 10 women are likely to experience PPD. The greatest risk of developing PPD is about 4 weeks after the birth of the baby.
The nurse has been asked to assess a client to determine if the client has a suicide plan. Which question would assist the nurse in assessing this area?
"Are you thinking about killing yourself right now?" Explanation: Potential questions to assess a suicide plan include the following: Are you thinking about killing yourself right now? Are you feeling so badly that you have thought of taking your own life? Have things been so bad that you feel you can't go on? What have you thought about doing? Have you thought about a specific time or place? Do you have access to a firearm, pills, knife?
An elderly client is admitted to the hospital with fatigue and weight loss of 20 pounds in 1 month. Upon further assessment, the client is diagnosed with depression. What other thing should the nurse assess this client for based on the weight loss?
Dehydration Explanation: When there is a significant wight loss in older adults with moderate to severe depression, they need to be assessed for dehydration as well as weight changes. They also need to be monitored for suicide, sleep disturbance, and decreased energy, but they are not related to nutrition and the weight loss.
A 35-year-old client with bipolar disorder has a history of discontinuing medication when feeling well and then becoming manic again. During the client's last episode of mania, the client lost several thousand dollars in risky investments. Which intervention will be most helpful in achieving medication adherence?
During stabilization, discuss the client's individual signs, symptoms, and consequences of relapse. Explanation: To help link the importance of taking medication with relapse prevention, the nurse lists target symptoms and identifies signs of imminent relapse. The nurse engages in problem solving with the client about early management of symptoms so severity does not increase.
A client has been successfully treated on the psychiatric mental health unit following a suicide attempt. In preparation for discharge, the nurse should prioritize what action?
Ensuring a plan is in place for the client's community-based care Explanation: Following a suicide attempt, it is imperative that a plan be in place for continuity of care in the community. Arrangements such as advance directives and commitment to treatment statements are optional, not mandatory. Communication with the pharmacy is just one component of a discharge plan and is not necessary in every circumstance.
Following the failure of a woman's recent in vitro fertilization (IVF), the nurse recognizes that she may be at risk of depression. Which intervention is considered a primary suicide prevention measure?
Establishing a support system for the woman and teaching her some coping measures Explanation: Primary prevention involves the identification and elimination of factors that cause or contribute to the development of an illness or disorder that could lead to suicide. Medication management, psychotherapy, and suicide precautions are more aggressive measures that would not be classified as primary prevention.
A client with a history of bipolar disorder is at home with family. The family calls the mental health clinic because they suspect that the client may be experiencing a relapse of mania. Which would support the family's suspicions?
Excessive energy levels Explanation: Indicators of a possible relapse include: having more energy than usual; inability to focus on one topic; feelings of constant hunger; and friends remarking about changes in mood. Avoidance of people would suggest depression, not mania.
A nurse providing community education for parents regarding adolescent suicide should include in the teaching session that the most frequent cause or motive for suicide in this age group is what?
Feelings of alienation or isolation Explanation: In adolescent clients, the developmental task is of a sense of belonging. When adolescents feel alienated or isolated, suicidal thoughts may emerge. In adolescence, therefore, the most common motives are feelings of alienation or isolation.
The nurse knows that the most dangerous time period following a previous suicide attempt is what?
First 3 months Explanation: The first 2 years after a suicide attempt represent the highest risk period, especially the first 3 months.
Psychodynamic theory attributes the development of mood disorders to what?
Unexpressed and unconscious anger Explanation: Psychodynamic theories postulate that clients with depression have unexpressed and unconscious anger about feeling helpless or dependent on others. They cannot express this anger toward the person or people on whom they feel dependent, so their anger turns inward.
A client comes to the clinic for an evaluation of headache, fatigue, and an overall feeling of being "down." When assessing the client, which statement by the client would alert the nurse to suspect possible suicide? Select all that apply.
"I've been drinking about three or four more beers every night." "I'm so tired that all I ever want to do is sleep all the time." "Most times, I feel like I'm trapped with no way out." Explanation: Warning signs for suicide include increased substance use (drinking three or four more beers every night), an inability to sleep or sleeping all the time, and feeling trapped. Social isolation or withdrawal (rather than going out with friends or looking for a new job) would suggest suicide.
A psychiatric-mental health nurse is conducting a suicide assessment with a client. Why is it important to conduct a lethality assessment?
It may assist in predicting how likely a person is to die by suicide. Explanation: Lethality assessment is part of conducting a risk assessment. Once it is determined that someone is thinking of suicide, a lethality assessment is necessary. It is an attempt to predict how likely a person is to die by suicide.
A depressed older adult client is being treated with a tricyclic antidepressant (TCA). For which clinical manifestations should the nurse monitor the client?
Orthostatic hypotension and urinary retention Explanation: Orthostatic hypotension and urinary retention are common side effects of TCAs. Photosensitivity, skin rashes, pseudoparkinsonism, and tardive dyskinesia are common side effects of older antipsychotics. Diarrhea and electrolyte imbalances are side effects of lithium.
A client who is prescribed a tricyclic antidepressant is brought to the emergency department with a suspected overdose. Which would the nurse assess to support this suspicion? Select all that apply.
blurred vision urinary retention In acute overdose, almost all symptoms develop within 12 hours. Anticholinergic effects are prominent and include dry mucous membranes, warm and dry skin (not pale, moist skin), blurred vision, decreased bowel motility (not diarrhea), and urinary retention. Central nervous system suppression (ranging from drowsiness to coma) or an agitated delirium may occur. Headache is a side effect of monoamine oxidase inhibitors.
Which mental health disorder has the most significant risk factor for suicide?
depression Explanation: Depression is a major risk factor of suicide. Anxiety, schizophrenia, and mania are significant risk factors but to a lesser degree than depression.
Which is the greatest predictor of a future suicide attempt?
previous attempt Explanation: The greatest predictor of a future suicide attempt is a previous attempt, in part because that individual already has broken the "taboo" around suicidal behavior. Assessing for risk includes determining the seriousness of the suicidal ideation, degree of hopelessness, and suicide planning.
A bipolar client presents to the clinic with reports of headaches and feeling more irritable than usual. What is the best nursing response?
"Can you tell me more about these symptoms?" Explanation: Additional assessment is needed for the bipolar client at this time. By asking an open-ended question, the nurse will be able to determine if the symptoms described by the client are examples of a depressive episode. Telling the client to continue taking medication as prescribed may be warranted, but telling the client that the symptoms are minor minimizes the expressed concern. Asking the client whether or not they have been taking their medication correctly may be needed but it is not the best response at the time because it can be construed as implicit bias. There may be a need for bloodwork, but more information is needed before an order should be obtained.
The nurse conducts a health history interview for a client who presents with severe depression. Which question does the nurse ask the client to determine social risk factors associated with suicide?
"Did you recently lose your job?" Explanation: Social isolation is a primary risk factor for suicide. Social distress leads to despair and can prevent the client from accessing the support that is necessary to prevent suicidal acts. Social factors associated with suicide risk include the following: economic deprivation, unemployment, poverty, knowing someone who died by suicide, and a lack of access to behavioral health care. Based on this information, the question that assesses the client's social risk factors for suicide is, "Did you recently lose your job?" The other questions assess the client's psychological risk factors for suicide and sexuality risk factors.
The nurse is conducting an interview with an adult client who is being treated for major depression. What question should the nurse prioritize in an effort to determine the client's risk for suicide?
"Do you ever feel like your situation is hopeless?" Explanation: Hopelessness is a significant risk factor for suicide among persons who are depressed. For an adult client, relationships with parents are significant but not among the major risk factors for suicide. Similarly, the client's perception of medication effectiveness is important but not a key risk factor. It is common for depressed individuals to lack firm plans for their days, and a lack of planning does not necessarily indicate a heightened suicide risk.
The nurse provides care for a client who is depressed and expresses hopelessness with the current situation. Which client statement indicates a need to implement safety precautions?
"I haven't been able to sleep for the past week because I am anxious." Explanation: Identification of clients who are considering suicide is a priority nursing action. The nurse can use the mnemonic IS PATH WARM to assess the client for warning signs for suicide. The A in this mnemonic stands for anxiety and may be manifested by an inability to sleep; therefore, the statement that indicates a need to explore the implementation of safety precautions is, "I haven't been able to sleep for the past week." Starting a new antidepressant and stating, "I hope I feel better soon; I decided that I should stop drinking alcohol for a while; I just started a new job so at least I have that." do not correspond with any of the warning signs for suicide.
The nurse reviews the medication list for a client who is newly prescribed a selective serotonin reuptake inhibitor (SSRI) for the treatment of depression. Which client statement indicates a need to assess the client for serotonin syndrome?
"I started taking diet pills to assist with weight loss." Explanation: Serotonin syndrome is a potentially serious side effect caused by drug-induced excess of intrasynaptic serotonin, 5-hydroxytryptamine (5-HT). Combining medications that increase CNS serotonin levels, such as SSRIs + MAOIs, St. John's wort, diet pills, dextromethorphan, or alcohol (especially red wine) or an SSRI + street drugs (e.g., LSD, MMDA, or ecstasy). The client statement "I started taking diet pills to assist with weight loss." requires the nurse to assess the client for symptoms of serotonin syndrome, which include mental status changes, agitation, ataxia, myoclonus, hyperreflexia, fever, shivering, diaphoresis, and diarrhea. The other client statements do not indicate that the client is at risk for serotonin syndrome.
A client comes to the clinic for an evaluation of headache, fatigue, and an overall feeling of being "down." When assessing the client, which statement by the client would alert the nurse to suspect possible suicide? Select all that apply.
"I've been drinking about three or four more beers every night." "I'm so tired that all I ever want to do is sleep all the time." "Most times, I feel like I'm trapped with no way out." Explanation: Warning signs for suicide include increased substance use (drinking three or four more beers every night), an inability to sleep or sleeping all the time, and feeling trapped. Social isolation or withdrawal (rather than going out with friends or looking for a new job) would suggest suicide.
A client is to receive three treatments of electroconvulsive therapy (ECT) per week for 3 weeks. After the third treatment, the client is forgetful and confused. When the client's spouse arrives to take the client home, the nurse discusses the client's condition with the spouse. Which statement is best?
"Some people experience mild confusion after ECT. Generally it clears in a few days, though it may take longer." Explanation: A frequent consequence of ECT is memory impairment, ranging from mild forgetfulness of details to severe confusion. This may persist for weeks or months after treatment but usually resolves.
A client with a diagnosis of depression tells the nurse that the client's mood was especially bad this morning but that the client pushed through it to attend a support group. How can the nurse best validate the client?
"That shows an admirable level of perseverance on your part. Well done!" Explanation: Acknowledging the effort and perseverance that it took for the client to attend the support group is a good example of validation. Because the client has depression, the client likely had to battle hopelessness more than fear or anxiety. A statement about the benefits of support groups is irrelevant and does not validate the client. It is presumptuous to claim that the client has nearly recovered.
When conducting a suicide risk assessment with a client, the nurse should identify the client as a high imminent risk if which statement is made?
"There are no solutions to my problems." Explanation: Hopelessness is the pervasive belief that undesirable events are likely to occur coupled with the belief that one's situation is unlikely to improve. 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. The statement, "There are no solutions to my problems" is consistent with the risk that the client has lost hope; therefore, the risk of suicide is high and possibly imminent. The nurse should ensure the suicide risk assessment and associated interventions are a high priority. Having a child can be a protective factor against suicide. Stating one is not going to engage in the act of suicide because of a family member lowers the risk of an imminent attempt. The client who states he or she thinks about starving sometimes has made a vague statement with a plan that is not highly lethal. The risk is likely low with this client but support should be provided, nonetheless. The client who reaches out by asking for someone to talk to is calling for help and being proactive before getting to the point of making the decision to commit suicide.
A client comes to the emergency department reporting a severe pounding headache in the temples and a stiff neck. The client is flushed and diaphoretic, and the client's pulse is racing. The client states that the client is being treated for depression with an MAOI. Which question by the nurse would be most important to ask at this time?
"What have you had to eat or drink today?" Explanation: The client is exhibiting signs of a hypertensive crisis, which can occur when a client is receiving MAOI therapy and ingests food or other substances that contain tyramine. Thus, the nurse should ask the client what the client has had to eat or drink. Drug levels are used to monitor tricyclic antidepressants. Asking about chest pain would be appropriate after obtaining information related to what the client has ingested. Herbal remedies can interact with medications, but this information would be obtained after determining whether the client has ingested foods and fluids containing tyramine.
A client is admitted to the unit in an acute manic episode. The client has had three major depressive episodes in the past 10 years and two other hospitalizations for mania. Which disorders would reflect the client's symptom profile?
Bipolar I Explanation: Bipolar I disorder is characterized by one or more manic episodes, usually alternating with major depressive episodes.
Nursing interventions for the depressed person should include which approach?
Acceptance, honesty, empathy, and patience Explanation: When working with depressed individuals, it is most therapeutic to maintain an attitude of acceptance, honesty, empathy, and patience. Being too cheerful can convey a nongenuine approach. Being too businesslike can convey the attitude of not having time to care for the client, and confrontation is not necessary under the condition of depression.
After being diagnosed with a chronic disease, a client has been feeling depressed. Which diagnosis has the strongest association with an increased suicide risk?
Acquired immunodeficiency syndrome Explanation: The World Health Organization notes that chronic physical illness and certain physical illnesses contribute to higher suicide risk in some individuals. Neurologic diseases such as epilepsy and spinal and brain injury have been associated with increased suicide risk. HIV infection and AIDS also pose increased suicide risk, particularly at the time of diagnosis. Pain also has been identified as a significant contributing factor.
A loss of pleasure or interest in a client diagnosed with depression would be documented as what?
Anhedonia Explanation: A person with depression has a sustained period of feeling depressed, sad, or hopeless and may experience anhedonia (loss of interest or pleasure). The client may report "not caring anymore" or not feeling any enjoyment in activities that were previously considered pleasurable. Flat affect is the complete or near absence of affective expression. Hopelessness and discouragement would not be the correct documentation for this symptom.
A nursing instructor is reviewing a case study with students about a client with mania who was admitted to a mental health unit. The instructor asks the students what medical diagnosis is most likely responsible for the mania. Which would be the best answer by a student?
Bipolar disorder Explanation: In most cases, mania is a symptom that manifests in people with underlying bipolar disorder. Mania is reflected in periods of euphoria, exuberant activity, grandiosity, and a false sense of well-being. There can be periods of mood instability and irritability as well.
A client has just been admitted to the inpatient psychiatry unit following a suicide attempt. During the client's first 24 hours of care, what outcome should be identified?
Client will express that the client feels safe on the unit Explanation: The initial care of a client who has had a suicide attempt focuses on helping the client feel safe and instilling the beginnings of hope. It would be premature to expect the client to learn and apply new stress management strategies after only 24 hours. Cognitive behavioral therapy would not begin during the acute stage of recovery. A sense of overall optimism will likely require long-term therapy to achieve it.
The major difference between bipolar I and bipolar II disorder is what?
Clients with bipolar II disorder do not have symptoms of mania that interfere enough to cause marked functional disturbances. Explanation: Bipolar II disorder is characterized by a major depressive episode (either current or past) and at least one hypomanic episode. Bipolar II disorder differs from bipolar I in that the client has never had a manic or mixed episode but may have had an episode in which he/she experienced a persistently elevated, expansive, or irritable mood. The hypomanic symptoms are not severe enough to cause marked social or occupational dysfunction.
When a nurse assesses prior self-harm behavior, this can provide information about the motivation behind the client's actions and allows the nurse to do what?
Communicate concern and empathy to the client Explanation: Assessing the context of each act of prior self-harm behavior begins to paint a picture of motivation behind the behavior. Exploration of prior behavior also gives a message of interest and concern on the part of the health professional.
The nurse is providing client education to an individual who has recently been diagnosed with bipolar disorder and is starting divalproex sodium therapy. What priority information should the nurse include in the plan of care?
Confirm baseline labs have been ordered prior to starting therapy. Explanation: Prior to the initiation of divalproex sodium therapy, baseline CBC with differential and liver function tests should be taken. Because this medication can lead to hepatotoxicity, it is important to both establish a baseline and continue to monitor on a weekly basis to verify therapeutic levels. Finding out the name of the client's pharmacy may be needed to fill the prescription. Weight gain is an associated side effect of therapy, not weight loss.
A nurse is preparing a presentation for family members of clients who have been diagnosed with depression. When describing the family response to depression, which would the nurse include?
Depression in one family member affects the entire family. Explanation: Depression in one member affects the whole family. Spouses, children, parents, siblings, and friends experience frustration, guilt, and anger when the family member is immobilized and cannot function. It is often hard for others to understand the depth of the mood and how disabling it can be. The lack of understanding and difficulty of living with a depressed person can lead to abuse. Women between the ages of 18 and 45 years constitute the majority of those experiencing depression, and thus their families experience the majority of problems.
Which is an anticonvulsant used as a mood stabilizer?
Divalproex Explanation: Divalproex is an anticonvulsant that may be used as a mood stabilizer. Venlafaxine, bupropion, and phenelzine are antidepressants.
The nurse is conducting an admission assessment with a 45-year-old client who has been demonstrating signs of bipolar disorder. While conducting the assessment, the client starts speaking in illogical rhymes and using word associations. What is the name for this thought pattern?
Flight of ideas Explanation: Rapid "flights of ideas" lead to excessive and illogical rhyming, punning, and word associations, along with pressured speech.
A 32-year-old client is admitted to the inpatient unit for depression with suicidal thoughts. During the nursing assessment, why it is important for the nurse to assess and explore if there is any family member who has committed suicide?
Genetic predisposition Explanation: Suicide rates tend to be higher in families in which suicide has occurred, which are genetic and familial factors. 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.
The nurse is preparing to discharge a client from the inpatient facility where the client was treated following an unsuccessful suicide attempt. The priority assessment for the nurse to make is to assess whether or not the client can do what?
Identify a person to whom he or she can turn to for help after discharge. Explanation: The priority assessment for the nurse to make is whether or not the client can identify a person or, ideally, persons to whom he or she can turn to for help after discharge. Inability of the client to name any significant others portends a poor outpatient course.
A nurse is preparing a client for discharge. As part of the discharge process, the nurse provides education to the client regarding safety from self-harm. Which intervention should the nurse employ?
Include family members to provide a better understanding of symptoms of the illness Explanation: In addition to trying to reduce the stigma that the client and family may associate with suicide, the nurse must educate them about depression, suicidal behavior, and treatments. When possible, the nurse should schedule educational sessions to include significant others so that they will better understand the client's illness and also learn what is necessary in providing outpatient care.
A 56-year-old client who suffers from seasonal affective disorder is being assessed by the nurse in an outpatient mental health clinic. The nurse is aware which treatment is the most effective type of treatment for this condition?
Light therapy Explanation: Phototherapy has proven effective for clients with symptoms of depression associated with a seasonal pattern. This condition, called seasonal affective disorder, may be related to lack of light and decreased melatonin production.
A client taking lithium therapy has a serum therapeutic level of 0.8 mEq/L. What priority dietary instruction should the nurse include in the teaching plan?
Maintain daily sodium intake. Explanation: Consistent sodium intake is critical with lithium therapy. A serum therapeutic level of 0.8mEq/L is within the therapeutic range of 0.6-1.2 mEq/L. Fluid intake on lithium therapy should be increased to 2 L/day. Switching to a DASH diet is used to treat HTN. Monitoring weight pattern should be included but it is not the current priority.
Which medication classification is considered first-line drug therapy for bipolar disorder?
Mood stabilizers Explanation: Mood stabilizers are first-line drugs for bipolar disorders. They stabilize depressive and manic cycles.
Which is a true statement regarding depressive disorders?
Norepinephrine, dopamine, and serotonin have been implicated. Explanation: The monoamines that have been implicated in depression are norepinephrine (NE), dopamine (DA), and serotonin (5-HT). Disturbances in mood may result when absolute concentrations of NE, 5-HT, or both are deficient. Depressive disorders are more prevalent in women than in men. Depression in older adults may be difficult to diagnose because many older people have comorbid diseases. It is currently the leading cause of U.S. disability in clients 15 to 44 years of age.
A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to the client's feelings of sadness and hopelessness, the nurse would expect to assess what?
Psychomotor retardation Explanation: Associated signs and symptoms of depression include an inability to think or concentrate, increased complaints of pain, psychomotor retardation, and lack of energy and fatigue.
After assessing a client, the nurse identifies that the client is at risk for suicide. Which would be the nurse's priority intervention?
Remove means of suicide from the client's access. Explanation: Immediate interventions involve removing the means of suicide to reduce the risk of it happening. If the person is hospitalized, methods may include ensuring pills or medications are not available to clients or that they are not taking any measures to accumulate needed drugs. If in a community or home care setting, nurses may enlist the help of family or friends to remove the means and to provide immediate support.
After observing a bipolar client on the mental health unit, the nurse determines that the client is at risk for violence. Which would be an appropriate intervention?
Restrict the client to the client's room until the client can calm down. Explanation: If clients are determined to be at risk for violence, establishing geographic boundaries, such as room or half-hall restriction, is part of ongoing monitoring. Other environmental approaches include reducing stimuli and opportunities for interaction with other clients. Nurses remove all dangerous items from client rooms and monitor closely for use of any dangerous items. A pen or pencil that is used to write a letter can be a dangerous object.
A nursing student is caring for an elderly client who is taking sertraline for depression. The instructor quizzes the student about the medication and its actions. To what classification of drugs should the student assign sertraline?
Selective serotonin reuptake inhibitor Explanation: Sertraline is a selective serotonin reuptake inhibitor.
A client with major depression is prescribed paroxetine. The nurse develops an education plan for the client based on the understanding that this drug belongs to which class of drugs?
Selective serotonin reuptake inhibitors Explanation: Paroxetine is a selective serotonin reuptake inhibitor. Serotonin norepinephrine reuptake inhibitors include venlafaxine, nefazodone, duloxetine, and desvenlafaxine. Amitriptyline is an example of a tricyclic antidepressant. Monoamine oxidase inhibitors include phenelzine, tranylcypromine, isocarboxazid, and selegiline.
Trying to kill oneself and surviving the ordeal is identified as what?
Suicide attempt Explanation: An attempt of suicide can be characterized as living through an experience of suicide despite having expected or intended to die.
A client has been treated following a suicide attempt. When providing anticipatory guidance during the client's discharge education, the nurse should teach the client that:
The client is likely to experience stigma around the suicide attempt from some people. Explanation: Clients should be made aware that they are likely to face stigma from individuals who are uncomfortable with the topic of suicide. A commitment to treatment statement is not a binding document that is in effect for a fixed period of time. Determination of legal competence is made on the basis of numerous factors and variables. Many clients benefit from group therapy, but this is not considered to be the primary variable in long-term recovery.
The nurse is assessing a client who has presented to the emergency department in emotional distress. What client data represents the greatest risk for suicide?
The client overdosed on pills 2 years earlier Explanation: The greatest predictor of suicide risk is a previous attempt. All of the other listed variables must be addressed, but none is as significant a risk factor as a previous suicide attempt.
For which client would the nurse be obligated to take immediate and focused action to prevent imminent death?
The client with depression who has been using alcohol and owns a gun Explanation: 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 client who is depressed, using alcohol and has access to the most lethal means to commit suicide is the highest risk and requires imminent intervention. The client who is depressed, lives in poverty and has chronic pain meets criteria for someone at risk, however, the risk in this case is not imminent and would not warrant immediate intervention. The client who is depressed, withdrawn and spending most of the time playing video games would certainly warrant assessment and therapeutic intervention, however, based on the information provided the client would not be deemed an imminent risk. The grieving client who is tearful and does not want to be left alone is experiencing a normative response to death and does not meet the criteria for imminent suicide intervention.