Chapter 11: Suicide Prevention PDF

**Chapter 11: Suicide Prevention** - Suicide is not a diagnosis or a disorder; it is a behavior - Suicide is the second-leading cause of death among Americans ages 10 to 24 and 25 to 44 and the eighth-leading cause of death for ages 45 to 64. The tenth-leading cause of death overall -...

**Chapter 11: Suicide Prevention** - Suicide is not a diagnosis or a disorder; it is a behavior - Suicide is the second-leading cause of death among Americans ages 10 to 24 and 25 to 44 and the eighth-leading cause of death for ages 45 to 64. The tenth-leading cause of death overall - **KNOW The most recent statistics say that the highest rate of suicide occurs in the 45-64 yr old age group** Predisposing Factors: Theories of Suicide - Psychological theories - Anger turned inward, Hopelessness, History of aggression and violence, Shame and humiliation - Sociological Theories - Durkheim's three social categories of suicide: Egoistic suicide. Altruistic suicide. Anomic suicide - Joiner's interpersonal-psychological theory - **The Three Step Theory (the factors that elevate SI to an active risk for attempts):** - Pain (usually psychological pain) when combined with hopelessness significantly increases suicide ideation (for both men and women and across age-groups). - When pain and hopelessness exceed one's sense of connectedness to others, suicide ideation becomes active. - When strong, active suicide ideation is present, it leads to an attempt only if one has the capacity to make an attempt. - Biological theories: Genetics, Neurochemical factors **KNOW Risk Factors** - **Individual Risk Factors** - **Previous suicide attempt: Usually future attempts get worse** - **Change in marital status, more women than men attempt suicide BUT men succeed more often, financial strain, highest rates of suicide occur in white populations** - History of depression and other mental illnesses, Serious illness such as chronic pain - Criminal/legal problems, Job/financial problems or loss - Impulsive or aggressive tendencies, Substance use/misuse - Current or prior history of adverse childhood experiences - Sense of hopelessness, Violence victimization and/or perpetration - **Adolescent risk factors:** - Impulsive and high-risk behaviors, untreated mood disorders (e.g., major depression and bipolar disorder), access to lethal means (e.g., firearms), and substance abuse. - **Relationship Risk Factors** - Bullying, Family/loved one's history of suicide, Loss of relationships - High conflict or violent relationships, Social isolation - **Community Risk Factors** - These challenging issues within a person's community contribute to risk: - Lack of access to healthcare, Suicide cluster in the community - Stress of acculturation, Community violence, Historical trauma, Discrimination - **Psychological risk factors:** - Mood disorders, substance use disorders, schizophrenia, anorexia nervosa, borderline and antisocial personality disorders, anxiety disorders, and attention deficit-hyperactivity disorder. - **Societal Risk Factors** - These cultural and environmental factors within the larger society contribute to risk: - Stigma associated with help-seeking and mental illness - Easy access to lethal means of suicide among people at risk, Unsafe media portrayals of suicide **Sociological theories:** - **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). - **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 their life for the group. - **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. **Nursing Process: Assessment** - **KNOW Suicidal Ideas/Acts/Behaviors:** - Individuals may provide both behavioral and verbal clues about their intentions to act. - Examples of **behavioral clues** that may indicate a decision to carry out suicidal intent include: - Giving away prized possessions, getting financial affairs in order, writing suicide notes, and a sudden shift in mood. - Verbal clues may be both direct and indirect. - Examples of **direct** statements include: "I want to die" and "I'm going to kill myself." - Examples of **indirect** statements include: "This is the last time you'll see me," "I won't be around much longer for the doctor to have to worry about," and "I don't have anything worth living for anymore." - Other assessments include determining whether individuals have a plan, and if so, whether they have the means to carry out that plan - **KNOW Self-injurious behaviors**: such as head banging or biting the hands or arms, cutting, burning, self-hitting - **Analysis of the suicidal crisis:** - **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. - **Relevant history:** Has the individual experienced multiple failures or rejections that might increase their vulnerability for a dysfunctional response to the current situation? - **Life-stage issues:** The ability to tolerate losses and disappointments is often compromised if the individual is also struggling with the developmental tasks associated with different life stages (e.g., adolescence, midlife, old age). - Demographics - Age, Sex, Ethnicity/race, Marital status, Occupationn, Religion, Family history of suicide, Military history - Presenting Symptoms; Medical and Psychiatric Dx: History - Suicidal ideas or acts: Intentions, Plan, Means, Lethality - Coping strategies and protective factors, Interpersonal support system **KNOW Interacting with people who are suicidal, pg. 237:** - 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 the person seek professional help. - Remove any items from the home with which the person may harm themselves. - 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. **KNOW Suicidal thoughts in children/adolescents:** - S/s: hopelessness, withdrawn from social activities, changes in eating and sleeping, sudden mood swings - They might also talk about death and dying in a way that seems unusual for their age **KNOW Suicidal thoughts in older adults:** - S/s: talk about wanting to die, feeling hopeless, having no reason to live, feeling trapped, extreme mood swings, increased ETOH or drug use, withdrawn from friends. They may engage in risky behaviors Nursing Process: Diagnosis/Outcome Identification - Nursing diagnoses for the suicidal client may include Risk for suicide, Hopelessness - Outcome criteria - No physical harm to self, Sets realistic goals for self, Expresses some optimism and hope for the future **KNOW Guidelines for Treatment of the Suicidal Client** - **Develop a detailed safety plan** - Ask directly regarding SI, Establish a no-suicide contract with the client, Safe milieu - Establish rapport and promote a trusting relationship - Encourage expression of feelings, Discuss the current crisis situation in the client's life - Identify areas of self-control, Be direct and talk matter-of-factly about suicide - Give antidepressant medications as prescribed. Ensure access to support systems and tie to a system of care - Enlist the help of family or friends, Schedule frequent appointments Information for Family and Friends of the Suicidal Client - Suicide warning signs, Take any hint of suicide seriously. Do not keep secrets, Be a good listener - Express feelings of personal worth to the client. 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 **KNOW Safety plans**: **BOX 11-2** - **Essential components of a safety plan**: - Recognizing warning signs that precede suicide crises - Identifying and employing internal coping strategies that the client can implement without needing to contact additional support people - Identifying supportive family members and friends with whom the client can discuss suicide and who may help resolve a potential crisis - Identifying people and healthy social settings that the client can use for general support and distraction from suicidal thoughts and urges - Identifying resources and contact information for mental health professionals and agencies when needed in an escalating crisis situation - Problem-solving with the client ways to reduce the potential for access to and use of lethal means - **Critical times for reassessment of risk and reevaluation of the safety plan include:** - When there is a change in the client's clinical presentation or worsening of symptoms - When medications or treatments are changed, When significant others identify an increase in concern - When a client stops treatment - Establish a trusting, therapeutic relationship to encourage open discussion of suicide - Collaborate with the pt to develop a safety plan that includes recognition of warning signs, coping strategies, supportive people, and places, resources and contact information for crisis management, and plans to restrict access to lethal means - Assess verbal and nonverbal clues to identify the likelihood that pts intended to follow through with the established safety plan **KNOW Safety contracts/no-harm contract, pg. 236** - **Safety contracts:** a strategy used by some clinicians in the context of a long-term, therapeutic relationship in which the client "promises" to contact the clinician before acting on suicidal ideation. - Typically, we do safety contracts b/c there is a level of accountability for us as nurses BUT in general they are not recommended (lecture) - Such contracts should never be used in short-term encounters with clients, **such as in emergency departments or during brief hospital stays, or with clients who are unknown, agitated, psychotic, impulsive, or under the influence of drugs and alcohol** - **The general consensus**: safety contracts can give a false sense of security and may not be effective in preventing harm or suicide - With safety contracts, the danger is that clinicians may become less watchful or feel less need to reassess the client, thus missing critical signs of increasing suicide risk - **Can you contract for safety? Simple answer is NO** - Initially patients may say yes that they will communicate with a staff member when they have thoughts of self-harm but when those thoughts actually come about they tend to not tell anyone and the risk of self-harm dramatically increases. **KNOW Difference in safety plans and safety contracts/no-harm contracts:** - **Safety plans are comprehensive and personalized strategies for managing crises while safety contracts are formal agreements to avoid self-harm and notify a provider if feeling unsafe.** 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,