Week 13 MHD Self-Harm and Suicidal Behaviors 2024-2025 PDF

SELF-HARM AND SUICIDAL BEHAVIOURS (SUICIDAL IDEATION) NURS 1028 Chapter 20 1  DEFINITIONS Suicide: The intentional act of taking one’s own life: Attempted: A self-destructive behaviour that did not result in death despit...

SELF-HARM AND SUICIDAL BEHAVIOURS (SUICIDAL IDEATION) NURS 1028 Chapter 20 1  DEFINITIONS Suicide: The intentional act of taking one’s own life: Attempted: A self-destructive behaviour that did not result in death despite the expectation or intention that it would. Completed: Self-termination of one’s own life. Suicide is associated with deep despair and distress; and death is perceived to be a solution to life’s problems. Suicidal Plan: People who are in distress enough to consider suicide may plan the suicide event in detail, possibly leaving a suicide note about the anticipated event, the method, location, circumstance, and time Suicidal Ideation: Thinking about or planning one’s own death and/or the wish to relieve oneself of severe emotional pain. 2  SUICIDALITY A ND S PECIFIC P OPULATIONS Suicide occurs in all age groups, social classes, and cultures. The WHO (2017) reports that nearly 1 million people suicide every year. Globally, suicide is a greater cause of death than war and homicide combined About 4,000 Canadians per year die by suicide—an average of almost 11 suicides a day. It affects people of all ages and backgrounds Suicide is more common among groups with specific risk factors and has been associated with loss, unemployment, transience, recent life events (e.g., financial problems, divorce, moving, problems with children), interpersonal distress, and earlier attempts. Prepubertal Children Adolescents/Youth Midlife Elderly 3  PREPUBERTAL CHILDREN ADOLESCENTS/YOUTH Children younger than 10 years of More teenagers die from suicide than from age can fully understand the finality cancer, heart disease, birth defects, stroke, of death and, although rare can pneumonia, influenza, and chronic lung intentionally kill themselves disease combined In 2016, suicide accounted for 29% among youth In 2016, suicide accounted for 19% aged 15 to 19, and 23% among young adults of deaths among youth aged 10 to aged 20-24 14 Risk Factors: Risk Factors: Family and social problems Body image concerns Insufficient coping skills Peer pressure Anorexia nervosa Challenges of sexuality Substance abuse Histories of childhood abuse Chronic disease Existing mental health disorder Interpersonal relationship problems School problems 4  MIDLIFE ELDERLY In Canada, however, suicide rates Increased risk from the age of 65 are at their highest at midlife (age 45 Passive suicide and an often- to 59) overlooked problem More than half of suicides involve Stronger intent to die, plan their people aged 45 or older suicide more carefully, and are more Risk Factors: likely to use more lethal means of Issues with intimate partners, killing themselves than are younger people Problems with job/finances Risk Factors: Health decline Chronic illness and pain Family issues Loss of friends and significant Criminal/legal problems other and loss of independence 5  INDIGINEOUS PEOPLE “I am here today because my ancestors, starving as they often were, fought to survive. Why did the old people strive to live … and the young people now want to die?” (Nishnawbe Aski Nation Youth, 2004). The suicide rate among Indigenous populations in Canada is several times the national rate First Nations youth die by suicide about 5 to 6 times more often than non-Aboriginal youth. Suicide rates for Inuit youth are among the highest in the world, at 11 times the national average The risk factors for suicide among Indigenous people are the same as for non-Indigenous (depression, abuse, poverty, isolation, etc.) but Crisis Line: are compounded by the effects of Indigenous- For immediate mental health and specific experiences such as colonization, the crisis intervention for Canadian residential school system, and children being taken off reserves to be fostered or adopted by Indigenous people: non-Indigenous families https://www.hopeforwellness.ca Note. It is important to note that Indigenous 1-855-242-3310 suicide rates may be underreported 6  GENDER LGBTQIA2S+ Worldwide, males complete Sexual orientation has been more openly suicide at a rate three times that of addressed as a risk factor for suicide females, although women are four “Coming out” can be a risk factor because times more likely to attempt of the possible negative reactions of suicide than men. others, particularly peers and family Men are seven times more likely to Unable to disclose sexual identity because use firearms than are women it is unsafe to do so may contribute to a (completed suicides), whereas deep sense of isolation women are twice as likely to die by During adolescence, when the major focus poisoning (e.g., overdose) of a youth’s life is on peers and sexuality, a More than 75% of suicides involve gay, lesbian, bisexual, or transgender males, but females are more likely (GLBT) youth’s search for self-identity may heighten depression and suicidal attempt suicide 3 to 4 times more behaviour often About 33% of lesbian, gay and bisexual Factors that affect suicide risk youth have attempted suicide, compared differently by gender include to 7% of youth in general experiences of violence, family The suicide attempt rate for transgender upbringing, and economic (trans) people ranges from about 32%– deprivation 50% 7  DSM-5 CRITERIA According to the DSM-5, there are five proposed criterion suicidal behaviour disorder, with two specifiers: 1. The individual has made a suicide attempt within the past two years. 2. The criterion for non-suicidal self-injurious behaviour is not met during the aforementioned suicide attempts. 3. The diagnosis is not applied to preparation for a suicide attempt, or suicidal ideation. 4. the act was not attempted during an altered mental state, such as delirium or “ confusion”. 5. The act was not ideologically motivated (e.g., religious or political). Other specifiers are: Current: Not more than 12- 24 months since last attempt In Remission: More than 24 months since last attempt 8  ETIOLOGY OF SUICIDAL B EHAVIOUR Usually triggered by stressors that are unmanageable and exceed typical coping efforts. BIOLOGIC PYSCHOLOGICAL SOCIAL Genetic predisposition Few or maladaptive Isolation First-degree family coping strategies Poverty member (i.e., parent) and vulnerable to Helplessness Contagion depression Hopelessness Religion Excessive physiologic Worthlessness Culture stress response Medical illness and Guilt Unemployment alcohol and drug use Negative thinking Changes in Neurotransmitter Distressed significant socioeconomic status depletion relationships Bullying, cyber- Serotonin Early and significant Loss bullying childhood trauma Previous suicide Physical, sexual and attempts emotional abuse 9  LEG AL CO N SI D ER ATI O NS W H EN C AR I N G F OR PEO PLE AT R I SK O R E NG AG IN G IN SU I C I DA L BE HAV IO U R S Counselling or assisting suicide is a criminal act Involuntary (when the client is a risk to themselves and/or others) versus voluntary hospitalization Changes to legislation in Canada to allow euthanasia and physician-assisted suicide Known as Medical Assistance in Dying passed through Bill C-14, and C-7 in legislation Confidentiality Informed consent 10  NURSING CARE Family Response Significant others may feel guilty, angry, ashamed, and sad. To reduce the stigma family may associate with suicide, the nurse must provide education about depression, substance use, suicidal behaviour, 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. Nurse’s Response The nurse does not blame or act judgmentally when asking about the details of a planned suicide. Rather, the nurse uses a nonjudgmental tone of voice and monitors his or her body language and facial expressions to make sure not to convey disgust or blame. Nurses must realize that no matter how competent and caring interventions are, a few clients will still be successful with suicide. A client’s suicide can be devastating to the staff members who treated the client. 11  NURSING ASSESS MENT Significance of the Therapeutic Relationship The foundation of all nursing practice is the therapeutic relationship. Assessment and care for people experiencing suicidal thoughts and behaviours must be grounded in the core principles of a therapeutic relationship. Persons experiencing suicidal ideation often experience hopelessness, helplessness, and powerlessness, which need to be assessed and integrated into their plan of care. All clients who indicate verbally or nonverbally their intention to engage in any self-harm behaviour, or actually harm themselves, must be taken seriously and assessed for suicide risk. Nurses play an essential role in suicide prevention because they practice in diverse health care settings and thus work with many different kinds of clients. Nurses are typically the first frontline health care providers to come in contact with a self-harming or suicidal client and are pivotal in making a difference in the outcome and preventing death. 12  NURSING CARE Example of a Positive Family Response (Personal Friends’ Son of Andrea and her husband) Reference: Public Published Obituary Suicide has stolen our cherished son on Wednesday, September 30, 2020 at the age of 18. Dylan struggled through many difficulties, but even through his pain, he brought many people joy and happiness. He had a kind and caring heart. During many conversations, he would say “he wished people would be kind to each other”. During the last few days of his life, he spent time giving out care packages that he made to homeless people. 13  NURSING ASSESS MENT Assessment includes collection of adequate data to provide a clear picture of the client’s life and relevant stressors from the patient’s perspective. Includes a good understanding of the client’s family, peers, and social relationships as well as workplace issues. Changes related to loss need to be explored to identify possible precipitating factors. Stressors: What is troubling you most at the moment? Symptoms: Can you tell me about your sleep patterns? Prior Behaviour: Have you ever thought of harming yourself? What did you expect to happen? What did you want to happen? Current Plan: Do you currently have a plan to harm yourself? Do you have access to the pills (other methods)? Have you picked a specific day or time? Resources and Support: Do you have someone you recognize as supportive? Questions to Guide a Comprehensive Assessment of Risk 14  NURSING DIA GNOS IS Risk for suicide related to prior behaviour Example: Risk for suicide related to helplessness as evidenced by client stating the following “No one will miss me”; “No reason to live for”; “I’d be better off dead”. Risk for self-directed violence related to aggression Interrupted family processes related to emotional withdrawal Ineffective health maintenance related to depression Impaired social interaction related to isolation Chronic low self-esteem related to feelings of worthlessness Ineffective coping related to poor decision-making skills Disturbed sleep pattern related to anxiety Social isolation related to shame Spiritual distress related to guilt or shame 15  CLIENT CA RE AND A CUTE TREATMENT Objectives of Hospitalization Maintain the Client’s Safety: Determine if they have a current plan and access to the means to end life (i.e., hanging, firearms, stabbing, overdosing) and remove any potential methods from the room. Decrease the Level of Suicidal Ideation: Explore with the patient reasons for living, which are considered protective factors as they protect a person from acting on thoughts, feelings, and plans. It is important, therefore, to assess a patient’s reasons for living. Initiate Treatment for Underlying Disorder: Personality disorders experiencing sudden emotionally negative feelings of abandonment and rage, and episodes of psychoses may respond to “voices” directing them to kill themselves. Evaluate for Substance Abuse: Alcohol or other substance use may be at risk to impulsively end their lives. Reduce Level of Social Isolation: Interest in the client’s life and attention received during a thorough assessment are therapeutic and can provide connectedness and engagement with the client and family. Supports not available through the client’s personal sphere may need to be supplemented through community supports. 16  CLIENT CA RE AND A CUTE TREATMENT Assessment and Reassessment: Suicide may be a single event in a person’s life and with rapid interventions may resolve. Since thoughts and feelings underlying suicide are complex, multifaceted and dynamic, which may make a situation very fluid for many people who suffer such despair. A suicidal state can be a continuum of wanting to live and wanting to die. Client’s thoughts and feelings may change rapidly with fluctuating personal and physical circumstances. Nurses to be alert to subtle as well as overt changes in the client's behaviours that may indicate a shift in suicidal thinking and reassess as often as required. Documentation: Nurses must thoroughly document assessments and interactions with suicidal clients. This action is for both the client’s ongoing treatment and the nurse’s protection. Nursing notes must reflect that the nurse took every reasonable action to provide for the client’s safety, inclusive of thorough assessments and reassessments. 17  NURSING I NTERVENTIONS Ensuring Safety Hospital protocol for safety (i.e., restraints if necessary) Engage in a therapeutic relationship Observe the client regularly Remove dangerous objects Medical Management Assist With Somatic Therapies Assist with Treatment of Substance Abuse Evaluate the client’s ways of thinking about problems and generating solutions. Nurses help clients identify what needs to change in their life and how that change can come about most effectively. Develop plans to prevent future suicide attempts. Prevention of further suicidal behaviour is dependent on the client’s belief that they can make changes with the necessary support and resources and that there is hope for the future. Help client develop social skills that can be used in engaging others. Nurses need to assist the client improve their communication skills and identify people in their life who may be supportive. Make appropriate referrals to professionals with expertise in the area. Identify family and friends who are willing to be supportive. Before discharge, it is ideal for the client to be able to name people who can act as a support. 18  MEDICAL MANAGEMENT Assist with Somatic Therapies Electroconvulsive Therapy (ECT): Although commonly used for depressive manifestations, it can be used to treat acute suicidal behaviour. Evidence for short-term reduction of suicide. Side Effect: Transitory short and long-term memory loss and confusion Benzodiazepines: Reduce risk by decreasing anxiety. Antidepressants: Treatment option for suicidal clients with depressive illness and symptoms. Lithium: Has a demonstrated anti-suicide effect. Antipsychotics: Evidence for Clozapine reducing suicidality. Note. Regardless of the medication that is prescribed, further ongoing assessment regarding the client’s suicidal ideation and behaviours is required. As a client’s depression is lifting, they may find they have the energy to carry out their plan. Assist with Treatment for Substance Abuse When substance use is an issue for the suicidal client, the use must be addressed. Nurses should help the client understand the role that alcohol and other drugs play in their suicidal behaviour. Males: Substance use disorder may be the primary psychiatric disorder, with depression a side effect of it. Females: Depression commonly is the primary psychiatric disorder, and substance use disorders result from attempts to medicate the underlying depressive condition. 19  EVALUATION AND TREATMENT OUTCOMES The most desirable treatment outcome is the client’s return to the community Discharge planning must begin immediately Identify continuing sources of social support Short-term Outcomes: Maintain the client’s safety, averting suicide, and mobilizing the client’s resources Long-term Outcomes: Focus on maintaining the client in psychiatric treatment Prevention Campaign CAMH: Not suicide. Not today https://www.camh.ca/en/suicide-prevention 20  OVERALL IMPACT ON NURSES Avoiding Compassion Fatigue Professional work centred on relief of emotional suffering involves empathy as a key tool. Over time, being empathetic can become exhausting, even when the caregiver is diligently maintaining self-care skills. Compassion fatigue is a genuine concern and one that may result in diminished capacity to function at work, at home, and within personal and professional relationships. Nurses may begin to avoid the stress through absenteeism or presentism (i.e., being physically present but not truly engaged in one’s role). 21  REFERENCES Kunyk, D., Peternelj-Taylor, C., & Austin, W. (2022). Psychiatric and mental health nursing for Canadian practice (5th ed.). Wolters Kluwer. 22