1 Suicide

2 “Recognizing the warning signs is the first step in preventing suicide”(Suicide Prevention Resource Center)

3 Deadly Myths about Suicide

4 Suicide Intentional act of killing oneself by any meansTenth leading cause of death Fourth leading cause of death among children 10 to 14 years of age Third leading cause of death in 15 to 24 age group Fourth leading cause of death in 25 to 44 age group Eighth leading cause of death in 45 to 64 age group Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

5 Suicide Statistics 34,000 a year / 105 individuals a day, One suicide every 14 minutes 10th major leading cause of death for all ages combined Third leading cause of death in youth More people kill themselves than are murdered 15-24 yr old most likely and those > 65 years (CDC, 2012)

6 Biological Factors Low serotonin levels are related to depressed moodCopyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

7 Psychosocial Factors Freud—aggression turned inward MenningerWish to kill Wish to be killed Wish to die Aaron Beck—central emotional factor is hopelessness Recent theories—combination of suicidal fantasies and significant loss (job/status/prison) (copycat) Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

8 Cultural Factors Protective factors African AmericansReligion, role of the extended family Hispanic Americans Roman Catholic religion and importance of extended family Asian Americans Adherence to religions that tend to emphasize interdependence between the individual and society Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

9 Application of the Nursing ProcessAssessment Verbal and nonverbal clues Overt statements Covert statements Lethality of suicide plan Assessment tools Columbia Suicide Severity Scale Self assessment Why is this important? Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

10 “Things will never work out.” “I won’t be a problem much longer.” Covert statements – Examples: “Things will never work out.” “I won’t be a problem much longer.” “Nothing feels good to me anymore, and probably never will.” “I just don’t want to suffer anymore.” “I don’t want to see my parents suffer anymore.”

11 Columbia Suicide Severity Rating Scale (CSSRS)Update to text book recommends Widely used: brief screenings or longer forms Should be done on admission to inpatient and compare at discharge Captures specific thoughts/intentions recent/remote & current Video of use of the scale: Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

12 Zero Suicide InitiativeWhat is this? Is this a fantasy? Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

13 Risk Rating Scales Best Predictor is past history of suicide attemptRisk factors do not predict suicide, they give potential for suicide Best Predictor is past history of suicide attempt Intent to die Plan involved Available means Important considerations: What is this person’s suicide risk? What is helping to keep this person alive?

14 Risk Assessment There are no fail-safe methods of assessing risk of suicide There are questions that can be asked to help discover evidence about the patient’s state of mind and intentions. Examples: Do you ever wish you could go to sleep and never wake up? Sometimes when people feel sad, they have thoughts of harming or killing themselves. Have you had such thoughts? Are you thinking about killing yourself? (Suicide Prevention Resource Center)

15 Suicide Assessment If a patient discloses suicidal thoughts:Ask 3 things to assess lethality: Plan: Specificity and lethality indicates risk Urge or intent Access to means Ask about passive thoughts: are you having thoughts about wishing you were dead?

16 Levels of InterventionPrimary—activities that provide support, information, and education to prevent suicide Secondary—treatment of the actual suicidal crisis Tertiary—interventions with a circle of survivors left by individuals who completed suicide to reduce the traumatic aftereffects Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

17 Nonsuicidal Self-Injury (aka self injurious behavior)This is behavior that is NOT intended to lead to death. It is quite different than suicide behavior It is a symptom of something else Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

18 Psychological commonalities of suicide:Purpose – to solve a problem Goal – often not trying to end their life, but rather they are trying to end the pain Stimulus – escape from intolerable pain/decision not to experience pain Stressor – frustrated psychological needs Cognitive state – ambivalence Perceptual state - restricted

19 Many Mental Health Diagnoses Associated with SuicideDepression Narrowed perceptual field makes it difficult to consider other options: “death is better than life” Feelings of worthlessness may contribute : “I am flawed. The world would be better without me”. Post-Partum depression Premenstrual dysphoric disorder Bipolar Disorder Bipolar Depression (vs. unipolar type) tends to cause deeper despondence/despair/hopelessness

20 Many Mental Health Diagnoses Associated with Suicide (cont’d)Schizophrenia Command hallucinations or hopelessness related to chronic severe mental illness Psychosis that involves altered thoughts or perceptions involving terror Anxiety especially Panic Disorders 20% of persons with a diagnosis of anxiety attempt suicide Keep in mind that anxiety states cause narrowed perceptual field and loss of ability to consider a range of options Coupled with this may be desperation to escape unrelenting anxiety

21 Many Mental Health Diagnoses Associated with Suicide (cont’d)Borderline Personality Disorder Personality Disorders with labile mood states are higher risk Chronic chaotic lifestyle that has gone on for years, always on the “brink” of suicide. Substance Abuse/Addiction Alcohol and drug abuse are second only to mood disorders as the most frequent risk factor for suicide (Institute of Medicine, 2002) Fear of inability to achieve sobriety Impulsivity increased while under the influence of substances of abuse

22 Particularly significant emotions:Hopelessness The problem cannot be solved I will always be in pain Helplessness I cannot control my life or circumstances

23 Evaluation of Suicide Risk: Demographic FactorsHistory of Previous Suicide Attempts: 20-60% of successful suicides have attempted before Those who have made previous attempts are more likely to succeed Second attempts most commonly come within 3 months of first attempt Financial problems Occupational status Unemployed and unskilled have higher risk than employed Higher rate occurs in police, musicians, dentists, insurance agents, physicians, and lawyers

24 Evaluation of Suicide Risk: Demographic FactorsMarital Status Single are at highest risk followed by widowed, separated, and divorced men People “all alone in the world” People who have lost a loved one in last 6-12 months No young children in the home Recent divorce Family History Suicide more common if immediate family member of significant person attempted or committed suicide Death or loss of one or both parents early in life increases risk

25 Evaluation of Suicide Risk: Demographic FactorsRace/Religion In the U.S. the risk is higher in white men than in African American men, except in the year old group where African American men have rate two times that of white men Historically suicide is the lowest among followers of Judaism and Catholicism, higher among Protestants Certain cultural and religious beliefs could include a belief that suicide is a noble resolution of a personal dilemma

26 Evaluation of Suicide Risk: Demographic FactorsAge: Frequency increases sharply in men with age especially in 70’s and 80’s Frequency increases slightly in women with age until sixth decade Peak frequency in men 75, and in women 55

27 Evaluation of Suicide Risk: Demographic FactorsGender: Women attempt suicide three TIMES as often as men Men succeed in suicide three time as often as women Males tend to choose methods that are more lethal

28 Evaluation of Suicide Risk: Demographic FactorsHealth Factors: Recent Surgery or Serious Illness Intractable Pain Terminal Illness All increase risk !

29 A Closer Look at Chronic PainIntractable Chronic Pain NEVER underestimate the impact of chronic, poorly managed pain on an individual Biopsychosociospiritual dimensions are all affected Refrain from making assumptions/labeling a patient as a “med seeker” Like any reasonable person: they are desperate for relief from suffering! Yes, they may “watch the clock” for the next available analgesic dose, they are forced into trusting us as clinicians, to come through with their meds. Many fear breakthrough pain will emerge. They usually KNOW what they need. Persons suffering with chronic pain often do not “look like” they are having pain, but rather become more flat in affect due to unrelenting distress

30 Other Factors associated with SuicideSevere insomnia even without depression Gender identity problems Stigma of help-seeking behavior Recent humiliation Child and Adolescent concerns: Recent humiliation may be more serious risk factor Cyberbullying may increase risk Exposure to and influence of others who have died by suicide

31 Be Very Vigilant When: When a patient has a cluster of risk factors from among the various demographic factors, the risk for suicide is extremely heightened. Consider the context that brought the patient to our unit and what context they are likely returning to at discharge Be alarmed if a person with suicidal ideation is returning to the same turmoil that brought them here

32 Presenting Suicidal EventWhy now? What is different? What has changed? Final Straw? What stopped the patient / How were they found Attitudes now to being found / saved

33 Presenting Suicidal Event: Thoughts, Plans, Behaviors, IntentIdeation: frequency, intensity, duration- in last 48 hours, past month, and worst ever Plan: timing, location, lethality, availability, discoverability, preparatory acts Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self injurious actions Intent: extent to which the patient expects to carry out the plan and believes the plan/act to be lethal vs. self injurious Explore ambivalence: reasons to die vs. reasons to live

34 Evaluate Current Suicidal Action Ask about preparation for death, include significant others where possible to assess warning signs: Did the person write a suicide note? Have they been giving away possessions? Is there a lack of concern about personal welfare? Are there changes in social behavior? Are there difficulties with concentration and thinking clearly? A decline in school achievement/work productivity?

35 Evaluate Current Suicidal ActionAsk about preparation for death, include significant others where possible to assess warning signs: Altered patterns of sleeping and/or eating? Attempts to put personal affairs in order? Intense interest in how others are feeling? Preoccupation with themes of death and violence? Sudden/increased risk taking behaviors? Increase in substance use/abuse? There can be a small slip between “gesture” and “death” The more specific and detailed the plan, the more available and lethal the method, the higher the risk

36 Do not dismiss suicidal feelings with casual reassuranceAllowing people to talk about their suicidal thoughts is the first step to healing. “If you bring up suicide with people who are struggling with those thoughts, invariably they are relieved because someone understands, and because it's not a secret anymore. Give the person a chance to talk about wanting to die and wanting to live before helping them decide to live.“ (Diamond, R. MD) Do not let the patient become carried away with apologetic, remorseful, or self – punitive behaviors about their suicidal feelings

37 Two Questions How can I help you?There are two questions a clinician can ask to convey empathy and invite the suicidal person to connection: Where do you hurt? How can I help you?

38 Essential Assessment Piece: Future OrientationAsk the patient questions that reveal future orientation: Do you have any plans for the summer (or whatever season) Where do you see yourself in a month from now? A year from now? Do you plan on returning to school/work, etc. ? Do you have appointments to keep with your therapist?

39 Risk for Suicide Nursing Diagnosis Outcomes Interventions Risk for Suicide related to poor impulse control AEB urges to act on suicide plan, hopelessness, helplessness Suicide Self Restraint By discharge patient will seek help when feeling self- destructive By discharge patient will verbalize suicide ideation By discharge patient will refrain from inflicting serious injury By discharge patient will disclose plans for suicide if present By discharge patient will uphold suicide contract By discharge patient will refrain from attempting suicide Suicide Prevention Determine presence and degree of suicidal risk Determine if patient has available means to follow through suicide plans Instruct patient about coping strategies such as assertiveness training and impulse control Contract for patient for no self- harm Identify immediate safety needs Observe for signs of incongruence that may indicate lack of commitment to fulfilling the contract

40 Interventions: Preparing for DischargeEnhance and Enlist support: Determine available social support Identify and verify persons who can provide safeguarding Enlist family if possible Support family concerns Feelings of frustration, helplessness, and guilt Teach signs of increased risk Identify support persons patient can phone Remember to list at least one “support” who the patient can “call at midnight” Telephone hot line DOCUMENT ALL TEACHING AND SUPPORT PROVIDED

41 Protective Factors Protective factors, even if present, may not counteract significant acute risk Internal factors: ability to cope External factors: responsibility to children, positive/therapeutic relationships, social supports

42 Protective Factors One way to prevent suicide is to promote and support the presence of protective factors, such as learning skills in problem solving, conflict resolution, and nonviolent handling of disputes. Skill building increases the chances for preventing those individuals from acting on their despair and distress in self-destructive ways (Samhsa)

43 Protective Factors AmbivalenceSuicidal persons are often ambivalent. If their perceptual field can widen, reasons for living and other solution focused alternatives can be identified

44 References Centers for Disease Control and Prevention/National Center for Injury Prevention and Control:Fatal Suicidal Behavior SUMMER Retrieved 2016 from: Diamond, R. MD (n.d.) University of Wisconsin School of Medicine and Public Health Harris, K., McLean, J. Sheffield, J. & Jobes, D. (2010) The Internal Suicide Debate Hypothesis: Exploring the Life versus Death Struggle. Suicide and Life-Threatening Behavior 40 (2)  Suicide Myths: Suicide.org

45 References Suicide Prevention Paper. Substance Abuse and Mental Health Services Administration Retrieved June 1, 2010 from: Suicide Prevention Resource Center: Substance Abuse and Mental Health Services Administration (SAMHSA) (2008) Risk and Protective Factors for Suicide Retrieved June 1, 2010 from: U.S Public Health Service: Centers for Disease Control and Prevention: Injury Prevention and Control:Suicide Risk and Protective Factors Retrieved June 1, 2010 from: Yellow Ribbon Suicide Prevention Program. Light for Life Foundation International. Retrieved May 23, 2010 from: