SUICIDE

2. LEARNING OBJECTIVES
Recognize the genetic, biologic,
sociologic, and psychological factors
believed to precipitate suicidal behavior
Identify those clients or groups of
individuals considered to be at risk for
suicide
Illustrate at least two examples of verbal,
behavioral, and situational suicidal clues
2

3. LEARNING OBJECTIVES (cont.)
Distinguish among suicidal ideation, intent,
threat, gesture, and attempt
Describe the purpose of suicide
precautions, no-suicide contracts, and
seclusion and restraints in the clinical
setting
3

4. LEARNING OBJECTIVES (cont.)
Explain the rationale for the use of
medication, interactive therapies, and
family and client education when providing
care for clients who are exhibiting suicidal
behavior
Articulate the importance of self-
assessment when providing care for
suicidal clients
4

5. 5
JACHO
NATIONAL PATIENT SAFETY GOAL
#15
The Organization identifies safety
risks inherent in its patient population
The Organization identifies patients at
risk for suicide

6. SUICIDE: A MULTI-FACTORIAL EVENT
Neurobiology
Severe Medical
Illness
Impulsiveness
Access To Weapons
Hopelessness
Life Stressors
Family History
Suicidal
Behavior
Personality
Disorder/Traits
Psychiatric Illness
Co-morbidity
Psychodynamics/
Psychological Vulnerability
Substance
Use/Abuse
Suicide

7. AREAS TO EVALUATE IN SUICIDE ASSESSMENT
Psychiatric
Illnesses
Comorbidity, Affective Disorders, ETOH/
Substance Abuse, Schizo., Cluster B PD.
History Prior suicide attempts, aborted attempts or self
harm; Med Dx., Family hx. of suicide/
attempts/mental illness
Individual
strengths/
vulnerability
Coping skills; personality traits; past responses
to stress; capacity for reality testing; tolerance of
psychological pain
Psychosocia
l situation
Acute and chronic stressors; changes in status;
quality of support; religious beliefs
Suicidality
and
Symptoms
Past and present suicidal ideation, plans,
behaviors, intent; methods; hopelessness,
anhedonia, anxiety symptoms; reasons for
living; associated substance use; homicidal idea

8. 8
INTRODUCTION
Suicide is not a diagnosis or a disorder; it
is a behavior
Approximately 95 percent
of suicides are by individuals
who have a diagnosable
mental illness at the
time of death

9. 9
INTRODUCTION (cont.)
Highly stigmatized
Stimulates fear in others
Direct consequences of certain mood
disorders
Highly preventable

10. 10
SUICIDE TERMINOLOGY
Suicide ideation
Suicide
Parasuicide
Passive death wish
Lethality

11. 11
ATTEMPTS
Intention is severe
but is found early
or revived
Direct: suicidal acts
Indirect: risky
behaviors, living on
the edge

12. DETERMINATION OF RISK
Psychiatric Examination
Risk
Factors Protective
Factors
Specific Suicide
Inquiry
Modifiable Risk
Factors
Risk Level:
Low, Med., High

13. RISK FACTORS (blue = modifiable)
Demographi
c
male; widowed, divorced, single; increases
with age; white
Psychosoci
al
lack of social support; unemployment; drop
in socio-economic status; firearm access
Psychiatric psychiatric diagnosis; comorbidity
Physical
Illness
malignant neoplasms; HIV/AIDS; peptic
ulcer disease; hemodialysis; systemic lupus
erthematosis; pain syndromes; functional
impairment; diseases of nervous system
Psychologic
al
Dimensions
hopelessness; psychic pain/anxiety;
psychological turmoil; decreased self-
esteem; fragile narcissism & perfectionism

14. Behavioral
Dimensions
impulsivity; aggression; severe anxiety;
panic attacks; agitation; intoxication; prior
suicide attempt
Cognitive
Dimensions
thought constriction; polarized thinking
Childhood
Trauma
sexual/physical abuse; neglect; parental
loss
Genetic &
Familial
family history of suicide, mental illness, or
abuse
RISK FACTORS (blue = modifiable)

15. 15
RISK FACTORS (cont.)
Other risk factors
– Psychiatric illness - Mood
disorders (major depression and bipolar disorder) are
the most common psychiatric illnesses that precede
suicide. Other psychiatric disorders that
account for suicidal behavior include
* anxiety disorders
* personality disorders
* psychosis with command hallucinations
* schizophrenia
* substance-related disorders
– Severe insomnia is associated
with increased risk of suicide

16. 16
PREDISPOSING FACTORS:
THEORIES OF SUICIDE
Biological theories
– Genetics
– Neurochemical
factors
– Low levels of
serotonin (as levels
of 5-HT decrease,
people become
more impulsive,
more aggressive,
and lose control
more quickly)
Psychological theories
– Anger turned inward
– Hopelessness
– Desperation and guilt
– History of aggression
and violence
– Shame and
humiliation
– Developmental
stressors
Children
Adolescents
Older adults

17. 17
PREDISPOSING FACTORS:
THEORIES OF SUICIDE (cont.)
Sociological theories
–Lack of social support
–Interpersonal stress (women=related to
painful or lost relationships)
–Intrapersonal stress (men=related to
financial problems or the loss of a job)

18. 18
NURSING PROCESS:
ASSESSMENT
Demographics
– Age
– Ethnicity
– Gender
– Martial status
– Occupation
– Religion
– Socioeconomic status
– Other Factors
Family history of suicide
Lethality and availability of method

19. 19
NURSING PROCESS:
ASSESSMENT (cont.)
Presenting symptoms/medical-psychiatric
diagnosis
Suicidal ideas or acts
– Seriousness of intent
– Plan
– Means
– Verbal and behavioral clues
Interpersonal support system

20. 20
NURSING PROCESS:
ASSESSMENT (cont.)
Case-finding
–Ask about suicide
Use specific words
–Primary care settings - should be
screened for depression
–Previous suicide attempts and a
sense of hopelessness are the most
powerful clinical predictors of future
completed suicide

21. 21
NURSING PROCESS:
ASSESSMENT (cont.)
Analysis of the suicidal crisis
– The precipitating stressor
– Relevant history
– Life-stage issues
Psychiatric/medical/family history
Coping strategies

22. 22
NURSING PROCESS:
DIAGNOSIS/OUTCOME
IDENTIFICATION (cont.)
Nursing diagnoses for the suicidal client may
include
– High risk for violence, self-directed, related
to acute suicidal state
– Hopelessness
– Chronic low self-esteem
– Disturbed sleep pattern
– Impaired social interaction
– Ineffective health maintenance
– Interrupted family processes
– Social isolation
– Spiritual distress

23. 23
NURSING PROCESS:
PLANNING/IMPLEMENTATION
(cont.)
Guidelines for Treatment of the Suicidal
Client on an Outpatient Basis
Do not leave the person alone
Enlist the help of family or friends
Schedule frequent appointments
Establish rapport and promote a trusting
relationship

24. 24
NURSING PROCESS:
PLANNING/IMPLEMENTATION
(cont.)
Guidelines for Treatment of the Suicidal Client
on an Outpatient Basis
No-Suicide Contract
– Written or verbal agreement between health
care professional and the patient
– States that patient will not engage in suicidal
behavior for a specific period of time
– Patient must be competent to enter a contract
– Must help patient dismantle suicide plan
– Must refrain from use of substances

25. 25
NURSING PROCESS:
PLANNING/IMPLEMENTATION
(cont.)
Guidelines for Treatment of the Suicidal
Client on an Outpatient Basis (cont.)
Be direct and talk
matter-of-factly about
suicide
Discuss the current
crisis situation in the client’s life (use problem-
solving approach)
Identify areas of self-control
Give antidepressant medications

26. 26
NURSING PROCESS:
PLANNING/IMPLEMENTATION
(cont.)
Information for Family and Friends of the
Suicidal Client (cont.)
Take any hint of suicide seriously
Do not keep secrets
Be a good listener
Express to the client
feelings of personal worth
Know about suicide
intervention resources
Restrict access to firearms
or other means of self-harm

27. 27
NURSING PROCESS:
PLANNING/IMPLEMENTATION
(cont.)
Interventions with Family and Friends of
Suicide Victims (cont.)
Encourage them to talk about the suicide
Discourage blaming and scapegoating
Listen to feelings of guilt and self-perception
Talk about personal relationships with the victim
Recognize differences in styles of grieving
Assist with development
of adaptive coping strategies
Identify resources that provide
support

28. 28
INPATIENT CARE
Protect patient from suicide and establish
treatment of underlying psychiatric
disorder
Objectives of hospitalization:
–Maintain patient’s safety
–Decrease the level of suicidal ideation
–Initiate treatment for underlying disorder
–Evaluate for substance abuse
–Reduce level of social isolation

29. 29
INPATIENT MANAGEMENT
Confidentiality
Reporting in the medical record
Inpatient suicides
Precautions
Prepare for discharge
–No guns, no means in the house
–A plan to call someone

30. 30
BIOLOGIC INTERVENTIONS
Ensuring safety
– Hospital protocol for safety
– Observing patient regularly
– Removing dangerous objects
– Providing outlets for expression of patient’s
feelings
– Suicide precautions
Somatic therapies
– Medications
– ECT
Substance abuse treatment

31. 31
PSYCHOLOGICAL INTERVENTIONS
Evaluating patient’s ways of thinking about
problems and generating solutions
(problem solving)
–Have clients write a prioritized list of
reasons to live and reasons to die, to
help them conceptualize the conflict
more clearly
Cognitive interventions
Developing plans to prevent future suicide
attempts

32. 32
SOCIAL INTERVENTIONS
Help patient develop social skills that can
be used in engaging others
Identify family and friends who are willing
to help

33. 33
DISCHARGE PLANNING &
OUTPATIENT CARE
Educating patient and family
Identifying continuing sources of social
support
Establishing an outpatient care plan
–Have enough medication to last until
first outpatient visit
–Plan for ongoing supervision

34. 34
LEGAL CONSIDERATIONS
Confidentiality (Explain limits.)
Informed consent (Explain limits of right to
self-determination and least restrictive
environment.)
Competence (Must judge.)
Beneficence
Documentation and reporting
Involuntary hospitalization

35. 35
KEY TERMS
Euthanasia
Parasuicide
Physician-assisted
suicide (PAS)
Primary prevention
Secondary
prevention
Tertiary prevention
Theory of Self