suicide and non suicidal self injury

epidemiology

10th leading cause of death in the US in 2018

increased by 2.6% from 2021-22

in 2021, 48, 183 people died by suicide in the US; that is 1 death every 11 mins

decreased in the age group of 10-24 years; highest rate in >85 years of age

12.3 million adults seriously thought about suicide

3.5 million made a plan

1.7 million attempted suicide

firearms most common cause; 54.6%

highest rates in non Hispanic American indian, non Hispanic alaska native people, and non Hispanic white people

suicide attempt

aka suicidal act, is engaging in potentially self injurious behavior with the intention of death

suicidal ideation

thinking about death, including the wish to be dead, considering methods of accomplishing death, and formulating plans to carry the act out

suicide

death caused by self directed injurious behavior with the intent to die as a result of the behavior

non suicidal self injury

the intentional damage to one’s own body tissue, without conscious suicidal intent, and for purposes not socially or culturally sanctioned

co morbidities

MDD: ~50% who complete suicide are experiencing a major depressive episode

SUD

psychosis (schizophrenia); long term

anxiety

personality disorders

eating disorders

trauma related disorders

common precursors

loss of relationships; self esteem, unworthy

financial difficulty

impulsivity; bipolar, psychosis

risk factors

biological: genetics

neurobiological: low NT levels (serotonin)

cognitive: hopelessness, rigid thinkers

environmental: ACEs, cluster or contagion, copycat

cultural: religion (positive or negative), family values, bullying, gender identity, sexual orientation, immigrant related (fear of deportation, language barrier)

social: social media; websites designed to encourage suicide (blue whale), society of isolation, texting replaced communicating verbally

suicide risk factors

chronic physical illness (pain)

family history of completed suicide

history of childhood trauma, abuse, including sexual abuse

feelings of hopelessness, shame or humiliated (bullied)

lethal suicide plan with access to lethal weapons

sexual orientation issues (LGBTQIA+)

job, loss of status

any situation that causes significant loss of self esteem

substance abuse

impending incarceration

ineffective coping skills

significant losses

warning factors (immediate risk)

dramatic mood changes

increased alcohol use or drug misuse

withdrawal from friends and families

reckless behavior

talk about feelings of being trapped or a burden to others

comments of being hopeless, helpless, or worthless, “everyone would be better off if I died”

talking or writing about death, dying, or suicide: “i have no reason to live,” “i wish I were dead”

protective factors

ability to cope with stress

religious beliefs that prohibit suicide

ability to tolerate frustration

resilience

responsibility to children or pets

positive therapeutic relationships

social supports

problem solving and conflict resolution skills

assessment tools: SAFE-T

five step safety and triage tool based on sponsored research outcomes from the substance abuse and mental health services administration

1 identify risk factors

2 identify protective factors

3 conduct suicide inquiry

4 determine risk level/intervention

5 document

suicidal inquiry

ideation: thoughts, idea of

plan: have they made a plan, how to carry it out, timeframe, details

behaviors: verbal and nonverbal

intent: access to carrying out plan, lethality; high risk (hard methods) or lower risk (soft methods)

ambivalence: “not really sure”

hopelessness

red flag if heard said

#1 indicator

determine whether the client feels hopeless. does the client feel that things will get better? does the client feel trapped?

key assessment questions: have you always felt like this, can you remember a time when life was better, what would it take to get you to that point again

suicide history

find out the history surrounding the impending action. is there a history of suicidal gestures

is there a family history of suicide attempts and completions

is there a mental health history of depression, schizophrenia, or substance abuse. has the client been hospitalized for mental or emotional disorders

current or “here and now” assessment

ask the question: are you thinking of harming yourself/killing yourself? be direct, you can’t put the idea into someones head

determine whether the client has a plan of action that includes the time, means, and place to complete suicide. ask, “how do you plan to complete suicide?” “do you have access to a weapon?” “what weapon?” “where do you plan to do this?”

primary intervention

educate!

focus is on preventative activities that provide support, info and education to prevent suicide

primary intervention is practiced in community settings such as schools, churches, clinics, hospitals, and work environments

psychosocial interventions

counseling and establishing a therapeutic alliance

realistic problem solving

pt safety plan

health teaching and health promotion

case management; financial assistance

pharmacological interventions

antidepressants for depressive disorder/anxiety disorder

mood stabilizers for bipolar mania

antipsychotics indicated for psychotic symptoms

antianxiety meds for anxiety symptoms

suicidal behavior; inpatient

1:1 nursing observation and interaction 24hours/day

chart the pts wherabouts: record mood, verbatim statements, and behavior every 15-30 mins per protocol

ensure meal trays contain no glass or metal silverware. use plastic utensils; count them when the tray is collected

pt is sleeping, hands should always be in view, not under the covers

observe pt swallow each dose of med

do not assign pt to a private room; ensure that the door remains open at all times

jump proof and hang proof the bathrooms by installing breakaway shower rods and recessed shower nozzles

keep electrical cords to minimum length

tertiary intervention

also called postvention, involves interventions for people who have experienced the death of a loved one through completed suicide

survivors have a 20% greater risk of completing suicide following the death of a loved one

ex: grief counseling and survivors of suicide self help groups

non suicidal self injury (NSSI)

deliberate shallow, painful injuries inflicted without the intent of completing suicide

includes: cutting, burning, scraping skin, biting, hitting, skin picking, interfering with wound healing, ice burning, pinching, and intentional fractures

approximately 5.9% of adults and 18% of adolescents

average age of onset is 13-14 and second age of onset is 18-19

NSSI indicate maladaptive coping strategies

clinicians often do not include or overlook asking about NSSI in assessments

NSSI assessment

gather the history of NSSI

include the types of behavior

include triggers for the behavior

ask about what has helped to extinguish the behavior

NSSI recovery planning

set limits for safety

develop self esteem

discover motives for self injury; reasons why

learn that self injury can be self controlled

replace self injurious behavior with adaptive coping skills

maintain new adaptive behaviors

NSSI interventions

care for the pts wounds

establish a therapeutic alliance

teach coping skills to replace maladaptive behaviors

refer pt to dialectical behavior therapy, cognitive therapy and/or group therapy