Suicide Prevention

What is suicide?

• The Center for Disease Control and Prevention define suicide as “death caused by self-directed injurious behavior with an intent to die as a result of the behavior”

What is suicidality?

All suicide-related behaviors and thoughts of completing or attempting suicide and suicidal ideations.

What is lethality?

The probability that a person will successfully complete suicide

What is suicidal ideation?

Thinking about and planning one’s own death

What is a suicidal attempt?

Nonfatal, self-inflicted destructive act with explicit or implicit intent to die

What is parasuicide?

Voluntary, apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death but must be taken seriously.

What to know about suicide?

• Suicide is a major health problem in the U.S. Accounting for more than 49,000 deaths in 2022 (AFSP, 2020)

• People with suicidal thought oftentimes will not seek treatment because of stigma

• Healthy people 2030 target the reduction of deaths by suicide

• Suicide is preventable when family and friends can identify symptoms.

• Suicide rates peak in the spring and fall.

• Improvement after a suicide crisis does not mean that the risk is over.  Most suicides occur within 3 months of “improvement” when the individual has the energy and motivation to actually follow through with his or her suicidal thoughts.

• Firearms most prominent method among white people.

• 50% of individuals who attempt suicide once will make another attempt

• Risk of repeat suicide attempt is greatest in the first three months after a first attempt.

• Many people who die by suicide have given definite warnings of their intentions.  Always take any comment about suicide seriously.

• Most people give many clues and warning signs regarding their suicide intentions.  However, some commit suicide with no warning(Impulsive Suicide)

• Most suicidal people are undecided about living or dying.  A part of them wants to live,  however death seems like the only way out of their pain or situation.  They may allow themselves to “gamble” with death, leaving it up to others to save them.

What to know about the epidemiology of suicide?

• 11th leading cause of death

• Suicide occurring every 11.1 minutes in the U.S.

• Mountain regions have the highest rate of suicide

• Suicides possibly disguised as vehicular accidents or homicides

• Occurrence across the lifespan

What to know about suicidal behavior?

• Suicidal behavior can look like many things

• It can look like self-destructive behavior(such as, frequent drug use, driving recklessly, and/or placing oneself in dangerous situations), it can take the form of non-suicidal self-injury and “accidental suicide”, or it can present as more blatant self-harm behavior(e.g., cutting, taking medications in excess, or swallowing objects)

• Suicidal behavior can be impulsive,  or it can be more rational and well planned.

What to know about suicide across the lifespan?

• Children, adolescents, and young adults

  • The second leading cause of death among those aged 10 to 34

  • In a recent survey female students were more likely to attempt suicide, but males were are likely to die from suicide.

• Adults and older adults

  • Major contributor to premature death in adults

  • Ranking the fourth leading cause of death among adults aged 35 to 54. 

  • Suicide rates peak during middle age, and a second peak occurs in those aged 75 years and older

What are the risk factors of suicide?

• Race and ethnicity rates among American Indian /Alaska native People/White people

• Family history of suicide

• Previous attempts

• Substance use and personality disorders, auditory hallucinations

• Sexuality: sexual minority history and suicidality (LGBTQI)

• Transgender Adults 40% reported an attempted suicide.

• Gender: males < females for suicide completion

• White males accounts for 70% of completed suicides

• Women at risk who experience domestic violence

• Social: Social isolation, divorce, parental neglect, abuse

• Psychological: internal distress, low self-esteem, interpersonal distress, poverty, feelings of hopelessness

• Medical illnesses

• Pandemic Impact (National survey: 41% Reported at least one adverse mental or behavioral health condition r/t Covid)

What is the etiology of suicidal behavior?

• Biologic theories

  • Depression

  • Severe childhood trauma

  • Genetic factors(First-degree relatives have higher risk)

  • Low levels of neurotransmitters (serotonin)

• Psychological theories

  • Cognitive theories: cognitive triad; hopelessness, helplessness, worthlessness  and other cognitive symptoms

  • Emotional factors, personality traits: poor self-esteem, shame, guilt, despair, impulsivity)

  • Ideation to Action Theories: suicidal ideation does not necessarily lead to suicide attempts

  • Interpersonal–psychological theory of suicidal behavior ) thwarted belonginess, perceived burdensomeness, acquired capability) “Everyone will be better off without me.

  • Three Step theory: Emotional pain & hopelessness leads > suicidal ideation>Actual attempt

• Social theories

  • Social distress: Lack of social connection (loneliness, alienation, social isolation)

  • Suicide contagion: Exposure to suicide especially prominent in adolescents; loss of a friend through suicide, copycat suicide).

  • Economic disadvantage: Poverty & economic disadvantage associated with depression, suicide ideation, suicide mortality.

What is the family response to suicide?

• Devastating effects on families

• Increased risk for suicide death in another family member if suicide death in a family occurs

• Survivors with increased grief, anxiety, depression, guilt, shame, self-blame, and family dysfunction

• Protective factors; family and community support, effective clinical care especially for mental, physical  and substance abuse disorders.

• Skills in problem solving are helpful.

• Religious and spiritual beliefs can provide support and relief

What are the protective factors of suicide?

• Effective clinical care for mental and physical health and SUD

• Access to care/interventions and family support for seeking help

• Connectedness to family and community

• Support though ongoing relationship with both mental and physical health care providers

• Developed skills in conflict resolution and problem solving

• Cultural and or religious beliefs that support self-preservation

What is included in the prevention of suicide and promotion of mental health?

• Assessment: greatest predictor is previous attempt

• Case Finding: identifying people who are at risk for suicide to initiate proper treatment

• Assessing risk

  • Determination of the severity of intent (Have you been thinking about hurting yourself

  • Identification of suicidal ideation (How often do you have these thoughts

  • Elicitation of a plan (Have you made any plans to kill yourself?)

  • Evaluation of availability of means? (Do you have access to materials, guns, pills, poison)

What is included in the treatment and nursing care for suicide prevention?

• Interdisciplinary treatment and recovery****

  • Clinical judgment

• Priority care: psychiatric emergency

  • Initiate the least restrictive care possible

• Ensuring safety

  • Help the patient feel more secure and hopeful

  • Observe regularly for suicidal behavior

  • Remove dangerous objects

  • Provide outlets for expression

What to look for when assessing suicide?

• The emotional theme of suicide is Hopelessness and Helplessness. 

  • Are they expressing feelings of hopelessness as they interact with others.

• Are they verbally expressing specific self deprecating statements of ineffectiveness that has recently increased .

  • Are they demonstrating depressive symptoms in action and behavior.

• Does their mood seem to have suddenly improved for no apparent reason.

  • Ex. Smiling a lot, especially if not before.

• Have they recently been giving things of value away to others

• Are they listening to music and drawing things that are dark and related to death.

What is included in the nursing interventions of suicide?

• Imminent risk:

  • Reconnecting the patient to other people and instilling hope

  • Restoring emotional stability and reducing suicidal behavior

  • Ensuring safety: Assist patient in developing protective strategies ; identifying personal and professional resources when patient is in crises

    • Inpatient safety considerations

      • Provide a safe, therapeutic environment, removal of dangerous and environmental hazards, close observation of patients; encourage patient to verbalize feelings and concerns and help to identify ways to manage safety needs.

  • Interventions for immediate and long-term risk: Patients need ongoing preventive Interventions as discouragement and hopelessness may persist

• Biologic Domain

  • Physical care of self-inflicted injury: Overdose of pills, gunshot wounds

  • Medication management: Treat underlying psychiatric disorder

  • For patients with schizophrenia recommended treatment is clozapine

  • For patients with depression, SSRI’s

  • Electroconvulsive therapy: used in both inpatient and outpatient settings. Recommended for elderly and medically compromised.

• Psychological Domain

  • Challenging the suicidal mindset: distract one’s thinking; participate in other activities when having negative cognitive thoughts, such as calling a friend, reading, watching tv.

  • Validating the patient’s experience (everyone has negative thoughts at one time or another).

  • Relaxation strategies to reduce anxiety, visualization

  • Developing new coping strategies( journaling, psychotherapy group)

  • Nurse can assist the patient in developing a written plan of strategies, friends, families, suicide crises hotline)

  • Committing to treatment

• Social Domain

  • Social skills training: participation in support groups, self-help groups, church activities, and so forth

  • Development of support networks

  • Stigma reduction: help to anticipate and reintegrate in a supportive social environment

What is included in the evaluation and treatment outcomes of suicide?

• Short-term outcomes: Must  have a workable plan

  • Maintaining the patient’s safety, frequent contact with the health care provider

  • Averting suicide

  • Mobilizing the patient’s resources; working with the family and significant others in creating a plan for care and ensuring safety.

• Long-term outcomes:

  • Continuum of care in outpatient setting

  • Maintaining the patient in psychiatric treatment

  • Enabling the patient and family to identify and manage suicidal crises effectively

  • Widening the patient’s support network

What is included in the documentation and reporting of suicide?

• History, assessment, and interventions

• Presence or absence of suicidal thoughts, intent, plan, and available means

• Use of drugs, alcohol, or prescription medications

• Level of the patient’s judgment

• Prescribed medications, dosage, and number of pills dispensed

• Plan for ongoing treatment

What are the myths and facts about suicide?

• Myth: Suicide only affects individuals with a mental health condition.

• Fact: Many individuals with mental illness are not affected by suicidal thoughts, and not all people who attempt or die by suicide have mental illness.

• Myth: Most suicides happen suddenly without warning.

• Fact: Warning signs, verbally or behaviorally, precede most suicides.

• Myth: People who die by suicide are selfish and take the easy way out.

• Fact: Typically, people do not die by suicide because they do not want to live. People die by suicide because they want to end their suffering.

• Myth: When people become suicidal, they will always be suicidal.

• Fact: Active suicidal ideation is often short term and situation specific. While suicidal thoughts can return, they are not permanent.

• Myth: Talking about suicide will lead to and encourage suicide.

• Fact: Talking about suicide not only reduces the stigma but also allows individuals to seek help, rethink their opinions, and share their story with others.

What are the warning signs for suicide?

• Ideation: Talking or writing about death, dying, or suicide

  • Threatening or talking of wanting to hurt or kill self

  • Looking for ways to kill self: seeking access to firearms, available pills, or other means

• Substance abuse: Increased substance (alcohol or drug) use

• Purposelessness: No perceived reason for living; no sense of purpose in life

• Anxiety: Anxiety, agitation, unable to sleep, or sleeping all the time

• Trapped: Feeling trapped (like there is no way out)

• Hopelessness

• Withdrawal: Withdrawal from friends, family, and society

• Anger: Rage, uncontrolled anger, seeking revenge

• Recklessness: Acting reckless or engaging in risky activities, seemingly without thinking

• Mood change: Dramatic mood changes