Nursing Continuing Education
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The purpose of this course is to educate health care professionals on the dynamic nature of suicide and interventions to prevent suicide. Suicide is a complex, multifactorial phenomenon involving various risk factors and warning signs.
Describe the statistical prevalence of suicide and suicide attempts
Outline definitions relevant to suicides such as mean and method
Discuss individuals at-risk for suicides by describing warning signs
Outline the factors that attribute to suicide risk such as risk factors, protective factors, environmental factors, health factors, and historical factors
Discuss special considerations of suicide for Veterans
Identify the symptoms and treatment options for Veteran’s mental health disorders
Identify common symptoms of depression
Describe the processes of assessments for suicide risks, suicidal thoughts, and suicidal intent
Discuss preparatory behaviors in individuals at-risk for suicide
Discuss the risk factors for individuals with previous suicide attempts
Identify indications for urgent and immediate action when suicide crisis presents
Describe common treatment for depression and brain stimulation theory
Discuss the role of nursing in suicide assessment and prevention measures
Suicide is the 10th leading cause of death in the United States (U.S). Approximately 123 people commit suicide daily and each year 44,965 die by suicide in the U.S. The emotional impact that suicide poses on family and friends can be devastating and consequently causes a financial burden to families. Furthermore, suicide costs the U.S. $69 billion annually (American Foundation for Suicide Prevention, 2018).
Suicide does not discriminate to race, gender, or age; however, there are statistics that provide demographic information to help identify vulnerable populations. In 2016, the highest suicide among adults between 45 and 54 years of age was 19.72 per 100,000 people of this age. The second highest rate, 18.9 per 100,000 people, occurred in those 85 years or older. Younger groups have had consistently lower suicide rates than middle-aged and older adults. In 2016, adolescents and young adults aged 15 to 24 had a suicide rate of 13.15 per 100,000 people of this age (American Foundation for Suicide Prevention, 2018).
It is reported that in 2016 the highest U.S. suicide rate, 15.17 per 100,000 peoole, was among Whites, followed by the second highest rate, 13.37 per 100,000 people, among American Indians and Alaska Natives. Other demographics reported lower rates among Asians and Pacific Islanders, 6.62 per 100,000 people, and Black or African Americans, 6.03 per 100,000 people, (American Foundation for Suicide Prevention, 2018). The most common method of death by suicide was firearms (51 %), followed by suffocation (25.89 %), and then poisoning (14.90%) (American Foundation for Suicide Prevention, 2018).
Suicide Attempts. It is difficult to estimate exact number of attempted suicides in the U.S. because there are no databases or tracking mechanisms for this type of event; however, each year the Centers for Disease Control (CDC) collect data from both hospitals and other national surveys on non-fatal injuries from self-harm. The results from 2015 indicated that 505,507 people visited a hospital for injuries due to self-harm but there is a limitation in the data; it cannot distinguish between intention and non-intentional self-harm behaviors (American Foundation for Suicide Prevention, 2018).
The National Survey of Drug Use and Mental Health conducted in 2016 estimated that 0.5 % of adults (18 years or older) have made at least one suicide attempt. This statistic equates to approximately 1.3 million adults. Adult females reported more frequent suicide attempts (1.2 times more frequent) as compared to males (American Foundation for Suicide Prevention, 2018).
Another national survey (Youth Risk Behaviors Survey) conducted in 2015 reported that 8.6 % of adolescents in grades 9-12 stated that they had made at least one suicide attempt in the past 12 months. Adolescent females attempted suicide twice as often as boys (11.6% vs. 5.5%). Adolescents of Hispanic origin reported the highest rate of attempts (11.3%), Hispanic females (15.1%) when compared with white students (6.8%) and White females (9.8%) (American Foundation for Suicide Prevention, 2018).
The statistical data on suicide and suicide attempts varies based on demographic characteristics and thus strengthens the precedent to be aware of suicide warning signs over statistical profiles.
Affected by suicide: All those who may feel the effect of suicidal behaviors, including those bereaved by suicide, community members, and others.
Behavioral health: A state of mental and emotional being and/or choices and actions that affect wellness. Behavioral health problems include mental and substance use disorders and suicide.
Bereaved by suicide: Family members, friends, and others affected by the suicide of a loved one (also referred to as survivors of suicide loss).
Imminent suicide: A suicide crisis that signals an immediate danger of suicide.
Means: The instrument or object used to carry out a self-destructive act (such as chemicals, medications, illicit drugs).
Methods: Actions or techniques that result in an individual inflicting self-directed injurious behavior (such as overdose).
Primary prevention programs: The aim for this program is to prevent people from attempting and completing suicide. These types of programs utilize public education and awareness messages or campaigns targeting people in the community. Crisis telephone lines, and other resources available for suicidal persons reaching out for help, are considered primary prevention strategies.
Educational training programs: The aim for this program is to educate health professionals on primary and secondary prevention strategies.
Secondary prevention: The goal for this is to keep those that have previously attempted suicide from committing suicide.Protective factors: Factors that make it less likely that individuals will develop a disorder. Protective factors may encompass biological, psychological, or social factors in the individual, family, and environment.
Suicidal behaviors: Behaviors related to suicide, including preparatory acts, suicide attempts, and deaths.
Suicidal ideation: Thoughts of engaging in suicide-related behavior.
Suicide: Death caused by self-directed injurious behavior with any intent to die because of the behavior.
Suicide attempt: A nonfatal, self-directed, potentially injurious behavior with any intent to die because of the behavior. A suicide attempt may or may not result in injury.
Most health experts agree that the key to determining whether an individual is in distress, depressed, in crisis, or at-risk for suicide is by identifying his or her warning signs, risk, and protective factors associated with suicide. It is important to take all warning signs seriously and engage appropriate help and support.
Warning Signs. Warning signs are indications that someone may be at imminent risk for suicide (immediately or in the near future). The more warning signs someone presents, the greater the risk of suicide. Some of the effective and physical behaviors and actions that are often related to an individual experiencing suicide ideation are:
Risk Factors. Risk factors are indications that someone is at higher risk for suicide. Some of the issues related to a person’s background, history, environment and/or circumstances that increase the risk potential or likelihood of suicidal behavior are:
Prior suicide attempt(s)
Previous self-destructive behavior
History of mood disorder(s)
History of alcohol and/or other form of substance abuse
Family history of suicide and/or psychiatric disorder(s)
Loss of parent or loved one through any means
History of trauma, abuse, violence or neglect
Easy access to lethal means (especially guns)
Social isolation and/or alienation
Barriers to accessing health care and treatment
Problems tied to sexual identity and relationships
Problems tied to other personal relationships
Recent or ongoing impulsive and aggressive tendencies and/or acts
Certain cultural or religious beliefs tied to suicide.
Protective Factors. Protective factors are characteristics that reduce the likelihood that someone will attempt suicide. Some of the key behaviors, environments and relationships that reduce the likelihood of suicidal behavior and enhance resilience are:
Supportive and caring family and friends
Connectedness to community, school, family, friends
Learned skills (such as problem-solving, conflict resolution, anger management, impulse control, etc.)
Access to appropriate medical and mental health care
Access to immediate and ongoing support and care
Cultural and religious beliefs that discourage suicide
Restricted access to lethal means.
As previously stated, suicide is complex. There are additional environmental, health factors, and historical factors that may influence the risk of suicide.
Access to lethal means including firearms and drugs;
Prolonged stress, such as harassment, bullying, relationship problems or unemployment;
Stressful life events, like rejection, divorce, financial crisis, other life transitions or loss;
Exposure to another person’s suicide, or to graphic or sensationalized accounts of suicide.
Previous suicide attempts;
Family history of suicide;
Childhood abuse, neglect or trauma.
Current statistics indicate that there are 23.4 million veterans in the United States. There are an estimated 2.2 million military service members and 3.1 million military family members. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 18.5 percent of service members returning from Iraq or Afghanistan have post-traumatic stress disorder or depression, and 19.5 percent reported sustaining a traumatic brain injury (TBI) during their deployment. Another compelling statistic from SAMHSA is that an estimated fifty percent of service members returning from Iraq and Afghanistan who need mental health actually seek it.
Veterans or current military members may seek care at a Military Treatment Facility (MTF) or a Veteran’s Administration Medical Center or Clinic. However, nurses who work in civilian environments, such as community hospitals, clinics, primary care practice settings, need to be prepared to care for military members and veterans. Reasons that military members may seek mental health care in the civilian sector include the perceived stigma of seeking mental health services. Will seeking mental health care be perceived as a weakness? Will seeking mental health care impact my chances for promotion to the next rank, and therefore my military career? Current military members, both active duty and reservists may choose to seek mental health care in the civilian sector for these reasons. The additional dynamic with military reservists is that these part-time citizen soldiers often have full time civilian careers and associated healthcare benefits from their civilian employer(s). Veterans may choose to seek mental health care in the civilian sector if they live a significant distance away from a Veterans Administration Medical Center (VAMC) or VA Clinic.
Included at the end of this course are a list of web-based resources and references for learners who want to access additional information and resources to assist in meeting the needs of veterans with mental health concerns.
A key component of any nursing assessment is to ask the question “Have you ever served in the military?” The veteran’s military service may have exposed him or her to chemical (pollutants, solvents, chemical weapons), biological (infectious diseases biological weapons), psychological (mental or emotional abuse, moral injury) or physical injury (blast injury, bullet wound, shell fragment. vehicular crash. radiation, noise injury) may impact his or her overall health status. Specific mental health concerns include post-traumatic stress disorder depression and suicide risk assessment. In addition, the veteran needs to be given information about applying for benefits from the Veterans Administration.
PTSD: Have you been concerned that you might suffer from Post-Traumatic Stress Disorder? Symptoms can include numbing, re-experiencing symptoms, hyperarousal/being on guard, and/or avoiding situations that remind(s) you of the trauma.
Depression: Have you been experiencing sadness, feelings of hopelessness, lack of energy, difficulty concentrating, and/or poor sleep?
Risk Assessment: Have you had thoughts of harming yourself or others?
Westphal and Convoy (2015) related that nurses need to attain a level of military cultural competence in order to be able to effectively work with member of the military and veteran’s health care and specifically their mental health care. A concept that is central to military culture is military ethos. Military ethos, also known as warrior ethos has six traits: Selflessness, loyalty, stoicism, moral code, social order and excellence. Each of these traits in a military member can be either a strength or a vulnerability. See the table below, adapted from the Uniformed Services University of the Health Sciences Center for Deployment Psychology Module 1 to illustrate each trait in terms of strengths and weaknesses (or vulnerabilities):
Resilience or the ability to regroup and recover is a key facet of military life, especially during and after a deployment. Military members may be deployed for combat operations, non-combat operations or humanitarian missions. Military ethos is a strength and contributes to the resiliency of a military member, and his or her family, when it helps to engage resources, leverage support and promote hope. Conversely. Military ethos can be a vulnerability when beliefs serve as a barrier to resources, support, and hope.
When working with military veterans it is critical to include the impact(s) of military service and deployments on both the veteran and the military family. Rossiter et al (2016) highlighted the importance of acknowledging and meeting the needs of military children in civilian practice. The initiative that these authors propose is termed “I Serve 2”, The aim of this initiative is to encourage primary care providers, including nurse practitioners, to ask if the child has a parent or parents that serve in the military. This question is important in completing a health history in children. Military children experience frequent moves, changes in schools associated with these moves, along with stress or anxiety related to deployment of one or both active duty parents to a war zone, military or humanitarian mission. Deployment of one or both parents who serve in the military also impacts the children of military reservists.
Patel (2015) examined the roles that veteran’s caregivers, often their spouse or another immediate family member, play in their recovery process. Patel noted that caregivers assist veteran’s with applying for Veterans Administration benefits, transportation to appointments, activities of daily living and medication management. The Substance Abuse and Mental Health Services Administration (SAMHSA) is a federal agency that supports mental health care. SAMHSA has five core principles to guide and improve behavioral health services for veterans and military families. These core principles include:
When appropriate, military families should have access to well-prepared civilian behavioral health care delivery systems;
Civilian, military, and veteran service systems should be coordinated;
Suicide prevention for military families must be implemented across systems;
Emotional health promotion for military families is important in reducing mental and substance use disorders and weathering increased exposure to adverse events;
Military families want and need stable housing.
Combat Stress. Stress is a normal component of everyday life. Once a stressor is no longer present, an individual will return to normal behaviors. Combat stress is defined as a common response to the mental and emotional strain when faced with dangerous or traumatic situations. Combat stress usually occurs for brief periods of time and symptoms resolve in a few weeks after the service member returns home Symptoms of combat stress include:
Irritability and angry outbursts
Headaches and fatigue
Depression and apathy
Loss of appetite
Changes in personality or behavior
There are several things that an individual experiencing combat stress can do to cope with combat stress:
Eat right: a healthy diet
Get adequate rest: at least seven hours of sleep each night
Reach out for help: talk to a clergy member or a counselor
Practice relaxation techniques such as deep breathing and doing things each day that you enjoy
Post-Traumatic Stress Disorder (PTSD). Post-traumatic stress disorder (PTSD) can occur when someone experiences a traumatic event such as war, assault, or disaster. PTSD differs from combat stress in that while initial symptoms may be similar to combat stress, PTSD is more severe and can manifest weeks, months or years after experiencing a traumatic event. PTSD often impacts an individual’s abilities to meet daily life responsibilities.
The Diagnostic and Statistical Manual of Mental Health Disorders (2013) specifies the following diagnostic criteria for PTSD:
Criterion A (one required) The person was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following ways:
Exposure to actual or threatened death, serious injury or sexual violation
Witnessing the trauma
Learning that a relative or close friend was exposed to a trauma
Indirect exposure to aversive details of the trauma, usually in the course of professional duties
Criterion B (one required) The traumatic event is re-experienced in one of the following ways:
Unwanted upsetting memories
Emotional distress after exposure to traumatic reminders
Criterion C (one required) Avoidance of trauma related stimuli after the trauma, in one of the following ways:
Trauma related thoughts or feelings
Trauma related reminders
Criterion D (two required) Negative thoughts or feelings that began or worsened after the trauma, in the following ways:
Inability to recall key features of the trauma
Overly negative thoughts or assumptions about oneself or the world
Exaggerated blame of self or others for causing the trauma
Decreased interest in activities
Difficulty experiencing positive affect
Criterion E (two required) Trauma-related arousal and reactivity that began or worsened after the trauma, in the following ways:
Irritability or aggression
Risky or destructive behavior
Heightened startle reaction
Criterion F (required): Symptoms last for more than one month
Criterion G (required) Symptoms create distress or impairment in normal functioning (occupational, social)
Criterion H (required) Symptoms are not due to medication, substance use or other illness
Acute PTSD lasts no longer than three months. Chronic PTSD lasts longer than three months. Some cases of PTSD may occur years or even decades after the traumatic event(s). In addition to the DSM-5 criteria (APA, 2013) above evidence-based screening tools are utilized by providers to screen for PTSD. One such tool is the PTSD Checklist for DSM-5 (PCL-5). This twenty-item checklist is used to screen individuals for PTSD. According to the American Psychiatric Association, the gold standard for diagnosing PTSD is a structured clinical interview. The structured clinical interview is completed by mental health providers, including psychiatric mental health nurse practitioners.
Treatment for Post-Traumatic Stress Disorder. The National Center for PTSD (2017) outlines the following evidence-based treatments for post-traumatic stress disorder. The recommended treatment for PTSD is either a trauma focused psychotherapy or medication. Trauma focused psychotherapies are the most highly recommended treatment modality for PTSD. Trauma focused psychotherapy is defined as treatment that is focused on the memory of the traumatic event. Veterans undergoing a trauma focused psychotherapy usually attend eight to sixteen sessions. Trauma focused psychotherapies use various techniques, such as visualizing, talking about or thinking about the traumatic memory. Other trauma focused psychotherapies involve changing unhelpful beliefs about the trauma. Trauma focused therapies with the strongest evidence are:
Prolonged Exposure (PE): this therapy includes relaxation skills. recalling details of the traumatic memory, reframing negative thoughts about the trauma, writing a letter about the traumatic event, and holding a farewell ritual to leave the trauma in the past.
Cognitive Processing Therapy (CPT): this therapy teaches the veteran to reframe negative thoughts about the trauma. This includes the veteran talking with the mental health provider about negative thoughts and doing short writing assignments.
Eye-Movement Desensitization and Reprocessing (EMDR): helps the veteran process and make sense of the trauma. EMDR involves calling the trauma to mind while paying attention to a back and forth movement or sound
According to the Veterans Affairs/ Department of Defense Clinical Practice Guideline for Post-Traumatic Stress Disorder and Acute Stress Disorder (2017) medication is the recommended treatment for PTSD when trauma focused psychotherapy is not readily available or not preferred. There are four antidepressant medications that are recommended for the treatment of PTSD:
Traumatic Brain Injury (TBI) and Veterans Mental Health. Westphal and Convoy’s (2015) article discusses the stresses associated with military service and deployments. Traumatic Brain Injury (TBI) and Post-Traumatic Stress Disorder (PTSD) have been called the invisible wounds of war because there are no obvious physical deformities or wounds that are evident. These wounds of war impact the veteran and his or her family. Kulas and Rosenheck (2018) completed a study of 164,884 veterans that examined veterans diagnosed with mild TBI, PTSD, and both disorders. They concluded that PTSD pays a dominant role in the development of psychiatric difficulties in veterans. Miles et al (2017) studied 583,733 veterans in the Veterans Health Administration national patient care database to examine TBI and mental health disorders in combat veterans. They concluded that TBI is linked with mental health disorders in veterans.
According to the National Alliance on Mental Health there are three primary mental health disorders that veterans may experience related to their military service: post-traumatic stress disorder (PTSD), depression, and traumatic brain injury (TBI).
Depression. The National Alliance on Mental Illness defines a depressive disorder an individual must have experienced a depressive episode lasting longer than two weeks. A depressive episode significantly interferes with a person’s ability to function day to day. Depression can be triggered by a life crisis, such as a trauma. Trauma that may be experienced by a veteran could include: combat. Injury, natural disasters, or military sexual trauma. Life changes including loss of a loved one or buddy from their unit, retirement, deployment, financial problems, job change, or divorce may also cause stress and could result in depression. Exposure to trauma can alter the body’s response to fear and stress which may lead to depression. It is important to note that not every veteran who is exposed to trauma or experiences life changes will subsequently experience a depressive disorder.
Symptoms of a depression disorder include:
Loss of interest or loss of pleasure in all activities
Changes in appetite or weight
Feeling agitated or feeling slowed down
Feelings of low self-worth, guilt or shortcomings
Suicidal thoughts or intentions
The Veterans Administration Suicide Prevention Program (2016) cites the following statistics about veteran suicide:
Veterans accounted for 18 percent of all deaths from suicide among adults in the United States in 2014. In 2010, veterans accounted for 22 percent of all deaths from suicide. Approximately sixty six percent of all veteran deaths from suicide were the result of firearm injuries. After adjusting for differences in age, the risk for suicide was eighteen percent higher for male veterans when compared with U. S. adult males. After adjusting for differences in age, the risk for suicide was 2.4 times higher among female veterans, when compared to U. S. adult females.
The Veterans Administration has identified the following factors that are associated with a veteran’s military service, which may contribute to his or her risk of a suicide attempt. These veteran specific risks include:
Deployments to hostile environments
Exposure to extreme stress
Physical/sexual assault while in the service (not limited to women)
Length of deployments
Service related injury
According to the Veterans Crisis Line, veterans who are considering suicide often show signs of depression, anxiety or low self-esteem. The Veteran’s Crisis Line has identified the following warning signs that may indicate a veteran is a suicide risk:
Performing poorly at work or school
Acting recklessly or engaging in risky activities—seemingly without thinking
Showing violent behavior such as punching holes in walls, getting into fights or self-destructive violence; feeling rage or uncontrolled anger or seeking revenge
Looking as though one has a “death wish,” tempting fate by taking risks that could lead to death, such as driving fast or running red lights
Giving away prized possessions
Putting affairs in order, tying up loose ends, and/or making out a will
Seeking access to firearms, pills, or other means of harming oneself
The National Guideline Clearing House (NGC) has summarized the assessment and management of suicide risk (2013). A suicide risk assessment is a process in which the healthcare provider gathers clinical information to determine the patient's risk for suicide. The risk for suicide is estimated based on the patient's suicidal thoughts and intent, suicide related behavior, warning signs, risk and protective factors. The list below outlines the assessment of risk for suicide:
A suicide risk assessment should first evaluate the three domains: suicidal thoughts, intent, and behavior including warning signs that may increase the patient's acuity;
The suicide risk assessment should then include consideration of risk and protective factors that may increase or decrease the patient's risk of suicide;
Observation and existence of warning signs and the evaluation of suicidal thoughts, intent, behaviors, and other risk and protective factors should be used to inform any decision about referral to a higher level of care;
Mental state and suicidal ideation can fluctuate considerably over time. Any person at risk for suicide should be re-assessed regularly, particularly if their circumstances have changed;
The clinician should observe the patient's behavior during the clinical interview. Disconnectedness or a lack of rapport may indicate increased risk for suicide;
The healthcare professional assessing suicide risk should remain both empathetic and objective. A direct non-judgmental approach allows the healthcare professional provider to gather the most reliable information in a collaborative way, and the patient to accept help.
Suicidal Thoughts. Ask the patient if he/she has thoughts about wishing to die by suicide, or thoughts of engaging in suicide-related behavior. The distinction between non-suicidal self-directed violence and suicidal behavior is important.
Patients should be directly asked if they have thoughts of suicide and to describe them. The evaluation of suicidal thoughts should include the following:
Onset (When did it begin)
Duration (Acute, Chronic, Recurrent)
Intensity (Fleeting, Nagging, Intense)
Frequency (Rare, Intermittent, Daily, Unabating)
Active or passive nature of the ideation ('Wish I was dead' vs. 'Thinking of killing myself')
Whether the individual wishes to kill themselves, or is thinking about or engaging in potentially dangerous behavior for some other reason such as cutting oneself as a means of relieving emotional distress
Lethality of the plan (No plan, Overdose, Hanging, Firearm)
Triggering events or stressors (Relationship, Illness, Loss)
What intensifies the thoughts
What distracts the thoughts
Association with states of intoxication (Elicit to explore if thoughts are triggered only when individual is intoxicated)
Understanding regarding the consequences of future potential actions.
Suicidal Intent. Assess for past or present evidence (implicit or explicit) that the individual wishes to die, means to kill him/herself, and understands the probable consequences of his/her actions or potential actions.
Preparatory Behavior. Assess if the patient has begun to show actual behavior of preparation for engaging in self-directed violence such as assembling a method or preparing for one's death.
Previous Suicide Attempt. Obtain information from the patient and other sources about previous suicide attempts. Historical suicide attempts may or may not have resulted in injury, and may have been interrupted by the patient or by another person prior to fatal injury. The assessment of risk for suicide should include information from the patient and collateral sources about previous suicide attempt and circumstances surrounding the event (i.e., triggering events, method used, consequences of behavior, role of substances of abuse) to determine the lethality of any previous attempt:
Inquire if the attempt was interrupted by self or other, and other evidence of effort to isolate or prevent discovery
Inquire about other previous and possible multiple attempts
For patients who have evidence of previous interrupted (by self or other) attempts, obtain additional details to determine factors that enabled the patient to resist the impulse to act (if self-interrupted) and prevent future attempts.
Indications for Urgent/Immediate Action. Recognize precipitating emotions, thoughts, or behaviors that are most proximally associated with a suicidal act and reflect high risk.
Assessment of Factors That Contribute to the Risk for Suicide. Assess factors that are known to be associated with suicide and those that may decrease the risk.
Treatment for depression may include counseling, therapy and/or antidepressant medication. The most effective treatment for depression combine psychotherapy with antidepressant medication.
Psychotherapy for depression may include:
Cognitive Behavioral Therapy (CBT): There is a strong evidence-base that supports the use of Cognitive Behavioral Therapy(CBT) as an effective treatment for depression. CBT helps to assess and change negative thinking patterns associated with depression. The goal of CBT is for the veteran to recognize negative thoughts and to teach coping strategies. CBT is time limited, usually consisting of eight to sixteen sessions.
Interpersonal Therapy (IPT): IPT focuses on improving problems in personal relationships and other life changes that may contribute to depressive disorder. Therapists teach individuals undergoing IPT to evaluate their interactions and to improve how they relate to others. IPT is often time limited like CPT.
Psychodynamic Therapy: Psychodynamic therapy is a therapeutic approach that focuses on recognizing and understanding negative patterns of behavior and feelings that are rooted in past experiences and working to resolve them. Another component of this psychotherapy is examining a person’s unconscious processes.
Antidepressant medications are the treatment of choice for depression. The aim of medication therapy for depression is to help to reduce or control symptoms of depression. Regardless of the medication that is prescribed, patients need to know that antidepressant medication may take two to four weeks to be effective, and up to twelve weeks to reach maximum effect.
Medications that are prescribed for depression include:
Selective serotonin uptake inhibitors (SSRIs) are the most common medications prescribed for depression:
Serotonin and norepinephrine reuptake inhibitors (SNRIs):
Norepinephrine-dopamine reuptake inhibitors (NDRIs):
Bupropion (Wellbutrin) Therapy
Second generation antipsychotics (SGAs) are classified as atypical antipsychotics that treat schizophrenia, acute mania, bipolar disorders and bipolar mania. SGAs have been used for treatment resistant depression:
Tricyclic antidepressants, such as Amitriptyline (Elavil) are older medications that are seldom used today as initial treatment for depression. Likewise, MAOIs such as Phenelzine (Nardil) are used less today because they have more side effects than SNRIs. However, MAOIs may be effective for people who do not respond to other medications.
Brain stimulation therapies are utilized when other treatments for depression (as specified above) have not been effective. Brain stimulation therapy includes:
Electroconvulsive therapy (ECT): ECT involves transmitting short electrical impulses into the brain. Electroconvulsive therapy can cause some significant side effects, including memory loss. The veteran needs to understand both the potential risks and benefits of ECT before beginning treatment with ECT.
Repetitive Transcranial Magnetic Stimulation (rTMS) is a relatively new type of brain stimulation that uses a magnet instead of electrical current to activate the brain. It has not been proven effective as maintenance therapy.
Complementary and Alternative Medicine (CAM):
Complementary and Alternative Medicine (CAM) treatments can be used as an adjunct to other evidence-based treatments for depression in veterans. When complementary and alternative medicine interventions are combined with more evidence-based treatment options, such as prescribed medications and psychotherapy, CAM can contribute to the overall treatment plan for depression in veterans. Complementary treatment which have an evidence-base, indicating that this intervention will contribute positively to the treatment of depression include:
Exercise: exercise increases endorphins and stimulates the secretion of norepinephrine, which can improve a person’s mood
Folate: Studies have shown that when individuals with depression lack folate, or folic acid, they may not be receiving the full therapeutic effect from their prescribed antidepressant medication. Studies have shown that adding a folate supplement, such as L-methyl folate, can enhance the effectiveness of antidepressant medication.
St John’s Wort: is a supplement with chemical properties similar to selective serotonin uptake inhibitors (SSRIs). Veterans who are taking St John’s Wort for depression need to tell their provider. There are substantial risks associated with combining St John’s Wort with prescribed SSRIs. In addition, while herbal and complementary medicines may show some effectiveness, herbal remedies are not regulated by the Food and Drug Administration.
Nursing plays in important role in the assessment and prevention of suicide in a variety of healthcare settings such as in-patient psychiatric centers, acute care, emergency department, ambulatory care, and the community. Furthermore, nurses are instrumental members of the healthcare team that work with patients at-risk. The Joint Commission (TJC), a national organization providing accreditation to health care facilities, released a Sentinel Event Alert (2016) detailing suggested actions for conducting a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease risk for suicide (National Patient Safety Goal 15.01.01). The recommendation is the following:
(1) Review each patient’s personal and family medical history for suicide risk factors
(2) Screen all patients for suicide ideation, using a brief, standardized, evidence-based screening tool. A waiting room questionnaire including a question specifically asking if the patient has had thoughts about killing him or herself may help identify individuals at risk for suicide who otherwise may not have been identified. Research shows that a brief screening tool can identify individuals at risk for suicide;
(3) For patients who screen positive for suicide ideation and deny or minimize suicide risk or decline treatment, obtain corroborating information by requesting the patient’s permission to contact friends, family, or outpatient treatment providers. If the patient declines consent, HIPAA permits a clinician to make these contacts without the patient’s permission when the clinician believes the patient may be a danger to self or others (TJC, 2016).
Patients in suicidal crisis. Take immediate action and implement a safety plan:
Keep patients in acute suicidal crisis in a safe health care environment under one-to one observation
Do not leave these patients by themselves
Arrange immediate access to care through an emergency department, inpatient psychiatric unit, respite center, or crisis resources
Check these patients and their visitors for items that could be used to make a suicide attempt or harm others
Keep these patients away from anchor points for hanging and material that can be used for self-injury. Some specific lethal means that are easily available in general hospitals and that have been used in suicides include: bell cords, bandages, sheets, restraint belts, plastic bags, elastic tubing and oxygen tubing.
Patients at lower risk of suicide. Make personal and direct referrals to outpatient behavioral health and other providers for follow-up care within one week of initial assessment rather than leaving it up to the patient to make the appointment.
Patients with suicide ideation. Give every patient and his or her family members the number to the National Suicide Prevention Lifeline, 1-800-273TALK (8255), as well as to local crisis and peer support contacts. Conduct safety planning by collaboratively identifying possible coping strategies with the patient and by providing resources for reducing risks. A safety plan is not a “no-suicide contract” (or “contract for safety”), which is not recommended by experts in the field of suicide prevention. Review and reiterate the patient’s safety plan at every interaction until the patient is no longer at risk for suicide. A safety plan can include a discussion on how to restrict access lethal means, assess patient access to firearms or other lethal means, such as prescription medications and chemicals, and discuss ways of removing or locking up firearms and other weapons during crisis periods. Restricting access is important because many suicides occur with little planning during a short-term crisis, and both intent and means is required to attempt suicide.
To improve outcomes for at-risk patients, the healthcare team should provide evidence-based clinical approaches that help to reduce suicidal thoughts and behaviors include:
(1) Cognitive Therapy for Suicide Prevention (CBTSP)
(2) the Collaborative Assessment and Management of Suicide (CAMS)
(3) Dialectical Behavior Therapy (DBT)
(4) Caring Contacts has a growing body of evidence as a post-discharge suicide prevention (TJC, 2016).
Evidence-based interventions focus on key elements of patient engagement, collaborative assessment and treatment planning, problem-focused clinical intervention to target suicidal “drivers,” skills training, shared service responsibility, and proactive and personal clinician involvement in care transitions and follow-up care, such as:
Documentation. Thoroughly document every step in the decision-making process and all communication with the patient, his or her family members and significant others, and other caregivers. Document why the patient is at risk for suicide and the care provided to patients with suicide risk in as much detail as possible, including the content of the safety plan and the patient’s reaction to and use of it; discussions and approaches to means reduction; and any follow-up activities taken for missed appointments, including texts, postcards, and calls from crisis centers. Be generous in documentation, as it becomes the main method of communication among providers.
Suicide Myths and Realities
The next section below includes several case scenarios. Read through the scenarios and think about the presenting warning signs for suicide. Suicide cannot be predicted by age or demographic profiling and each individual, as in life, have unique circumstances and risk factors.
Case Scenario #1
Sandy is a 15-year-old girl who lives in the Midwest. Her parents had recently divorced, which forced her to move to a new community of 3,000 people. She hated the small-town atmosphere and didn't make any new friends. Her sister Tiffany, her 'only' friend, was going away to college in the fall, which made her feel even worse. Sandy was having trouble sleeping, her grades were falling, and she was crying almost every day. She tried to tell her dad and new stepmom that she was feeling terrible, but they said that things would get better if she would just give it some time. She gave her sister her birthstone ring, and said she wouldn't need it anymore.
What warning signs for suicide did Latosha exhibit?
Giving away a prize possession
Case Scenario # 2
Debbie is a 16-year old girl who has been dealing with depression since she was 12 years old. She never felt 'quite right' in middle school, feeling like she didn't fit in. She started using alcohol on a regular basis, and then marijuana.
Most of her old friends didn't drink alcohol or do drugs so she started hanging around with a different group of teenagers. She put herself at risk by having unprotected sex with friends in the group. Since school didn't seem important anymore she started skipping classes.
She was sinking lower and lower and thinking that it was not going to get any better. She told her mom that she accidentally threw away her prescription anti-depressant drugs and needed a new bottle. Her mom got the bottle refilled. She told her friends that "life wasn't worth living," and said she was going to run away the next weekend.
What is a potential outcome of this scenario?
The clues add up to a potential suicide by overdosing with her prescribed medications.
Case Scenario # 3
Larry is an 85-year-old who older adult who lives independently in his home. He recently lost his wife to a long battle with cancer. Larry is normally active in the community and attends church and the Lions Club regularly but over the last month has stopped attending church and club meetings. He also stopped socializing and talking to neighbors. Larry and his deceased wife’s 60-year wedding anniversary is coming up and has stated to friends that life is not worth living without his wife.
What is the cause of Larry’s change in behaviors?