Suicide and Suicide Prevention

6 Contact Hours

Notice for nurses licensed in Washington state: This course is not currently approved by the Washington Department of Health, with an application pending. If you would like a notification when this course is approved please email [email protected] 

Syllabus

Purpose

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.

Objectives

  1. Describe the statistical prevalence of suicide and suicide attempts
  2. Outline definitions relevant to suicides such as mean and method
  3. Discuss individuals at-risk for suicides by describing warning signs
  4. Outline the factors that attribute to suicide risk such as risk factors, protective factors, environmental factors, health factors, and historical factors
  5. Discuss special considerations of suicide for Veterans
  6. Identify the symptoms and treatment options for Veteran’s mental health disorders
  7. Identify common symptoms of depression
  8. Describe the processes of assessments for suicide risks, suicidal thoughts, and suicidal intent
  9. Discuss preparatory behaviors in individuals at-risk for suicide
  10. Discuss the risk factors for individuals with previous suicide attempts
  11. Identify indications for urgent and immediate action when suicide crisis presents
  12. Describe common treatment for depression and brain stimulation theory
  13. Discuss the role of nursing in suicide assessment and prevention measures

Background

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).

Statistics

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.

Definitions

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.

Risk factors
Factors that make it more likely that individuals will develop a disorder. Risk 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.



Identifying People At-Risk for Suicide

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:

  • Extreme mood swings or changes in personality
  • Changes in eating and sleeping habits (such as sleeping too little or all the time);
  • A heightened fixation with death or violence
  • Expressing feelings of hopelessness or no reason to live
  • Engaging in self-destructive or risky behavior
  • Withdrawal from loved ones, friends and community
  • Announcing a plan to kill one’s self
  • Talking about or writing about hurting one’s self, wanting to die or kill one’s self
  • Giving away prized possessions
  • Obtaining a weapon or some other means of hurting one’s self
  • Increased use of alcohol or drugs
  • Telling people he or she is ‘going away’
  • Loss of interest in things one used to care about
  • Being a victim of bullying, sexual abuse, violence
  • For youth, a sudden worsening of school performance
  • For youth, indications that the teen is in some form of an abusive relationship
  • Verbalizing the following:
    • “I wish I were dead.”
    • “I’m going to end it all.”
    • “You will be better off without me.”
    • “What’s the point of living?”
    • “Soon you won’t have to worry about me.”
    • “Who cares if I’m dead, anyway?”

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.

Environmental Factors

  • 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.

Health Factors

  • Mental health conditions; 
    • Depression
    • Substance Abuse Problems
    • Bipolar disorder
    • Schizophrenia
    • Personality traits of aggression, mood changes and poor relationships
    • Conduct disorder
    • Anxiety disorders
  • Serious physical health conditions including pain;
  • Traumatic brain injury

Historical Factors

  • Previous suicide attempts;
  • Family history of suicide;
  • Childhood abuse, neglect or trauma.


Special Considerations for Veterans

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.

Veterans and Mental Health Care: Have You Ever Served in the Military?

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.

Behavioral Health History Screening Questions to Ask

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?

Military Culture

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.

The Military Family and Veterans Mental Health

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
  • Problems sleeping
  • 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
  • Exercise regularly
  • 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
  • Nightmares
  • Flashbacks
  • 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
  • Negative affect
  • Decreased interest in activities
  • Feeling isolated
  • 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
  • Hypervigilance
  • Heightened startle reaction
  • Difficulty concentrating
  • Difficulty sleeping

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:

  • Sertraline (Zoloft)
  • Paroxetine (Paxil)
  • Fluoxetine (Prozac)
  • Venlafaxine (Effexor)

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
  • Sleep disturbances
  • Feeling agitated or feeling slowed down
  • Fatigue
  • Feelings of low self-worth, guilt or shortcomings
  • Difficulty concentrating
  • Suicidal thoughts or intentions

Veterans and Suicide Risk

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:

  • Frequent deployments
  • 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


Risk Assessment for Suicide

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:

  1. 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;
  2. The suicide risk assessment should then include consideration of risk and protective factors that may increase or decrease the patient's risk of suicide;
  3. 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;
  4. 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;
  5. The clinician should observe the patient's behavior during the clinical interview. Disconnectedness or a lack of rapport may indicate increased risk for suicide;
  6. 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:

  1. Onset (When did it begin)
  2. Duration (Acute, Chronic, Recurrent)
  3. Intensity (Fleeting, Nagging, Intense)
  4. Frequency (Rare, Intermittent, Daily, Unabating)
  5. Active or passive nature of the ideation ('Wish I was dead' vs. 'Thinking of killing myself')
  6. 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
  7. Lethality of the plan (No plan, Overdose, Hanging, Firearm)
  8. Triggering events or stressors (Relationship, Illness, Loss)What intensifies the thoughts
  9. What distracts the thoughts
  10. Association with states of intoxication (Elicit to explore if thoughts are triggered only when individual is intoxicated)
  11. 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.

Patients should be asked the degree to which he/she wishes to die, mean to kill him/herself, and understand the probable consequences of his/her actions or potential actions.

The evaluation of intent to die should be characterized by:

  • Strength of the desire to die
  • Strength of determination to act
  • Strength of impulse to act or ability to resist the impulse to act.

The evaluation of suicidal intent should be based on indication that the individual:

  • Wishes to die
  • Means to kill him/herself
  • Understands the probable consequences of the actions or potential actions;

These factors may be highlighted by querying regarding how much the individual has thought about a lethal plan, has the ability to engage that plan, and is likely to carry out the plan.

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.

Healthcare professionals should evaluate preparatory behaviors by inquiring about:

  • Preparatory behavior like practicing a suicide plan. For example:
    • Mentally walking through the attempt
    • Walking to the bridge
    • Handling the weapon
    • Researching for methods on the internet.
    • Thoughts about where they would do it and the likelihood of being found or interrupted;
  • Action to seek access to lethal means or explored the lethality of means. For example:
    • Acquiring a firearm or ammunition
    • Hoarding medication
    • Purchasing a rope, blade
    • Researching ways to kill oneself on the internet.
  • Action taken or other steps in preparing to end one's life:
    • Writing a will, suicide note
    • Giving away possessions
    • Reviewing life insurance policy.
    • Obtain collateral information from sources such as family members, medical records, and therapists.

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.

Assess for other warning signs that may indicate likelihood of suicidal behaviors in the future and require immediate attention:

  • Substance abuse – increasing or excessive substance use (alcohol, drugs, smoking)
  • Hopelessness – expresses feeling that nothing can be done to improve the situation
  • Purposelessness – expresses no sense of purpose, no reason for living, decreased self-esteem
  • Anger – rage, seeking revenge
  • Recklessness – engaging impulsively in risky behavior
  • Feeling trapped – expressing feelings of being trapped with no way out
  • Social withdrawal – withdrawing from family, friends, society
  • Anxiety – agitation, irritability, angry outbursts, feeling like wants to "jump out of my skin"
  • Mood changes – dramatic changes in mood, lack of interest in usual activities/friends
  • Sleep disturbances – insomnia, unable to sleep or sleeping all the time
  • Guilt or shame – expressing overwhelming self-blame or remorse

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.

  • Healthcare professionals should obtain information about risk factors during a baseline evaluation – recognizing that risk factors have limited utility in predicting future behavior
  • Healthcare professionals should draw on available information including prior history available in the patient's record, inquiry and observation of the patient, family or military unit members and other sources where available
  • Assessment tools may be used to evaluate risk factors, in addition to the clinical interview, although there is insufficient evidence to recommend one tool over another
  • The baseline assessment should include information about risk factors sufficient to inform further assessment if conditions change such as firearm in the home, social isolation, history of depression, etc.
  • Risk factors should be considered to denote higher risk individuals (e.g., those with a history of depression) and higher risk periods (e.g., recent interpersonal difficulties);
  • Risk factors should be solicited and considered in the formulation of a patient's care
  • Reassessment of risk should occur when there is a change in the patient's condition (e.g., relapse of alcoholism) or psychosocial situation (e.g., break-up of intimate relationship) to suggest increased risk. Healthcare professionals should update information about risk factors when there are changes in the individual's symptoms or circumstances to suggest increased risk.
  • Patients ages 18 to 25 who are prescribed an antidepressant are at increased risk for suicidal ideation and warrant increase in the frequency of monitoring of these patients for such behavior.
  • For Military Service person in transition the health care professional should:
    1. Inquire about changes in the patient's life and be aware of other indicators of change (retirement physical, overseas duty screening, etc.)
    2. Be willing to discuss and consider methods to strengthen social support during the transition time if there are other risk factors present.


Treatment for Depression

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:

  • Fluoxetine (Prozac)
  • Sertraline (Zoloft)
  • Paroxetine (Paxil)
  • Citalopram (Celexa)
  • Escitalopram (Lexapro)

Serotonin and norepinephrine reuptake inhibitors (SNRIs):

  • Venlafaxine (Effexor)
  • Desvenlafaxine (Pristiq)
  • Duloxetine (Cymbalta)

Norepinephrine-dopamine reuptake inhibitors (NDRIs):

  • Bupropion (Wellbutrin) Therapy
  • Mirtazapine (Remeron)

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:

  • Aripiprazole (Abilify)
  • Quetiapine (Seroquel)

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 Therapy

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 Practice

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:

  1. Keep patients in acute suicidal crisis in a safe health care environment under one-to one observation
  2. Do not leave these patients by themselves
  3. Arrange immediate access to care through an emergency department, inpatient psychiatric unit, respite center, or crisis resources
  4. Check these patients and their visitors for items that could be used to make a suicide attempt or harm others
  5. 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:

  • Cognitive Therapy for Suicide Prevention (CBTSP)
  • the Collaborative Assessment and Management of Suicide (CAMS)
  • Dialectical Behavior Therapy (DBT)
  • 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.



Resources

Call the U.S. National SuicidePrevention Lifeline at 800–273–TALK/8255

Don’t feel like talking on the phone? Try Lifeline Crisis Chat (www.suicidepreventionlifeline.org/gethelp/lifelinechat.aspx) or the Crisis Text Line at 741741. 

If you might be at risk of suicide again, download the My3 App from the National Suicide Prevention Lifeline. You can use the app to list your crisis contacts, make a safety plan and use emergency resources. For more information:  www.suicidepreventionlifeline.org/gethelp/my3-app.aspx

Recommendations for Reporting on Suicide website (www.reportingonsuicide.org)

Military Health History Pocket Card for Health Professions Trainees and Clinicians
https://www.va.gov/oaa/archive/Military-Health-History-Card-for-print.pdf 
This Veteran’s Administration resource is a pocket military health history card for use by health care professionals in both military and civilian healthcare settings. This resource contains key questions that should be asked when obtaining a health history from a veteran.

Military Culture continuing Education Modules
https://deploymentpsych.org/military-culture-course-modules
This free online continuing education course for health care professionals is sponsored by the Center for Deployment Health at Uniformed Services University of the Health Sciences. The three modules enable nurses who may be unfamiliar with the military learn about military culture to be able to better serve and relate to veterans. The course contains four online self-paced modules.

Mental Health Clinical Practice Guidelines
https://www.healthquality.va.gov/guidelines/MH/
This Veterans Administration website contains the most up to date evidence-based clinical practice guidelines for Veterans Mental Health Care.

PTSD Checklist for DSM-5 (PCL-5)
https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp

Veteran Health Benefits and Services
www.myhealth.va.gov 
This website can be accessed by veterans, family members, and caregivers and provides information on veteran’s health benefits and services.

Veterans Crisis Line
https://www.veteranscrisisline.net/
The Veterans Crisis Line is a Department of Veterans Affairs (VA) resource that connects Veterans and Service members in crisis and their families and friends with information and qualified, caring VA responders through a confidential, toll-free hotline, online chat, and text messaging service. Veterans and their families and friends can call 1-800-273-8255 and Press 1, chat online at www.VeteransCrisisLine.net, or send a text message to 838255 to receive support from specially trained professionals, 24 hours a day, 7 days a week, 365 days a year. 


Suicide Myths and Realities

MythReality
Asking about suicide will plant the idea in a person’s headAsking about suicide does not create suicidal thoughts. The act of asking the question simply gives the veteran permission to talk about his or her thoughts or feelings
There are talkers and there are doersMost people who die by suicide have communicated some intent. Someone who talks about suicide gives the guide and/or clinician an opportunity to intervene before suicidal behaviors occur
If somebody really wants to die by suicide, there is nothing you can do about itMost suicidal ideas are associated with treatable disorders. Helping someone find a safe environment for treatment can save a life. The acute risk for suicide is often time-limited. If you can help the person survive the immediate crisis and overcome the strong intent to die by suicide, you have gone a long way toward promoting a positive outcome
"They really wouldn't commit suicide because they…"
  • just made plans for vacation
  • have young children at home
  • made a verbal or written promise
  • knows how dearly their family loves them
The intent to die can override any rational thinking. Someone experiencing suicidal ideation or intent must be taken seriously and referred to a clinical provider who can further evaluate their condition and provide treatment as appropriate.



Wrap-Up Exercise

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?  

  • Trouble Sleeping

  • Falling grades

  • Crying daily

  • Feeling isolated

  • 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?

  • The loss of his wife catapulted a series of behavior changes that indicates Larry is at-risk for suicide.


References

Assessment and Management of Risk for Suicide Working Group, (2013). VA/DoD clinical practice guideline for assessment and management of patients at risk for suicide. Washington (DC): Department of Veterans Affairs, Department of Defense, 190 p.

Bolster, C., Holliday, C., Oneal, G., Shaw, M., (January 31, 2015) "Suicide Assessment and Nurses: What Does the Evidence Show?" OJIN: The Online Journal of Issues in NursingVol. 20, No. 1, Manuscript 2.

American Foundation for Suicide Prevention (2018).

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5thEdition), Washington, DC.

Cipriano, P. (2014). A powerful question: have you ever served in the military? American Nurse Today, 9 (3).

Complementary and Alternative Medicine (CAM) for PTSD. (March 30. 2017).

Ganzer, C. (2016). Veteran Women: Mental Health Related Consequences of Military Service. American Journal of Nursing, 116 (11), 32-39.

The Joint Commission Accreditation (2014). Behavioral health care national patient safety goals.

The Joint Commission (2016). Sentinel Event Alert.

The Samaritan (2018). Retrieved on May 29th, 2018 from samaritansnyc.org/know-the-warning-signs/

Kulas, J. and Rosenheck, R. (2018). A comparison of veterans with post-traumatic stress disorder, with mild traumatic brain injury and with both disorders: understanding multimorbidity. Military Medicine, 183 (3.4), e114-e122.

Mental Health Effects of Serving in Afghanistan and Iraq. (August 13, 2015). 

Mental Health (April 2, 2018).

Mental Health Clinical Practice Guidelines 

Miles, S., Harik, J., Hunt, N., Mignogna, J., Pastorek, N, Thompson, K., et al. (2017). Delivery of mental health to combat veterans with psychiatric diagnoses and TBI histories. PLoS ONE 12 (9), e0814265. 

Military OneSource (January 3, 2018), Understanding and dealing with combat stress and PTSD

Military Health History Pocket Card for Health Professions Trainees and Clinicians. (April 2017).

National Action Alliance for Suicide Prevention, (2012). National Strategy for Suicide Prevention: Goals and Objectives for Action: A Report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention. Washington (DC): US Department of Health & Human Services (US). Retrievedfrom https://www.ncbi.nlm.nih.gov/books/NBK109906/

National Alliance on Mental Illness, (August 2017). Depression

National Alliance on Mental Illness, (2018). Veterans and Active Duty: Mental Health Concerns

National Center for PTSD (February 22, 2018), PTSD and DSM-5

National Center for PTSD (May 11, 2017). PTSD Checklist for DSM-5 (PCL-5).
National Center for PTSD. (August 18, 2017). Treatment of PTSD. Retrievedfrom https://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp

Patel, B. (2015). Caregivers of Veterans with “Invisible” Injuries: What We Know and Implications for Social Work Practice. Social Work 60 (1), 9-17.

Rossiter, A., Dumas, M, Wilmoth, and Patrician, P. (2016). “I serve 2”: meeting the needs of military children in civilian practice. Nursing Outlook 64 (6), 485-490. 

Substance Abuse and Mental Health Services Administration. (September 15, 2017). Veterans and Military Families. 

Treatment of PTSD. (August 18, 2017).

U. S. Department of Veterans Affairs. (2016). Suicide Prevention Fact Sheets: New VA Statistics.

U. S. Department of Veterans Affairs. (June 3, 2015). Suicide Prevention

Uniformed Services University of the Health Sciences Center for Deployment Psychology (2015).  Military Culture Course Modules.

Veterans Crisis Line. (n d).

Westphal, R, and Convoy, S. (2015). Military culture implications for mental health and nursing care.Online Journal of Issues in Nursing, 20(1), 47-54. 


Notice for nurses licensed in Washington state: This course is not currently approved by the Washington Department of Health, with an application pending. If you would like a notification when this course is approved please email [email protected] 



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