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]
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
- List evidence-based suicide treatment and management
- Describe an evidence-based assessment tool 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
- Discuss the role of nursing in suicide assessment and prevention measures
- Outline case management ethical principles of professional code of conduct for nurse managers
Suicide is the 10th leading cause of death in the United States (U.S). Approximately 123 people die by suicide daily and each year 45,000 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 based on race, gender, or age; however, there are statistics that provide demographic information to help identify vulnerable populations. In 2016, the highest suicide rate was 19.72 per 100,000 people between 45 and 54 years of 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).
The reported suicide rate in the U.S. in 2016 was highest among Caucasians (15.17 per 100,000 people) followed by Native Americans and Alaska Natives (13.37 per 100,000 people). Other demographic groups reported significantly lower rates, such as Asian Americans and Pacific Islanders (6.62 per 100,000 people) and African Americans (6.03 per 100,000 people). 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).
It is difficult to estimate the 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 and Prevention (CDC) attempts to collect data from both hospitals and national surveys on non-fatal injuries from self-harm. The primary limitation in the data is that it is not able to distinguish between intentional and accidental self-harm behaviors. The results from 2015 indicated that 505,507 people visited a hospital for injuries due to self-harm (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 1.2 times more frequent suicide attempts as compared to males (American Foundation for Suicide Prevention, 2018).
The Youth Risk Behaviors Survey conducted nationally 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%). 11.3% of adolescents of Hispanic origin reported suicide attempts compared with just 6.8% of white adolescents. Amongst female students, Hispanic females reported suicide attempts at a rate of 15.1% compared to just 9.8% of white females (American Foundation for Suicide Prevention, 2018).
A survey looking at suicide statistics within Washington state (Action Alliance for Suicide Prevention) conducted in 2018 found the suicide rate from 2012-2106 was 14.6 per 100,000. Within the rural urban community areas (RUCA) rates of suicide were 14.6 per 100,000 in urban core areas, 18.1 per 100,000 people in suburban areas, 13.9 per 100,000 people in large rural towns and 20 per 100,000 people in isolated rural areas. The racial/ethnic breakdown reported was as follows: 26.6% amongst Native Americans/Alaskan Natives, 16.9% amongst Caucasians, 11.6% amongst people who identified as multiracial, 9.6% amongst Native Hawaiians/Pacific Islanders, 9.1% amongst African Americans, 7.9% amongst Asian Americans, and 6.5% amongst Hispanic Americans (Action Alliance for Suicide Prevention, 2018).
The statistical data on suicide and suicide attempts varies based on demographic characteristics and thus reinforces the importance of being 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.
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 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 warning signs 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 are indications that someone is at higher risk for suicide. These may include issues related to a person’s background, history, environment and/or circumstances that increase the risk potential or likelihood of suicidal behavior. Some risk factors 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 are key behaviors, environments and relationships that enhance resilience and reduce the likelihood that someone will attempt suicide. Some protective factors for suicide 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. The risk factors can also be broken down into environmental factors, 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.
- Mental health conditions;
- Substance Abuse Problems
- Bipolar disorder
- Personality traits of aggression, mood changes and poor relationships
- Conduct disorder
- Anxiety disorders
- Serious physical health conditions including pain;
- Traumatic brain injury (TBI).
- 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% of service members returning from Iraq or Afghanistan have post-traumatic stress disorder or depression, and 19.5% reported sustaining a TBI during their deployment. According to SAMHSA only an estimated 50% of service members returning from Iraq and Afghanistan who need mental health services actually seek them.
A question regarding current or previous military service should be a key component of any nursing assessment. 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 (PTSD) ,depression, and suicidality. In addition, the veteran needs to be given information about applying for benefits from the Veterans Administration (VA).
Veterans or current military members may seek care at a Military Treatment Facility (MTF) or a VA Medical Center or Clinic. However, nurses who work in civilian environments such as community hospitals, clinics, and primary care practice settings also need to be prepared to care for military members and veterans. Military members may seek mental health care in the civilian sector due to the perceived stigma of seeking mental health services. Concerns over perceptions of weakness or potential impact on their promotion to the next rank, and therefore their military career, may cause current military members to seek mental health care in the civilian sector instead. 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 VA Medical Center or 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.
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?
Suicide 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 members of the military, veterans 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 their 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, with associated changes in schools, along with stress or anxiety related to deployment(s) of one or both active duty parents. 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 may assist veterans with applying for VA benefits, transportation to appointments, activities of daily living and/or medication management. SAMHSA, the federal agency that supports mental health care, 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
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
- 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 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 enjoyable things each day
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
- 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
- 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 20 item checklist is used to screen individuals for PTSD. According to the American Psychiatric Association (APA), the gold standard for diagnosing PTSD is a structured clinical interview by a mental health provider (such as a psychiatric mental health nurse practitioner).
The National Center for PTSD (2017) recommends either a trauma focused psychotherapy and/or medication. 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 is 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
According to the National Alliance on Mental Health there are three primary mental health disorders that veterans may experience related to their military service: PTSD, depression, and traumatic brain injury (TBI). Westphal and Convoy’s (2015) article discusses the stresses associated with military service and deployments. TBI and 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 diagnosed with mild TBI, PTSD, or both disorders. They concluded that PTSD plays 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.
The National Alliance on Mental Illness defines a depressive disorder as an episode lasting longer than two weeks. A depressive episode significantly interferes with a person’s ability to function daily. Depression can be triggered by a life crisis such as a trauma. Trauma experienced by a veteran could include: combat, injury, natural disasters, or military sexual trauma. Exposure to trauma can alter the body’s response to fear and stress which may lead to depression. Life changes including the 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. 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 depressive 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
- 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% of all deaths from suicide among adults in the United States in 2014. In 2010, veterans accounted for 22% of all deaths from suicide. Approximately 66% of all veteran deaths from suicide were the result of firearm injuries. After adjusting for differences in age, the risk for suicide was 18% 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 risk 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
Evidence-Based DepressionTreatment and Management
Treatment for depression may include counseling, therapy, Complementary and Alternative Medicine (CAM) and/or medication. The most effective treatment for depression combines psychotherapy with antidepressant medication.
Psychotherapy for depression may include:
Cognitive Behavioral Therapy (CBT): There is a strong evidence-base that supports the use of 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 CBT.
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.
Complementary and Alternative Medicine (CAM):
CAM treatments can be used as an adjunct to other evidence-based treatments for depression. When CAM interventions are combined with more evidence-based treatment options, such as prescribed medications and psychotherapy, they can contribute to the overall treatment plan for depression. While herbal and complementary medicines may show some effectiveness, herbal and vitamin supplements are not regulated by the Food and Drug Administration (FDA). Complementary treatments which have an evidence-base, indicating that they 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). Patients who are taking St John’s Wort for depression need to tell their medical providers, as there are substantial risks associated with combining St John’s Wort with prescribed SSRIs.
CAM treatments can also have significant adverse effects and drug interactions despite being sold over the counter without a prescription.
Antidepressant medications are the pharmacological treatment of choice for depression. The aim of medication therapy for depression is to help to reduce or control symptoms of depression. The bulk of medications currently FDA-approved for the treatment of depression target the three neurotransmitters traditionally associated with depression: serotonin, norepinephrine, and dopamine. Symptoms such as sleep, appetite, and concentration often improve before mood. Most need to be tapered up slowly when starting and down when stopping. 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. While mild to moderate depression can often be treated with therapy alone (CBT, IPT, etc.), moderate to severe cases of depression often require the addition of medication (WHO, 2018). In 2004, the FDA asked manufacturers to add a black box warning to the labeling of all antidepressant medications. This labeling warns about the increased risk of suicidal thinking or suicidal behavior in children and adolescents taking antidepressants during initial treatment (typically during the first few weeks) and with dose increases. In 2007, FDA requested that the warning be extended to include young adults through age 24 (FDA, 2017).
According to the World Health Organization (WHO), as many as 300 million people worldwide are affected by depression, women more than men. It leads to significant amounts of disability in adult patients and is characterized by a period of at least two weeks of sadness, loss of interest or pleasure, guilt, low self-worth, disturbed sleep, poor appetite, tiredness, and/or poor concentration. When it is severe, depression can lead to suicide (WHO, 2018). Depression has a variety of causes such as genetics, environmental, psychological and biochemical. It can be persistent (also called dysthymia, lasting at least two years), postpartum (extreme sadness, anxiety, and exhaustion after giving birth), psychotic (with delusions or hallucinations), seasonal (symptoms appear during the winter months when there is less natural sunlight and is accompanied by increased sleep, weight gain, and social withdrawal), or bipolar (a separate disorder, but which includes periods of depression). Disruptive mood dysregulation disorder, which can be diagnosed in children and adolescents, and premenstrual dysphoric disorder, seen as a hormonal depression in women, are depressive disorders newly added to the DSM-5. Depression can occur in children and adolescents, but is most common in adults, and often presents as irritability or anxiety in children. Risk factors for depression include personal or family history, major life change/stress/trauma, and certain physical illnesses or medications (such as diabetes, cancer, heart disease, and Parkinson’s) (NIMH, 2018). A previously accepted theory that depression stems from a chemical imbalance in the brain regarding the monoamines serotonin, norepinephrine, and dopamine has shifted in the last 15 to 20 years. Theories regarding alterations in brain architecture and complex circuitry have led researchers to question if the neurotransmitters are not simply a messenger of information or a symptom as opposed to the cause itself. Advancements in the fields of genetics and functional neuroimaging have opened new and exciting investigational possibilities and altered the way depression is viewed in the last 20 years, hopefully leading to changes in treatment down the road (Goldberg, 2018). Cannabinoids may be a possibility for future further study, but at this time there exists only very low-quality evidence which suggests no benefit from the use of nabiximols* (a purified natural combination of equal parts Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) in an oromucosal spray) in the treatment of depression (Whiting, et al., 2015).
Selective serotonin reuptake inhibitors (SSRIs) are usually the safest initial choice and cause the least side effects. This includes medications such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox CR), paroxetine (Paxil), and sertraline (Zoloft). Serotonin-norepinephrine reuptake inhibitors (SNRIs) include duloxetine (Cymbalta), venlafaxine (Effexor), desvenlafaxine (Pristiq), and levomilnacipran (Fetzima) (Mayo Clinic, 2018). Tricyclics (TCA) and tetracyclics, which is an older class of medications including clomipramine, nortriptyline, imipramine and amitriptyline, inhibit norepinephrine and serotonin reuptake but with significantly more adverse effects (sedation, weight gain, anticholinergic effects, hypotension, cardiac effects and even seizures) (Mayo Clinic, 2016). Mirtazapine (Remeron) is an atypical tetracyclic antidepressant that antagonizes alpha-2 adrenergic and serotonin receptors. Monoamine oxidase inhibitors (MAOIs) such as tranylcypromine (Parnate), phenelzine (Nardil), isocarboxazid (Marplan), and selegiline (Emsam) are rarely used except when other medications have failed due to serious adverse effects, drug interactions, and even dangerous food interactions. There are also a few uncategorized atypical antidepressants. Bupropion (Wellbutrin), as previously mentioned, blocks the reuptake of norepinephrine and dopamine and can be used for depression as well as seasonal affective disorder and smoking cessation (NIMH, 2016). Vortioxetine (Trintellix) is also a newer medication for depression which works by inhibiting serotonin reuptake, but also as a mixed antagonist/agonist of specific serotonin receptors. Vilazodone (Viibryd) also acts as a selective serotonin reuptake inhibitor, as well as a partial serotonin receptor agonist. Trazodone antagonizes serotonin and alpha-1 adrenergic receptors and blocks the reuptake of serotonin. Similarly, nefazodone antagonizes serotonin receptors, as well as blocking the reuptake of norepinephrine and serotonin (Mayo Clinic, 2018). In general, antidepressants should not be abruptly stopped as this can cause withdrawal as well as a return of depression symptoms. The most common adverse effects seen with antidepressants include nausea/vomiting, weight gain, diarrhea, sleepiness, and sexual dysfunction. A drug interaction with other medications that increase serotonin levels, such as triptans used to treat migraines, can cause a condition called serotonin syndrome (agitation, hallucinations, high temperature, severe blood pressure changes). In women of childbearing age, they should be warned that most antidepressants were pregnancy category C (risk cannot be ruled out) with the exception of paroxetine (category D) and bupropion (category B), with slight variations between the medications’ safety in lactating mothers (NIMH, 2016). In 2011 the FDA issued a Drug Safety Communication (DSC) stating that citalopram should no longer be used at doses greater than 40 mg per day because it could cause potentially dangerous abnormalities in the electrical activity of the heart. Citalopram use at any dose is discouraged in patients with with underlying heart conditions and those who are predisposed to having low levels of potassium and magnesium in the blood. Because it may be important for some of these patients to continue to use citalopram, the drug label has been changed to describe the particular caution that needs to be taken when citalopram is used in such patients. The revised drug label also describes lower doses that should be used in patients over 60 years of age. Citalopram can cause changes in the electrical activity of the heart (specifically, prolongation of the QT interval of the electrocardiogram [ECG]) and lead to a risk of an abnormal heart rhythm called Torsade de Pointes, which can be fatal. The citalopram drug label was revised on August 12, 2011 and again on March 27, 2012, to include new warnings about the potential for QT interval prolongation and Torsade de Pointes, as well as new drug dosage and usage recommendations (FDA, 2017).
A published systematic review and network meta-analysis published in Lancet in 2018 reviewed 522 double-blind randomized controlled trials, involving 116,477 patients diagnosed with major depressive disorder (MDD) and 21 different antidepressants. Unfortunately, this analysis only recorded outcomes on or around 8 weeks, which is a rather short period of time, especially for such long-acting medications, and included 426 of 522 (81%) trials that were deemed by the authors to be moderate or high risk of bias. Despite these limitations/shortcomings, the results showed all antidepressants were more effective than placebo. Agomelatine*∗, amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine were among the most effective, while fluoxetine, fluvoxamine, reboxetine*, and trazodone were among the least effective. Agomelatine* is a novel antidepressant which acts as a melatonin agonist and serotonin antagonist. It has been marketed in Europe since 2009 and in Australia since 2010. Regarding tolerability, agomelatine*, citalopram, escitalopram, fluoxetine, sertraline, and vortioxetine had the lowest dropout rates, while amitriptyline, clomipramine, duloxetine, fluvoxamine, reboxetine*, trazodone, and venlafaxine had the highest dropout rates. Overall, when evaluating effectiveness as well as tolerability, the best options for the treatment of depression appear to agomelatine* and escitalopram and the worst options appear to be fluvoxamine, reboxetine*, and trazodone (Cipriani et al, 2018).
Treatment Options for Resistant Depression
Patients with major depressive disorder who, despite trying at least two antidepressant treatments given at adequate doses for an adequate duration in the current episode, have not responded to treatment are considered to have treatment-resistant depression. Ketamine (Ketalar) is an N-methyl-D-aspart antagonist that was approved by the FDA in 1970 as a dissociative anesthetic. It was also used in the military battlefield situations. Later, the drug became used as a “club drug” and a dissociative agent. Recently, it’s been used clinically for post-operative pain and treatment-resistant depression (TRD). It has shown efficacy for specific symptom clusters in depression, including anhedonia (inability to feel pleasure) and suicidality (Nicholas & Bishop, 2016).
Several small randomized, double-blind, placebo-controlled trials looking at TRD found an antidepressant effect after a single ketamine dose of 0.5 mg/kg. The response rate (defined as a 50% reduction in symptoms at 24 hours) is reported to be between 50%-71% with signification improvements noted in some patients at about 40 minutes. These effects peak at 24 hours, last ≥ 72 hours in about half of the patients but return to baseline over 1 to 2 weeks. The most common post-infusion adverse effects include dizziness, dissociation, blurred vision, nausea and poor concentration. Transient symptoms include a small but significant increase in blood pressure after the infusion, hallucinations, abnormal sensations, and confusion. (Nicholas & Bishop, 2016).
Use of repeated doses of ketamine has also been studied, although larger and extended-duration studies are lacking. Two studies (N=10) looked at trice and twice weekly infusions of 0.5mg/kg for 2 weeks (with 6 and 4 doses respectively). The findings showed with trice weekly dosing, 79% to 90% of patients showed symptomatic response overall and 25% to 100% of patients saw improvement after the first dose. Of the 20 patients who responded, 65% were still reporting improved symptoms 2 weeks after the last infusion and 40% showed response for ≥ 28 days. With twice weekly dosing, the response rate was 80% in 10 patients, while 5 patients (50%) achieved remission, lasting at least 28 days in 2 patients. A study by the Canadian Agency for Drugs and Technologies in Health also conducted an appraisal of ketamine for treating a variety of mental illnesses. It found that despite evidence in acute studies, the role of ketamine in clinical practice is unclear and further comparative studies as well as longer term studies are needed. Lastly, the APA Council of Research Task Force on Novel Biomarkers and Treatments conducted a systematic review and meta-analysis which concluded that ketamine produces a transient and robust effect. They warn that although results are promising, “enthusiasm should be tempered” and suggest that “its use in the clinical setting warrants caution” (Nicholas & Bishop, 2016).
Most recently in 2019, The FDA approved esketamine (sold under the brand names Spravato and Ketanest among others) nasal spray, in conjunction with an oral antidepressant, for the treatment of TRD in adults. Esketamine is the s-enantiomer of ketamine. Ketamine is a mixture of two enantiomers (mirror image molecules). This is the first FDA approval of esketamine for any use. Because of the risk of serious adverse outcomes resulting from sedation and dissociation caused by Spravato administration, and the potential for abuse and misuse of the drug, it is only available through a restricted distribution system, under a Risk Evaluation and Mitigation Strategy (REMS). The Spravato labeling has a black box warning that cautions that patients are at risk for sedation and difficulty with attention, judgment and thinking (dissociation), abuse and misuse, and suicidal thoughts and behaviors after administration of the drug. Because of these risks, patients must be monitored by a health care provider for at least two hours after receiving their Spravato dose. The REMS requires the prescriber and the patient to both sign a Patient Enrollment Form that clearly states that the patient understands they should make arrangements to safely leave the health care setting to get home and that the patient should not drive or use heavy machinery for the rest of the day on which they receive the drug. Additionally, Spravato must be dispensed with a patient Medication Guide that outlines the drug’s uses and risks. The patient self-administers Spravato nasal spray under the supervision of a health care provider in a certified doctor’s office or clinic, and the spray cannot be taken home. The health care provider should teach the patient how to operate the nasal spray device. During and after each use of the nasal spray device, the health care provider will check the patient and determine when the patient is ready to leave. (FDA, 2019).
The efficacy of Spravato was evaluated in three short-term (four-week) clinical trials and one longer-term maintenance-of-effect trial. In the three short-term studies, patients were randomized to receive Spravato or a placebo nasal spray. In light of the serious nature of TRD and the need for patients to receive some form of treatment, all patients in these studies started a new oral antidepressant at the time of randomization and the new antidepressant was continued throughout the trials. The primary efficacy measure was the change from baseline on a scale used to assess the severity of depressive symptoms. In one of the short-term studies, Spravato nasal spray demonstrated statistically significant effect compared to placebo on the severity of depression, and some effect was seen within two days. The two other short-term trials did not meet the standard of significance. In the longer-term maintenance-of-effect trial, patients in stable remission or with stable response who continued treatment with Spravato plus an oral antidepressant experienced a statistically significantly longer time to relapse of depressive symptoms than patients on placebo nasal spray plus an oral antidepressant. (FDA, 2019).
The most common side effects experienced by patients treated with Spravato in the clinical trials were dissociation, dizziness, nausea, sedation, vertigo, decreased feeling or sensitivity (hypoesthesia), anxiety, lethargy, increased blood pressure, vomiting and feeling drunk. Patients with unstable or poorly controlled hypertension or pre-existing aneurysmal vascular disorders may be at increased risk for adverse cardiovascular or cerebrovascular effects. Spravato may impair attention, judgment, thinking, reaction speed and motor skills. Patients should not drive or operate machinery until the next day after a restful sleep. Spravato may cause fetal harm and women of reproductive potential should consider pregnancy planning and prevention; women should not breastfeed while being treated. (FDA, 2019).
A recent study on the pharmacological adverse effects of antidepressants in older adults showed that depression may be linked to memory problems. Twenty five percent of older adults suffer from depression. Researchers also discovered older people with greater symptoms of depression may have structural differences in the brain compared to people without symptoms. Treating depression reduces memory and thinking problems. The study involved 1,111 people averaging 71 years of age who were all stroke-free. The study participants were mostly Caribbean Hispanic. At the beginning of the study, all participants had brain scans, a psychological exam and memory and thinking skills assessments. Their memory and thinking skills were tested again an average of five years later.
As part of the psychological exam, participants reported how often in the past week they agreed with statements such as “I was bothered by things that usually don’t bother me” and “I did not feel like eating”. To be defined as at-risk for clinical depression, participants needed a score of 16 or higher on a test with a range of 0-60. At the start of the study, researchers found that 22% of participants had greater symptoms of depression. Researchers also found after adjusting for age, race, antidepressant medications and other variables, greater symptoms of depression were linked to worse episodic memory, which is a person’s ability to remember specific experiences and events. Memory scores for participants with greater symptoms of depression were lower by 0.21 of the standard deviation compared to those without symptoms. Researchers also found those with greater symptoms of depression had differences in the brain, including smaller brain volume as well as a 55% greater chance of small vascular lesions in the brain. Researchers found no evidence of a relationship between greater symptoms of depression and changes in thinking skills over five years. They also found small vascular lesions in the brain are markers of small vessel disease. Additionally the study found that depression and brain aging may occur simultaneously and greater symptoms of depression may affect brain health through small vessel disease (Nauert, R., 2018).
In addition, Medicare now pays for genetic testing of seniors via GeneSight. Seniors take a longer time to reap the effects of antidepressants. So far, 8,500 doctors in the United States are registered to offer the test. The test measures how different genes influence the way a person may react to 38 FDA-approved psychotropic medications on the market today. Within 36 hours, GeneSight gives doctors a color-coded report that puts each of the medications into one of three categories. Green means “use as directed,” yellow advises doctors to “exercise caution,” and red warns doctors to use “increased caution and frequent monitoring.” Next to each drug listed in the yellow and red categories are footnotes offering additional information about why the drug might not be the best choice for a particular patient. A normal dose of an antidepressant for most people can be too much for people with genes that cause the compound to be metabolized more slowly. On the other hand, a drug may not work well for someone with genes that cause the body to metabolize the compound very quickly. A person’s genetic makeup also can determine whether a drug is likely to cause side effects. (Nauert, R., 2018).
Antidepressants and the risk for suicidal thoughts
The risk for suicide may occur as a person is taking an antidepressant as previously they were too paralyzed by depression to make a suicide plan. When they are feeling better and have more energy, their suicide risk increases temporarily. For that reason, the risk for suicide goes up while the depression symptoms are going down or are lessened. That risk is well known by mental health specialists and can occur regardless of the type of treatment that a patient is receiving, or even if the person is feeling less depressed without treatment. (Courtet & Lopez-Castroman, 2017).
An increase in suicidal thoughts can also be seen in patients taking antidepressants for other conditions or indications. As antidepressants became more commonly prescribed for anxiety and obsessive-compulsive disorder, the reports of patients’ suicidal thoughts and actions became more worrisome to physicians and family members. If a depressed person on antidepressants becomes suicidal, that is worrisome. However, if someone who was not previously depressed and taking antidepressants for other reasons becomes suicidal, that raises additional questions about the safety of these medications. Researchers found evidence that individuals taking antidepressant medication may be at even higher risk of suicide than individuals whose depression is improving for other reasons. That controversy has not yet been completely resolved.
The additional risks of antidepressants first became clear in research on children, and in the fall of 2004, the FDA issued a warning that children and adolescents taking antidepressant medications might experience increased suicidal thoughts and behaviors. In June 2005, this warning was extended to include young adults up to age 25. These studies showed that children and adolescents taking antidepressants were almost twice as likely to have suicidal thoughts or to attempt suicide compared to placebo. The FDA required antidepressant drug manufacturers to add a black box warning to the label about the increased risk for children. The warning also says that children and adolescents taking SSRIs should be carefully watched for increased depression, suicidal thoughts or behaviors, or “unusual changes in behavior, such as sleeplessness, agitation, or withdrawal from normal social situations”. Placing a black box around a warning, similar to those for cigarettes, is the strongest type of warning about risks that the FDA requires.
Violent behavior can also occur as a result of antidepressant use. A 2015 Swedish study of their entire population ages 15 and older reported that 11,225 out of 856,493 (1.3%) teens and adults taking SSRIs were convicted of a violent crime compared to 40,384 out of 7.1 million individuals (0.6%) of the same age not taking SSRIs. The risk of being convicted of a violent crime was the highest among the youngest age group: 3.3% of SSRI patients between the ages of 15 and 24 years old were convicted of a violent crime. The vast majority, 2,169 or 77%, of these convictions were in males in that age group who were taking an SSRI. However, when individually evaluating five of the most commonly prescribed SSRIs (fluoxetine, citalopram, paroxetine, sertraline, and escitalopram), only sertraline (Zoloft) increased the risk of a violent crime conviction. Since there is no evidence that certain antidepressants are more dangerous than others for children, the FDA includes the same black box warning on all antidepressants given to children and adolescents.
A UK study published in 2015 that included more than 238,000 adults ages 20 to 64 years of age reported that patients taking mirtazapine, venlafaxine, or trazodone were much more likely to commit suicide or attempt suicide/self-harm compared to patients taking an SSRI. In contrast, a study of almost 300,000 adults ages 18 and older who started taking antidepressants between 1997 and 2005 found no meaningful difference in risk for suicide when comparing the different types of antidepressants.
It is hard to make sense of these contradictory findings for adults. However, since antidepressants like venlafaxine and mirtazapine are usually tried only when SSRIs are not effective, the people who take them may have depression that is more difficult to treat with medication. Therefore, the lack of success in treating depression with different medications may be the reason why those patients are at increased risk for suicidality.
There is growing evidence that many antidepressants and anti-psychotics can cause akathisia, a type of body restlessness and an urgent need to keep moving. Sometimes misdiagnosed as restless leg syndrome, akathisia has in some cases caused suicide, perhaps because the person feels out of control. Forms of akathisia include pacing back and forth, rocking uncontrollably while sitting in a chair, shuffling the feet while walking, crossing and uncrossing legs, general irritability and agitation.
Depression and Menopause
When menopausal women cannot or do not want to take estrogen to combat bothersome hot flashes and night sweats, antidepressants may be an effective alternative. Although estrogen has long been the gold standard for treating the hot flashes and night sweats of menopause, some women are unable or unwilling to use it because of the associated risks. Consequently, SSRI or SNRI antidepressants, particularly the SNRI venlafaxine (Effexor), are often prescribed as a treatment for these vasomotor symptoms. However, while SSRI and SNRI antidepressants have been found to be more effective than placebo in countering hot flashes and night sweats, their effectiveness compared with estrogen had not been studied. Hadine Joffe, M.D., an associate professor of psychiatry at Harvard Medical School, and her colleagues conducted a study to compare the two types of medications, using venlafaxine (Effexor) as the test antidepressant. As reported in JAMA Internal Medicine, both estrogen and venlafaxine (Effexor) were significantly more effective than a placebo, but estrogen was slightly more effective than venlafaxine (Effexor). A total of 339 perimenopausal and postmenopausal women with at least two bothersome vasomotor symptoms a day—on average, eight a day—took part in the study. The researchers excluded candidates who had experienced major depressive episodes within the previous year (Arehart-Treichel, 2014).
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. ECT can cause some significant side effects, including memory loss. Patients need to understand both the potential risks and benefits of ECT before beginning treatment.
- 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 yet been proven effective as maintenance therapy, but is FDA-approved for the treatment of MDD and OCD.
Evidence-Based Risk Assessment for Suicide
The National Guideline Clearing House 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/intent, suicide-related behavior, warning signs, risk factors, 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 above 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.
To assess for suicidal thoughts, the provider should 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 if thoughts are triggered only when individual is intoxicated)
- Understanding regarding the consequences of future potential actions.
To assess for suicidal intent, a provider should 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, means 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 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.
To assess for preparatory behavior, the provider should assess if the patient has begun to prepare 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 things such as:
- 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.
Providers should 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 attempts 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.
To assess for the need for immediate or urgent action, the provider should recognize precipitating emotions, thoughts, or behaviors that are most proximally associated with a suicidal act and reflect high risk. Assess for warning signs that indicate likelihood of suicidal behaviors in the near 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.
Assess for risk factors that are known to be associated with suicide and protective factors 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:
- Inquire about changes in the patient's life and be aware of other indicators of change (retirement physical, overseas duty screening, etc.)
- Be willing to discuss and consider methods to strengthen social support during the transition time if there are other risk factors present.
An Evidence-based Assessment Tool for Suicide Risks, Suicidal Thoughts, and Suicidal Intent
The Suicide assessment five-step evaluation and triage (SAFE-T) model in combination with the Columbia Suicide Severity Rating Scale (C-SSRS) Recent, is an evidence-based screening tool that assesses suicide risks, thoughts and intent. The tool provides healthcare professionals with a framework to be able to assess for suicide risk and take appropriate action for different levels of risk. See attached for the full tool (Columbia Lighthouse Project, 2011).
Nurses play an important role in the assessment and prevention of suicide in a variety of healthcare settings such as inpatient psychiatric centers, acute care units, emergency departments, ambulatory care centers, and in the community. Furthermore, nurses are instrumental members of the healthcare team that work with patients at risk. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 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). They recommend 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 (JCAHO, 2016).
For 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.
For 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.
For patients with suicidal 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 contact information for 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 to lethal means. Start by assessing patient access to firearms or other lethal means, such as prescription medications and chemicals, and then discuss ways of removing or locking up firearms, other weapons, and medications 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 including:
- Cognitive Behavioral 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 (JCAHO, 2016).
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.
Case management principles of professional code of conduct for nurse managers
Although mental health staff including nurses are responsible for the evaluation and treatment of suicidal clients, survivors may also reach out to case managers for help during times of crisis. It’s important for case managers to also be prepared to identify risk factors, protective factors, and become familiar with basic suicide intervention skills. The newly revised Code of Professional Conduct from the Commission for Case Manager Certification (CCMC) provides a framework for ethical, high-quality care. The code contains 8 principles of professional conduct for case managers. Review how the code can be utilized from a board-certified case managers (CCM) role in the assessment and treatment of suicidal patients and significant others.
Case Mangers Example
1: CCM will place the public interest above their own at all times
Advocates for the clients and survivors and family interests above themselves and employer.
2: CCM will respect the rights and inherent dignity of all of their clients
Advocating for clients and family may require looking for alternatives that are not in conflict with the parties while respecting the dignity of all. This is especially true when there is a loss of life.
3: CCM will always maintain objectivity in their relationships with clients
Maintain a professional relationship to keep objectivity in place without becoming personal with clients and family. It’s important for CCM to remain objective and to not allow personal feelings to take over for professional empathy.
4: CCM will act with integrity and fidelity with clients and others
Recognize biases or conflicts of interest and to have the goal of remaining objective. It’s important for the CCM to recognize their viewpoints on suicide and to not transfer their beliefs onto others.
5: CCM will maintain their competency at a level that ensures their clients will receive the highest quality of service
Maintain awareness of the laws at the local, state and federal level that help with patient privacy and security. The CCM shall be knowledgeable about the laws surrounding death and suicide and know to whom to refer the family and survivors.
6: CCM will obey and honor the integrity of the CCM designation and adhere to the requirements for its use
The code provides a foundation and it is up to the CCM to honor and adhere to the requirements. The CCM follows the integrity of the code and is a role model for nursing and other staff regarding suicide and prevention.
7: CCM will obey all laws and regulations
Maintain currency with all laws and regulations and assure compliance. CCMs should remain current with laws so they can be advocates for change and take an active role in the policies that affect change in suicide and prevention programs and education.
8: CCM will help maintain the integrity of the Code, by responding to requests for public comments to practice review and revise the code, thus helping ensure its consistency with current practice
The code sets a baseline expectation for the public to be aware of standards. It also allows for feedback and for revisions of the code, thus ensuring it’s consistency with current practice. CCMs should encourage comments and feedback in order to help make improvements with the code and practice relating to suicide and prevention.
- Call the U.S. National SuicidePrevention Lifeline at 800–273–TALK/8255; and
- Adapted from Recommendations for Reporting on Suicide website (www.reportingonsuicide.org.)
- 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
- Lock it up. Promoting the Safe Storage of Fire Arms. For more information: https://www.kingcounty.gov/depts/health/violence-injury-prevention/violence-prevention/gun-violence/LOCK-IT-UP.aspx.
- 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
- Safe Home Coalition. Creating Safe Homes and Communities. http://makeitasafehome.org/
- 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
- Myth: Asking about suicide will plant the idea in a person’s head.
- Reality: Asking 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.
- Myth: There are talkers and there are doers.
- Reality: Most 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.
- Myth: If somebody really wants to die by suicide, there is nothing you can do about it.
- Reality: Most 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.
- Myth: He/she really wouldn't commit suicide because…
- he just made plans for a vacation
- she has young children at home
- he made a verbal or written promise
- she knows how dearly her family loves her
- Reality: 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.
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, has unique circumstances and risk factors.
Case Scenario #1
Sandy is a 15-year-old girl who lives in the Midwest. Her parents recently divorced, which forced her to move to a new community of 3,000 people. She hates the small-town atmosphere and hasn't made any new friends. Her sister Tiffany, her 'only' friend, is going away to college in the fall, which is making her feel even worse. Sandy is having trouble sleeping, her grades are falling, and she is crying almost every day. She tried to tell her dad and new stepmom that she is 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 signs for suicide did Sandy exhibit?
Assessment of warning signs indicates:
- Trouble sleeping
- Falling grades
- Crying daily
- Feeling isolated
- Giving away a prized possession
Assessment of risk factors indicates:
- Social isolation due to moving and loss of previous friends/support system
- Loss of a parent through divorce
- Problems tied to relationships and the move to the small town
Assessment of Sandy’s risk for suicide in the 3 domains: suicidal thoughts, suicidal intent and behavior
- Suicidal thoughts: Ask if she has thoughts of suicide and to describe them: She said she has no thoughts of suicide
- Suicidal intent: Ask if she has or ever had thoughts or wishes to die, means to kill herself, and if she understands the probable consequences of intent to die. Assess her risk for impulsivity related to coping strategies. She said she doesn’t wish to die, but she has thought of it in the past.
- Suicidal behavior: Ask her for past or present evidence that she wants to die, means to kill herself and understands the probable consequences of her actions. Inquire about her means for attaining lethal means. She said she doesn’t have means or intent.
Safety Planning for Sandy: Urgent/Immediate Action: Lower risk for suicide.
Provide her and her family 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 and family to make the appointment.
Recognizing her emotions, thoughts and behaviors that are most associated with a suicidal act listed in the assessment helps to guide a safety plan. Supportive third parties should be aware of the safety plan.
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 is sinking lower and lower and thinking that it is not going to get any better. She told her mom that she accidentally threw away her prescription antidepressant drugs and needed a new bottle, so 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.
Assessment of warning signs indicates:
- Engaging in self destructive risky sexual behavior
- Increased use of alcohol and marijuana
- Saying she’s going away
- Engaging in self destructive behavior: unprotected sex
- Verbalizing wanting to die “Life wasn’t worth living”
- Skipping classes in school
Assessment of risk factors indicates:
- History of mood disorder: Depression
- History of alcohol and marijuana use
- Relationship challenges: Spending time with friends that are drinking, doing drugs and having unprotected sex
Assessment of environmental factors indicates:
- Access to lethal means: Tricking her mom about mistakenly throwing away her medication is a risk factor for medication overdose and intent for self-harm.
- Prolonged stress: She felt she never fit in with other kids (feelings of rejection)
Assessment of Debbie’s risk for suicide in the 3 domains: suicidal thought, suicidal intent and behavior
- Suicidal thoughts: Ask if she has thoughts of suicide and to describe them: She said she has thoughts of dying.
- Suicidal intent: Ask if she has or ever had thoughts or wishes to die, means to kill herself, and if she understands the probable consequences of intent to die. Assess her risk for impulsivity related to coping strategies. She said she could easily take too many pills and end her life.
- Suicidal behavior: Ask her for past or present evidence that she wants to die, means to kill herself and understands the probable consequences of her actions. She has the extra medications and said she will take all of them when the time is right.
Safety Planning for Debbie: Initiate an immediate Safety plan for suicidal crisis
Her plan should include interventions aimed at patients with suicidal ideation. Give her and her family the number to the National Suicide Prevention Life Line as well as to local crisis and peer support contacts. In addition, the healthcare team should provide evidence-based clinical approaches and interventions to reduce suicidal thoughts and behaviors listed previously (CBST, CAMS, DBT and Caring Contacts).
Case Scenario # 3
Larry is an 85-year-old 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?
Assessment of warning signs indicates:
- Feelings of hopelessness: Stopped socializing and life is not worth living without his wife
- Withdrawal from friends and community: He’s stopped attending church and club meetings and stopped talking and socializing with neighbors.
- Loss of interest in things: He’s lost interest in things he used to do
Assessment of risk factors indicates:
Assessment of Larry’s risk for suicide in the 3 domains: suicidal thought, suicidal intent and behavior
- Suicidal thoughts: Ask if he has thoughts of suicide and to describe them: He states he’s feeling sad and doesn’t want to talk to anyone.
- Suicidal intent: Ask if him if he has or ever had thoughts or wishes to die, means to kill himself, and if he understands the probable consequences of intent to die. Assess his risk for impulsivity related to coping strategies. He said he never wants to kill himself, but he misses his wife so much and he’s not sure how to get through this.
- Suicidal behavior: Ask him for past or present evidence that he wants to die, means to kill himself and understands the probable consequences of his actions. Inquire about his means for attaining lethal means. He owns a gun, but it’s locked up and he uses it to hunt. He said he’s not thinking of killing himself.
Safety Planning for Larry: Urgent/Immediate Action: Lower risk for suicide.
Larry is grieving the loss of his wife and he may be also suffering from depression. Provide him and his family 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 and family to make the appointment.
American Foundation for Suicide Prevention. (2018). 2018 Annual Report. Retrieved from https://annual2018.afsp.org/.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders. DSM-5 (5th Edition). Washington, DC.
Assessments and Management of Risk for Suicide Working Group. (2013). VA/DOD clinical guidelines for assessment and management of patients at risk for suicide. Washington (DC). Department of Veterans Affairs. Department of Defense, 190 p. Retrieved from https://www.healthquality.va.gov/guidelines/MH/srb/VADODCP_SuicideRisk_Full.pdf.
Bolster, C. Holiday, C. Oneal, G., Shaw, M. (January 31, 2015). “Suicide Assessment and Nurses: What Does the Evidence How?” OJN: The Online Journal of Issues in Nursing VOL 20, No. 1, Manuscript 2. Retrieved from https://www.scirp.org/(S(351jmbntvnsjt1aadkposzje))/reference/ReferencesPapers.aspx?ReferenceID=1970575.
Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., . . . Geddes, J. R. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. The Lancet,391(10128), 1357-1366. doi:10.1016/s0140-6736(17)32802-7
Cipriano, P. (2014). A powerful question have you ever served in the military? American Nurse Today, 9 (3). Retrieved from https://www.americannursetoday.com/a-powerful-question-have-you-ever-served-in-the-military/
Columbia Lighthouse Project. (2011). SAFE-T with C-SSRS. Retrieved March, 2019, from http://cssrs.columbia.edu/documents/safe-t-c-ssrs/
Commission for Case Manager Certification (2015). Foundational principles Newly revised Code of Professional Conduct provides a framework for ethical, high-quality care. Retrieved from https://ccmcertification.org/sites/default/files/issue_brief_pdfs/23_-_updated_code_of_conduct.pdf.
Ganzer, C. (2016). Veteran Women: Mental Health Related Consequences of Military Service. American Journal of Nursing, 116 (11), 32-39. Retrieved from https://journals.lww.com/ajnonline/Abstract/2016/11000/CE___Veteran_Women_Mental_Health_Related.27.aspx.
Goldberg, J. F. (2018). The Psychopharmacology of Depression: Strategies, Formulations, and Future Implications. Psychiatric Times,35(7), 9-14. Retrieved from http://www.psychiatrictimes.com/depression/psychopharmacology-depression-strategies-formulations-and-future-implications
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. Retrieved from https://www.semanticscholar.org/paper/A-Comparison-of-Veterans-with-Post-traumatic-Stress-Kulas-Rosenheck/32d5ce6953e5d86e6e2fe30544ee2e98e7cd9eff
Levin, M., Jury, N. Mosheni, K. Srinivasan, V. (2018) Do Antidepressants Increase Suicide Attempts? National Center for Healthcare Research (2018). Retrieved from http://www.center4research.org/antidepressants-increase-suicide-attempts-risks/.
Mayo Clinic. (2018, February 03). Depression (major depressive disorder). Retrieved from https://www.mayoclinic.org/diseases-conditions/depression/diagnosis-treatment/drc-20356013.
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. Retrieved from https://paperity.org/p/81492025/delivery-of-mental-health-treatment-to-combat-veterans-with-psychiatric-diagnoses-and-tbi
Military.com. Combat Stress or PTSD? How to Know the Difference. Retrieved from https://www.military.com/spouse/military-life/wounded-warriors/combat-stress-symptoms.html.
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). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK109906/
National Alliance on Mental Illness (August 2017). Depression. Retrieved from https://www.nami.org/Learn-More/Mental-Health-Conditions/Depression.
National Alliance on Mental Illness (2018). Veterans and Active Duty: Mental Health Concerns. Retrieved from https://www.nami.org/Find-Support/Veterans-and-Active-Duty.
National Center for PTSD. (February 22, 2018). PTSD and DSM-5. Retreived from https://www.nami.org/Find-Support/Veterans-and-Active-Duty.
National Center for PTSD (May 11, 2017). PTSD Checklist for DSM-5 (PCL-5).National Center for PTSD. (August 18, 2017). Treatment of PTSD. Retrieved from https://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp
Ndiaye, M. (2018). Action Alliance for Suicide Prevention. Retrieved from: http://www.intheforefront.org/wp-content/uploads/2017/09/ACTION-ALLIANCE-FOR-SUICIDE-PREVENTION.pdf.
Nicholas, S. and Bishop J. (2016). Current Psychiatry. Is the Evidence Compelling for Using Ketamine to Treat Drug Resistant Depression? Retrieved from: https://www.mdedge.com/psychiatry/article/108306/depression/evidence-compelling-using-ketamine-treat-resistant-depression.
Patel, B. (2015). Caregivers of Veterans with “Invisible” Injuries: What We Know and Implications for Social Work Practice. Social Work 60 (1), 9-17. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25643571.
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. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0029655416300744.
Substance Abuse and Mental Health Services Administration. (September 15, 2017). Veterans and Military Families Treatment of PTSD. Retrieved from https://www.samhsa.gov/smvf-ta-center.
The Joint Commission (2017). Sentinel Event Alert. Behavioral health care national patient safety goals. Retrieved from: https://www.jointcommission.org/sentinel_event_policy_and_procedures/.
The Samaritans (2018). Know the Warning Signs. Retrieved from https://samaritansnyc.org/know-the-warning-signs/.
U.S. Department of Veterans Affairs. Assessment and Management of Patients at Risk for Suicide (2013). Retrieved from https://www.healthquality.va.gov/guidelines/MH/srb/
U. S. Department of Veterans Affairs (2014). Mental Health Effects of Serving in Afghanistan and Iraq. Retrieved from http://www.ptsd.va.gov/public/PTSD-overview/reintegration/overview-mental-healtheffects.asp
US Department of Veteran Affairs. Military Health History Pocket Guide for Health Professions and Trainees and Clinicians. Retrieved from https://www.va.gov/OAA/pocketcard/.
US Food and Drug Administration. FDA approves new nasal spray medication for treatment- resistant depression; available only at a certified doctor’s office or clinic. Retrieved from https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm632761.htm
Uniformed Services University of the Health Sciences Center for Deployment Psychology Course Modules.gy (2015). Military Culture. Retrieved from https://deploymentpsych.org/military-culture
World Health Organization. (2018, April). Mental disorders. Retrieved October 10, 2018, Retrieved from http://www.who.int/en/news-room/fact-sheets/detail/mental-disorders.