2. Youtube sites to review
• Teen Depression & Suicide
• http://www.youtube.com/watch?v=CHynDpYv1Gw
• self harm, suicide, depression
• http://www.youtube.com/watch?v=tsf0qYdAkDs
3. Concepts of Suicide
• Suicide: act of intentionally ending one’s own life and opting for
nonexistence
• Suicide attempt
– Includes all willful, self-inflicted life-threatening attempts
that have not led to death
• Suicide ideation
– Person is thinking about self-harm
• Physician-assisted suicide (PAS)
– Movement supporting right of mentally competent adults to
humanely end their own suffering
– Strict guidelines apply, few jurisdictions legally sanction this
“right to die”
4. Cultural Considerations
Related to Suicide
• In U.S., European Americans have twice the rate of minority
groups
– Exception is Native Americans (rate equal to European
Americans)
• African Americans
– Men more than women; peak rate in adolescence/young adult
– Protective factors include family/religion
• Hispanic Americans
– Protective factor: Roman Catholic religion/family
• Asian Americans
– Rate increases with age. ---Protective factor: belief that
individual and society are interdependent
5. The Suicidal Client
• Approximately 30,000 persons
in the United States end their lives
each year by suicide.
• Suicide is the 3rd leading cause of death
among Americans 15 to 24 years of age
5th leading cause of death for ages 25 to 44
8th leading cause of death for ages 45 to 64
6. Risk Factors
• Marital status
– The suicide rate for single
persons is twice that of
married persons.
• Gender
– Women attempt suicide more often, but more men succeed.
– Men commonly choose more lethal methods than women.
• Age
– Risk of suicide increases with age, particularly among men.
– White men older than 80 years are at the greatest risk of all
age/gender/race groups.
7. • Religion
– Affiliation with a religious group decreases risk of suicide
• Socioeconomic status
– Individuals in the very highest and lowest social
classes have higher suicide rates than those in the middle
class.
• Ethnicity
– Whites are at highest risk for suicide, followed by Native
Americans, African Americans, Hispanic Americans,
and Asian Americans.
8. Psychiatric illness - Mood disorders are the most common
psychiatric illnesses that precede suicide. Other psychiatric
disorders that account for suicidal behavior include
* substance-related disorders
* schizophrenia
* personality disorders
* anxiety disorders
– Severe insomnia is associated with increased risk of suicide.
Use of alcohol and barbiturates
– Psychosis with command hallucinations
– Affliction with a chronic painful or disabling illness
– Family history of suicide
9. – Having attempted suicide previously
increases the risk of a subsequent attempt.
About half of those who ultimately commit
suicide have a history of a previous attempt.
– Loss of a loved one through death or
separation is a risk factor.
– Lack of employment or increased financial
burden increases the risk of suicide.
10. Psychological theories
• Psychological theories
– Anger turned inward
– Hopelessness
– Desperation and guilt
– History of aggression and violence
– Shame and humiliation
– Developmental stressors
11. • Sociological theory
– Durkheim’s three social categories of suicide
• Egoistic suicide
• Altruistic suicide
• Anomic suicide
• Biological theories
– Genetics
– Neurochemical factors
12. Nursing Process:
Assessment Guidelines
• Use suicide assessment tools (SAD Persons Scale)
• Recognize verbal clues
– Suicide threats need to be taken seriously, including overt and
covert statements
• Recognize behavioral clues
– Sudden changes: giving away possessions, writing farewell
notes, making one’s will/putting affairs in order
– Sudden improvement after being depressed/withdrawn
– Neglecting personal hygiene
13. Nursing Process:
Assessment Guidelines
• Always ask person suspected of being at risk, “Are you thinking
about killing yourself?”
• Assess precipitating events/risk and protective factors
• Assess suicide history (family/friends)
14. • Common nursing diagnoses
– Risk for suicide, Ineffective coping, Hopelessness,
Social isolation, Spiritual distress
• Outcomes identification
– Crisis intervention aimed at optimizing events and
environmental factors to minimize self-destructive
acts
– Specific goals: help explore alternatives to suicide,
increase coping skills, minimize social isolation
Nursing Process: Diagnosis and
Outcomes Identification
15.
16. Nursing Process:
Planning and Implementation
• Planning directed toward:
– Crisis intervention
– Long-term treatment of any co-occurring mental illness
• Implementation
– Lack of evidence to support any particular approach to suicide
prevention
– Protective factors: social supports, treatment for mental illness,
restricted access to means of suicide, cultural/religious beliefs,
learned skills for problem solving
17. Nursing Interventions for Crisis
Period
• Follow institutional protocol
– Suicide precautions
– Suicide observation
• Keep accurate records of patient behavior,
documenting activity q 15 minutes or as per
protocol
• Establish no suicide contract
• Encourage patient to discuss
feelings/problem-solving alternatives
18. Nursing Interventions Postcrisis
Period
• Arrange for patient to stay with family/friends; if no one
available, hospitalization
• Weapons/pills removed by family/friends
• Encourage patient to discuss feelings
• Encourage patient to avoid decisions during crisis
• Activate links to community supports (self-help groups)
• If medication used for anxiety/depression:
– 1-3 day supply only
– Monitored by family/significant other
19. Guidelines for Treatment of the Suicidal
Client on an Outpatient Basis
• Do not leave the person alone.
• Establish a no-suicide contract with the client.
• Enlist the help of family or friends.
• Schedule frequent appointments.
• Establish rapport and promote a trusting relationship.
• Do not leave the person alone.
• Establish a no-suicide contract with the client.
• Enlist the help of family or friends.
• Schedule frequent appointments.
• Establish rapport and promote a trusting relationship.
20. Information for Family and Friends of the
Suicidal Client
• Take any hint of suicide seriously.
• Do not keep secrets.
• Be a good listener.
• Express to the client feelings of personal worth.
• Know about suicide intervention resources.
• Restrict access to firearms or other means of self-
harm.
21. Interventions with Family and Friends
of Suicide Victims
• Encourage them to talk about the suicide.
• Discourage blaming and scapegoating.
• Listen to feelings of guilt and self-perception.
• Talk about personal relationships with the victim.
• Recognize differences in styles of grieving.
• Assist with development of adaptive coping
strategies.
• Identify resources that provide support.
22. FACTS AND FABLES ABOUT SUICIDE
Indicate with a T or F whether each of the following statements is true or false.
_____ 1. Suicide is an inherited trait.
_____ 2. Gunshot wounds are the leading cause of death among suicide victims.
_____ 3. Most people give clues and warnings about their suicidal intentions.
_____ 4. If a person has attempted suicide, he or she will not do it again.
_____ 5. Suicide is the act of a psychotic person.
_____ 6. Once a person is suicidal, he or she is suicidal forever.
_____ 7. Most suicides occur when the severe depression has started to improve.
_____ 8. Most suicidal people have ambivalent feelings about living and dying.
_____ 9. If a suicidal person is intent upon dying, he or she cannot be stopped.
_____ 10. People who talk about suicide don’t commit suicide.
Editor's Notes
A. Suicide is not a diagnosis or a disorder; it is a behavior.
B. Approximately 95 percent of all persons who commit or attempt suicide
have a diagnosed mental disorder.
II. Historical Perspectives
A. In ancient Greece, suicide was an offense against the state, and individuals
who committed suicide were denied burial in community sites.
B. In the culture of the imperial Roman army, individuals sometimes resorted to
suicide to escape humiliation or abuse.
C. In the Middle Ages, suicide was viewed as a selfish or criminal act.
D. During the Renaissance, the view became more philosophical, and
intellectuals could discuss suicide more freely.
E. Most philosophers of the 17th and 18th centuries condemned suicide, but
some individuals began to associate suicide with mental illness.
F. Suicide was illegal in England until 1961, and only in 1993 was it
decriminalized in Ireland.
G. Most religions consider suicide a sin against God.
III. Epidemiological Factors
A. Approximately 30,000 persons in the United States end their lives each year
by suicide.
B. Suicide is the third leading cause of death among young Americans ages 15
to 24 years, the fifth leading cause of death for people ages 25 to 44, and the
eighth leading cause of death for individuals 45 to 64 years of age.
III. Risk Factors
A. Marital Status
1. The suicide rate for single persons is twice that of married persons.
B. Gender
1. Women attempt suicide more often, but more men succeed.
2. Men commonly choose more lethal methods than women.
C. Age
1. Risk of suicide increases with age, particularly so with men.
2. White males over the age of 80 are at the greatest risk of all
age/gender/race groups.
D. Religion
1. Roman Catholics have lower rates of suicide than Jewish persons and
Protestants.
E. Socioeconomic Status
1. Individuals in the very highest and lowest social classes have higher
suicide rates than those in the middle classes.
F. Ethnicity
1. Whites are at highest risk for suicide, followed by Native Americans,
African Americans, Hispanic Americans, and Asian Americans.
G. Other Risk Factors
1. Psychiatric illness
a. Mood disorders are the most common psychiatric illnesses that
precede suicide. Other psychiatric disorders that account for suicidal
behavior include substance-related disorders, schizophrenia,
personality disorders, and anxiety disorders.
2. Severe insomnia is associated with increased risk of suicide.
3. Homosexual individuals have a high risk of suicide.
4. Affliction with a chronic painful or disabling illness increases the risk
of suicide.
5. Family history of suicide, particularly of a same-sex parent, increases
the risk of suicide.
6. Having attempted suicide previously increases the risk of a subsequent
attempt. About half of those who ultimately commit suicide have a
history of a previous attempt.
7. Loss of a loved one through death or separation is a risk factor.
8. Lack of employment or increased financial burden increases the risk of
suicide.
IV. Predisposing Factors: Theories of Suicide
A. Psychological Theories
1. Anger turned inward. Freud believed that suicide was a result of an
earlier repressed desire to kill someone else. Anger that was previously
directed to another person was turned inward on the self.
2. Hopelessness. Studies indicate a high correlation between feelings of
hopelessness and suicide.
3. Desperation and guilt. Desperate feelings occur when an individual
senses a need for change, but feels helpless to bring about that change.
Guilt and self-recrimination are other aspects of desperation.
4. History of aggression and violence. Rage and violent behavior have
been identified as important psychological factors underlying suicidal
behavior.
5. Shame and humiliation. Some individuals view suicide as a “facesaving”
mechanism, following a social defeat such as a sudden loss of
status or income.
6. Developmental stressors. Certain life stressors that occur during
various developmental levels have been identified as precipitating
factors for suicide.
B. Sociological Theory
1. Durkheim believed that suicide was correlated to the cohesiveness of a
society in which the individual lived. He described three social
categories of suicide:
a. Egoistic suicide: the response of the individual who felt separate
and apart from the mainstream of society. Integration was lacking.
b. Altruistic suicide: the opposite of egoistic suicide. Individuals are
excessively integrated into the group, and allegiance to the group is
so strong that they will sacrifice their own life for the group.
c. Anomic suicide: occurs in response to changes in the individual’s
life that disrupt feelings of relatedness to the group. The
interruption in the customary norms of behavior instills feelings of
“separateness,” and fears of being without support from the
formerly cohesive group.
C. Biological Theories
1. Genetics. Twin studies have indicated a possible genetic
predisposition toward suicidal behavior.
2. Neurochemical factors. Some studies have revealed decreased levels
of serotonin (measured by decreased levels of 5-hydroxyindoleacetic
acid [5-HIAA] in cerebrospinal fluid) in depressed clients who
attempted suicide.
V. Application of the Nursing Process with the Suicidal Client
A. Assessment
1. The aspects of information that are gathered during a suicidal
assessment include:
a. Demographics
(1) Age
(2) Gender
(3) Ethnicity
(4) Marital status
(5) Socioeconomic status
(6) Occupation
(7) Method
(8) Religion
(9) Family history of suicide
b. Presenting symptoms/medical-psychiatric diagnosis
c. Suicidal ideas or acts
(1) Seriousness of intent
(2) Plan
(3) Means
(4) Verbal or behavioral clues
d. Interpersonal support system
e. Analysis of the suicidal crisis
(1) The precipitating stressor
(2) Relevant history
(3) Life-stage issues
f. Psychiatric/medical/family history
g. Coping strategies
B. Diagnosis/Outcome Identification
1. Nursing diagnoses for the suicidal client may include the following:
a. Risk for suicide
b. Hopelessness
C. Planning/Implementation
1. A care plan for the hospitalized suicidal client is presented.
2. Guidelines for treatment of the suicidal client on an outpatient basis:
a. Do not leave the person alone.
b. Establish a no-suicide contract with the client.
c. Enlist the help of family or friends.
d. Schedule frequent appointments.
e. Establish rapport and promote a trusting relationship.
f. Be direct and talk matter-of-factly about suicide.
g. Discuss the current crisis situation in the client’s life.
h. Identify areas of self-control.
i. Antidepressant medication, as prescribed by the physician.
j. Crisis counseling with the suicidal client:
(1) Focus on the current crisis and how it can be alleviated.
(2) Note client’s reactivity to the crisis and how it can be changed.
(3) Work toward restoration of the client’s self-worth, status, morale,
and control. Introduce alternatives to suicide.
(4) Rehearse cognitive reconstruction—more positive ways of
thinking.
(5) Identify experiences and actions that affirm self-worth and selfefficacy.
(6) Encourage movement toward the new reality.
(7) Be available for ongoing therapeutic support and growth.
3. Information for family and friends of the suicidal client:
a. Take any hint of suicide seriously.
b. Do not keep secrets.
c. Be a good listener.
d. Express to the client feelings of personal worth.
e. Know about suicide intervention resources.
f. Restrict access to firearms or other means of self-harm.
g. Acknowledge and accept their feelings.
h. Provide a feeling of hopefulness.
i. Do not leave them alone.
j. Show love and encouragement.
k. Seek professional help.
l. Remove children from the home.
m. Do not judge the person, show anger toward him or her, or provoke
guilt in him or her.
4. Interventions with family and friends of suicide victims:
a. Encourage them to talk about the suicide.
b. Discourage blaming and scapegoating.
c. Listen to feelings of guilt and self-persecution.
d. Talk about personal relationships with the victim.
e. Recognize differences in styles of grieving.
f. Assist with development of adaptive coping strategies.
g. Identify resources that provide support.