Case Finding and Care in Suicide: Children, Adolescents and Adults Chapter 36

Suicide Terminology Suicide - act of killing oneself Parasuicide - failed attempt to kill oneself, varies by intent, self-harm Suicide ideation - thinking about or planning one’s own death Lethality - degree of probability that an individual will be successful in completing suicide

Suicide Highly stigmatized Stimulates fear in others Directs consequences of certain mood disorders Highly preventable

Suicide: Epidemiology Ninth leading cause of death in the U.S. Lifetime rate - 10% chance for suicide Men more likely than women to attempt Lethality increases with age Suicide - most prevalent in the aged group and over 75 age group Whites more likely than nonwhites Comorbid with depression and schizophrenia

Epidemiology 56% - succeed first suicide attempt 25% - hospitalized for a failed suicide attempt within three months Handguns most common method Prepubertal children: increase in rates Adolescents: higher than in children

Risk Factors White man Older adulthood Adolescence Gay, lesbian or bisexual orientation Access to firearm

Other Risk Factors Vulnerability –Family member who competed suicide –Psychiatric disorder –Previous attempt Intent –Plan and execution –Loss –Unrelenting physical illness Disinhibition –Impulsivity –Isolation –Psychotic thought –Drug or alcohol abuse

Etiology of Suicide Biologic –Most have MDD –Low levels of serotonin –Higher among those who significantly reduce their fat intake, low cholesterol levels –Familial tendencies Psychological –Psychodynamic - anger and aggression turned inward –Stress-diathesis model –Cognitive model of depression Social –Lack of social support –Interpersonal stress

Effects of Suicide Estimated medical cost of suicide per person - $5,700 Estimated lost productivity - $844,184 Grief of family and friends

Legal Considerations Confidentiality (Explain limits.) Informed consent (Explain limits of right to self- determination and least restrictive environment.) Competence (Must judge.) Beneficence Documentation and reporting Involuntary hospitalization

Assessment Case-finding –Primary care settings - should be screened for depression –Variety of scales available Determining risk (Text Box 36.3) –Intent to die –Severity of ideation –Degree of planning –Lethality –Availability

Nursing Diagnoses Risk for suicide Interrupted family processes Ineffective health maintenance Impaired social interaction Chronic low self-esteem Disturbed sleep pattern Social isolation Spiritual distress

No-Suicide Contract Written or verbal agreement between health care professional and the patient States that patient will not engage in suicidal behavior for a specific period of time Patient must be competent to enter a contract Must help patient dismantle suicide plan Must refrain from use of substances

Inpatient Care Protect patient from suicide and establish treatment of underlying psychiatric disorder Objectives of hospitalization: –Maintain patient’s safety. –Decrease the level of suicidal ideation. –Initiate treatment for underlying disorder. –Evaluate for substance abuse. –Reduce level of social isolation.

Inpatient Management Confidentiality No-suicide contract Reporting in the medical record Inpatient suicides –1% in general hospitals –.03% in psychiatric hospitals –High risk times Precautions Prepare for discharge –No guns, no means in the house –A plan to call someone

Biologic Interventions Ensuring safety –Hospital protocol for safety –Observing patient regularly –Removing dangerous objects –Providing outlets for expression of patient’s feelings –No-suicide contract Somatic therapies –Medications –ECT Substance abuse treatment Assisting with Treatment of Substance Abuse

Psychological Interventions Evaluating patient’s ways of thinking about problems and generating solutions Cognitive interventions Developing plans to prevent future suicide attempts

Social Interventions Help patient develop social skills that can be used in engaging others. Identify family and friends who are willing to help.

Discharge Planning and Outpatient Care Educating patient and family Identifying continuing sources of social support Establishing an outpatient care plan –Have enough medication to last until first outpatient visit –Plan for ongoing supervision

Avoiding Secondary Trauma Nurses’ emotional reaction to patient’s circumstances or to repeated stress of coping with suicidal crises Nurse who experiences it may develop early stages of PTSD. Nurses must engage in active program of self-care.