Depression and Suicide

Suicide: Terminology Suicidal ideation (SI)--Thoughts Suicidal ideation (SI)--Thoughts Suicidal threats-- Stated intent to end life Suicidal threats-- Stated intent to end life Suicidal gesture-- Non-lethal self-injury Suicidal gesture-- Non-lethal self-injury Suicidal attempt-- Serious method with Suicidal attempt-- Serious method with intent intent

Incidence of Suicide Ninth leading cause of death in US Ninth leading cause of death in US Third leading cause of death in the age group Third leading cause of death in the age group Seventy three percent of suicides are white men Seventy three percent of suicides are white men Highest rate of suicide: white males over age 85 Highest rate of suicide: white males over age 85 Suicides, not homicide, is the leading cause of gun death-57% Suicides, not homicide, is the leading cause of gun death-57% 10-19yr olds use a gun to kill themselves every six hours 10-19yr olds use a gun to kill themselves every six hours

Adolescents and Suicide 3 rd leading cause of death in teens 3 rd leading cause of death in teens Rates quadrupled in 1990’s Rates quadrupled in 1990’s Risk factors: depression, substance abuse, sexual or physical abuse, disruptive behavior Risk factors: depression, substance abuse, sexual or physical abuse, disruptive behavior Psychosocial factors: Alienation, loneliness and impulsivity, sexual identity issues Psychosocial factors: Alienation, loneliness and impulsivity, sexual identity issues Firearms most commonly used Firearms most commonly used “Copy cat” aspect “Copy cat” aspect

Issues in Suicide Suicidal persons are usually ambivalent Suicidal persons are usually ambivalent Themes are: loss, hopelessness, loneliness, psychic pain, abandonment Themes are: loss, hopelessness, loneliness, psychic pain, abandonment  Goals of suicide: Escape, relief, manipulation, retaliation, reunion, redemption  Medical illness is factor, esp. in elderly

Risk factors for suicide Elderly single men with health problems Elderly single men with health problems Unemployed professional workers Unemployed professional workers H/o previous attempt(s) H/o previous attempt(s) Women make more attempts; males more lethal Women make more attempts; males more lethal Adolescents Adolescents Cultural aspects: how acceptable; role of shame Cultural aspects: how acceptable; role of shame

Suicidal Talk? “I’d be better off dead.” “_______ will be better off when I’m gone.” “I wish this pain I feel would just be over.” “I wish I could just get away from everything.” “I wish I just didn’t exist at all.” “I just want to be with (deceased person).”

Assessment of Suicidal Potential Plan--the more developed, greater risk Plan--the more developed, greater risk Method—Lethality and availability Method—Lethality and availability Rescue—does person try to block? Rescue—does person try to block? Can patient carry out plan? (energy) Can patient carry out plan? (energy) Are there inhibitors? (reasons to live) Are there inhibitors? (reasons to live) Pts. at greater risk as depression lifts Pts. at greater risk as depression lifts

Suicide and Mental Illness 90% have Diagnosable mental 90% have Diagnosable mental conditions: conditions: Substance abuse, Bipolar depression, Major Depression, Schizophrenia Substance abuse, Bipolar depression, Major Depression, Schizophrenia

Assessing Suicide Potential Does the Pt. have a plan? Lethality Does the Pt. have a plan? Lethality History of previous attempts History of previous attempts Lives alone or feels alienated; lacks social support Lives alone or feels alienated; lacks social support Recent loss(es) and excessive guilt Recent loss(es) and excessive guilt Poor physical health Poor physical health

Suicide Assessment, cont’d Agitated depression or when it lifts Agitated depression or when it lifts Co-existing substance abuse, or Mental Illness dx. Co-existing substance abuse, or Mental Illness dx. h/o Frequent threats of self-harm or suicide h/o Frequent threats of self-harm or suicide Giving away belongings Giving away belongings Depression and anger Depression and anger

Nurse-Client Relationship and Milieu Management Hospitalization: Locked area, PICU Hospitalization: Locked area, PICU Directly Assess: ask pt. if they are suicidal Directly Assess: ask pt. if they are suicidal Remove harmful objects Remove harmful objects 1-1 suicide watch if serious or immediate danger; restraint may be necessary 1-1 suicide watch if serious or immediate danger; restraint may be necessary Try to “make a connection,” establish rapport Try to “make a connection,” establish rapport Anti-depressant, anti-anxiety medication Anti-depressant, anti-anxiety medication Have pt. sign a “No-harm Contract” Have pt. sign a “No-harm Contract”

NANDA Nursing Diagnoses High Risk for Violence: directed at self High Risk for Violence: directed at self Risk for Suicide Risk for Suicide Self esteem disturbance Self esteem disturbance Hopelessness Hopelessness Powerlessness Powerlessness Ineffective Individual Coping Ineffective Individual Coping

Discharge Planning and Community Resources Careful assessment and documentation on discharge Careful assessment and documentation on discharge Having a Safety Plan Having a Safety Plan Hotlines: National Suicide Prevention Hotlines: National Suicide Prevention Hotline TALK Hotline TALK Support: individuals and groups Support: individuals and groups

Nursing Process Scenario A 45 year old divorced male made a suicide attempt with his hunting rifle under the influence of alcohol and marijuana, but was intercepted by a friend. He is brought to the mental health unit with a psychiatric dx. of Major Depression with Suicidal Ideation. He says he still feels he’d be better off dead, but willingly discusses stressors that contributed to his attempt: recently broke up with girlfriend, furloughs from his job, mother is terminally ill.

Scenario: Nursing Process Initial Nursing Diagnoses after interview: Risk for Suicide r/t hopelessness and actual or anticipated personal losses Risk for Suicide r/t hopelessness and actual or anticipated personal losses Ineffective Individual Coping r/t substance abuse Ineffective Individual Coping r/t substance abuse What is a short term goal for each of these?

Ethical and Legal Aspects The nurse writes this as one short term goal: The nurse writes this as one short term goal: Client will sign no-harm contract within 12 hrs Client will sign no-harm contract within 12 hrs  What is the value of this contract from: an ethical standpoint? an ethical standpoint? a legal standpoint? a legal standpoint?