Valente, Sharon M. PhD, PMHCNS, FAAN
EVERY 16 MINUTES in the United States, someone attempts suicide, and over 33,000 of these attempts are successful.1 As a nurse, you may be the first healthcare professional to assess a depressed and discouraged person who's contemplating suicide. You can take the first step to prevent a suicide attempt by detecting the warning signs in the patient's words, behavior, posture, and attitude. This article will help you update your knowledge of suicide risk factors and prevention strategies, and provide guidelines for effective intervention.
Recognizing the suicidal patient
Although suicide rates are higher among older adults, suicides among younger adults are rising, particularly among those in the military.2 See Who's at risk? for common risk factors.
Patients of any age with chronic, progressive medical conditions and chronic pain are also at risk. Suicidal ideas may be active (thoughts of killing one's self) or passive (feeling hopeless, worthless, and wishing for death).3,4 Patients with mood disorders, substance abuse problems, and a history of previous suicide attempts are at a higher risk for suicide.5
Ninety percent of people who commit suicide have an identifiable psychiatric diagnosis, typically a mood disorder. Another 30% also have a substance abuse disorder, mainly alcoholism.1
Suicide among American soldiers is on the rise. In 2005 and 2006, the number of American soldiers who took their own lives increased to the highest total since 1993, despite an effort by the Armed Services to detect and prevent suicides. The number of suicides among soldiers on active duty in the Army, Army Reserve, and Army National Guard has risen from 67 in 2004 to at least 128 in 2008.2 Returning soldiers or veterans should always be evaluated for suicide risk, depression, posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), and other physical injuries and emotional problems. PTSD and TBI increase the risk of suicidal ideation, suicide attempts, and completed suicides.
Determining suicide risk
When assessing a patient, look for both covert and overt signs of suicide. Look for sad facial expression, slowed behavior, or comments about wishing to be dead or having no reason to live. Such behaviors raise a suspicion of depression, distress, and suicide risk.
If you suspect that a patient may be at risk for suicide, the first step is to establish rapport and evaluate risk. Although you may be uncomfortable asking about suicidal ideas, you need to ask questions to determine the patient's risk. Open the discussion, share observations, and then ask directly if the patient is thinking about suicide.
Whos at risk,,1,6,15...Image Tools
* Open the discussion: "I'm concerned about your comment that life isn't worth living. No one feels this way without a good reason—tell me more." Or "Sometimes people with the setbacks and distress you describe feel hopeless. Do you feel this way? Tell me about it."
* Share observations: "You look pretty discouraged. Are you thinking of hurting yourself or anyone else?"
* Ask about suicidal thoughts: "Are you feeling distressed enough that you might do something to harm yourself? If you're feeling so distressed, what would you do? Do you have a plan, method, or means?"
Ask questions that help you understand what prompts these suicidal impulses. Don't be concerned that asking about suicide will give the patient dangerous ideas or prompt the patient to action. A patient who's thinking about suicide may welcome an opportunity to talk about it.3,6
Consider what the patient thinks a suicide attempt would accomplish (for example, death or revenge). Patients with a precise plan, lethal method (guns, knives, jumping, drowning, drug overdose, carbon monoxide), and poor chance of rescue (using a gun provides a poor chance of rescue; taking pills in the presence of others provides a good chance of rescue) need immediate safety and suicide precautions in the ED or hospital. Document your observations, notify the attending healthcare provider, and recommend a psychiatric consult. In a community setting, refer the patient to urgent or emergency care.
Myths that hinder assessment
Assessment may be impaired by false assumptions about suicide. Here are some common myths.
* Suicide happens without warning. Over 80% of people tell a healthcare professional, often a nurse, about their suicidal impulses.7 Remember that a lack of risk factors and denial of risk doesn't mean the person isn't suicidal. Many people are reluctant to disclose emotional distress. Assess for comments and body language that suggest the person feels hopeless, worthless, and has nothing to live for.
* People who talk about it don't commit suicide. Suicidal comments are an important risk factor that requires evaluation and shouldn't be ignored.3,6
* One suicide attempt reduces the person's future suicide risk. Previous attempts increase the risk of future attempts. Between 25% and 50% of those who kill themselves had previously attempted suicide.1
* Directing anger at others reduces or erases suicidal intent. People can be suicidal and homicidal at the same time.
* A no-suicide promise or contract is reliable. Research shows that no-suicide contracts (where patients are asked to sign an agreement not to commit suicide) are misleading and unreliable and don't prevent suicide.8
* Some people threaten suicide just to get attention; they're not really suicidal. Never dismiss the possible suicide risk of those who appear to be threatening suicide for secondary gains such as admission to the hospital. All suicidal ideas should be considered serious and evaluated (see Take it seriously).
According to the U.S. Preventive Services Task Force, healthcare providers should routinely screen all adults in primary care settings for depression and suicide risk.9 Self-report inventories such as the 21-item Beck Depression Inventory or the 10-item Geriatric Depression Scale to detect depression or suicide are used because depression or suicide risk is often overlooked during regular physical exams. Screening instruments help identify and track symptoms to improve assessment and clinical decisions.9,10 Clinicians in primary care and other nonpsychiatric settings may miss signs and symptoms of depression or alcohol abuse or dependence. However, because screening tools aren't infallible, use them only to identify people at risk for depression or suicide who need further evaluation.
Screening instruments that detect suicide risk include the Hopelessness Scale, which differentiates between those who threaten suicide and those who may attempt suicide.11 The Index of Potential Suicide and the Reasons for Living Inventory and Suicide Attempt Self-Injury Interview measure the suicide potential of those who are thinking about suicide and those who attempt suicide.12
Intervention and treatment
Treatment options for suicidal patients include hospitalization, psychiatric evaluation, and close outpatient follow-up. Patients who refuse treatment can be hospitalized against their will with the certification of a psychiatrist or authorized psychiatric team and nurse. This is called involuntary hospitalization based on the law due to risk of harm to self, others, or being extremely disabled. In some areas, a psychiatric emergency team from a community mental health center can make home visits to evaluate the patient.
Managing suicide risk involves interventions that address psychosocial and biomedical issues, medication and other treatments for underlying disorders (depression, anxiety, substance abuse, schizophrenia), counseling, and education. Combined cognitive-behavioral therapy, antidepressants, education, counseling, and self-management techniques effectively treat depression that may increase suicide risk.10
Treatment also includes monitoring mood and suicidal thoughts, and building coping strategies, social support, and self-esteem. Close monitoring by staff, consistent observation and assessment of suicide risk, and observation of behavior changes are important.
If the patient is hospitalized, place the patient in a room near the nurses' station and conduct safety rounds: Make sure bathrooms have breakaway fixtures, remove dangerous objects (such as ropes, belts, or cords and any sharp objects), and ensure that the patient doesn't hoard medications.13,14 Verify that medications are swallowed and not hidden in the cheek.
Standard practice dictates that you inspect everyone's belongings before they enter a mental health unit and often other units as well. This allows you to remove any sharp objects, medications, and other dangerous items (such as matches). The patient will receive a list of the items removed. Items stored in the facility are returned upon discharge.
Other patients often offer important clues to another patient's suicide risk. Although you're responsible for monitoring suicidal patients closely, another patient may hear suicidal comments or behavior and notify staff.
Patients with suicidal impulses need to understand their risk and the importance of emotional support and crisis intervention. Refer patients to suicide hotlines, local suicide prevention or crisis centers, suicide support groups, and substance abuse programs when needed. Provide them with self-help resources such as printed materials, audio or videotapes, and computer programs.
Suicidal thoughts are symptoms that can be helped and changed with the proper intervention. Patients will often feel discouraged and need education and ongoing therapy to build social support and coping skills. Your advocacy can help them manage symptoms and connect with self-help groups, social support, and therapeutic resources.
Many patients mention talking with a nurse who gave them hope, support, and referrals that saved their lives. You have the potential to offer that hope and support to your patients too.
Take it seriously
* Consistently monitor and document the severity of a patient's suicidal signs. Use behavioral descriptions of actions. Don't write "The patient made a suicide gesture or a warning"; describe what you saw. For example, write "Pt. cut both her wrists and bled about 40 mL; the wound was cleansed and dressed." Clarify when and where the incident occurred and your nursing interventions.
* Routinely ask about suicidal thoughts, ideas, and impulses. Document these and alert colleagues involved in the patient's care.
* Don't accept seemingly logical reasons. If a patient overdosed on prescription drugs and then says "I didn't mean it; I was just tired and wanted to sleep," you can reply "I hear what you're saying, but that amount of pills is lethal, and I'd suspect you were feeling pretty discouraged or depressed." Avoid an attitude that discounts the patient's depression. For example, when the patient says "I want to die," never say "Oh, you don't really believe that." A better response would be "You must be feeling pretty awful. Tell me more about your feelings and your discouragement."
* Question the patient, family, and friends about any of the patient's suicidal comments or warnings. When friends or family bring the patient to the hospital, ask for the patient's permission to talk to them about their concerns that led to hospitalization. Although you can't talk about the patient to the family, you can ask family or friends if there's anything they want you to know about the patient. They may provide you with important warnings that inform the suicide prevention plan and signal a high-risk patient.
2. Kuehn BM. Soldier suicide rates continue to rise: military, scientists work to stem the tide. JAMA. 2009;301(11):1111,1113.
3. Mitty E, Flores S. Suicide in late life. Geriatr Nurs. 2008;29(3):160–165.
4. Hawton K, van Heeringen K. Suicide. Lancet. 2009;373(9672):1372–1381.
5. Krysinska K, Martin G. The struggle to prevent and evaluate: application of population attributable risk and preventive fraction to suicide prevention research. Suicide Life Threat Behav. 2009;39(5):548–557.
6. Valente SM. Suicide risk in elderly patients. Nurse Pract. 2008;33(8):34–40.
7. Rudd MD. Suicide warning signs in clinical practice. Curr Psychiatry Rep. 2008;10(1):87–90.
8. Rudd MD, Mandrusiak M, Joiner Jr TE. The case against no-suicide contracts: the commitment to treatment statement as a practice alternative. J Clin Psychol. 2006;62(2):243–251.
9. Zung W. The role of rating scales in the identification and management of the depressed patient in the primary care setting. J Clin Psychiatry. 1990; 51(suppl):72–76.
10. Valente SM, Saunders J. Screening for depression and suicide: self-report instruments that work. J Psychosoc Nurs Ment Health Nurs. 2005;43(11):22–31.
11. Joe S, Woolley ME, Brown GK, Ghahramanlou-Holoway M, Beck AT. Psychometric properties of the Beck Depression Inventory-II in low-income, African American suicide attempters. J Pers Assess. 2008;90(5):521–523.
12. Linehan MM, Comtois KA, Brown MZ, Heard HL, Wagner A. Suicide Attempt Self-Injury Interview (SASII): development, reliability, and validity of a scale to assess suicide attempts and intentional self-injury. Psychol Assess. 2006;18(3):303–312.
13. Cardell R, Bratcher KS, Quinnett P. Revisiting "suicide proofing" an inpatient unit through environmental safeguards: a review. Perspect Psychiatr Care. 2009;45(1):36–44.
14. HΦH, Licht RW, Mortensen PB. Risk factors of suicide in inpatients and recently discharged patients with affective disorders: a case-control study. Eur Psychiatry. 2009;24(5):317–321.
15. Cassells C, Paterson B, Dowding D, Morrison R. Long- and short-term risk factors in the prediction of inpatient suicide: review of the literature. Crisis. 2005;26(2):53–63.
© 2010 Lippincott Williams & Wilkins, Inc.