SUICIDE IS A PUBLIC health crisis in the US and is the 11th leading cause of death for all ages. Since 2007, suicide mortality has increased by 31% for adolescent males; among female adolescents, suicide rates have doubled and are now at an all-time high.1 Suicide is the third leading cause of death in children ages 10 to 14, and the second leading cause of death in adolescents and young adults ages 15 to 34.2 The World Health Organization reports that suicide is the leading cause of death among children and adolescents ages 10 to 19.3 This article addresses the issue of suicide among adolescents and focuses on risk assessment, therapeutic interventions, and recommendations for successful outcomes.
Prevalent but preventable
Although increasing in prevalence, suicide is also one of the most preventable causes of death among children and adolescents. The increasing incidence of hospital admissions related to self-harm among adolescents highlights the need for effective suicide-screening assessments and interventions in all healthcare settings, including schools and primary care practices.4 Nonfatal suicide attempts encompass about 5% of ED visits. For an estimated 1.5 million adolescents, ED services are the only method of receiving healthcare.5,6 Thus, the ED visit may be the only opportunity for intervention in adolescents who present with suicidal ideation.
Given the prevalence of suicide attempts in young people, nurses are likely to work with suicidal patients in all areas of the healthcare system. However, since ED nurses are often the first to interact with suicidal adolescents, ED services should include suicide screening and prevention as essential aspects of care.3 Suicide screening is critical in determining the need for psychiatric hospitalization and ongoing follow-up care. Understanding common patterns of behavior helps nurses identify patients who may be suicidal.
Suicidal approaches frequently used by adolescents
Males are more likely to choose more violent and lethal means to end their lives, while females tend to use less disfiguring and violent forms of self-harm and, therefore, are more likely to survive suicide attempts.7 The most common way males attempt suicide is by firearm. Other means of self-harm include hanging, stabbing, motor vehicle crashes, jumping off high places, drowning, and carbon monoxide poisoning.5,8
Adolescent females are more likely to cut their wrists or overdose on medications or street drugs.9 Opioid-related suicides are on the rise, along with other drug-related suicides.10,11 Knowing the adolescent's history of drug use is critical for appropriate treatment and follow-up.10
When adolescents are depressed, hopeless, and decide life is not worth living, they can use just about any means to harm themselves. A psychological evaluation by an experienced professional and close supervision are critical to prevent a tragedy from occurring.
How social media affects risk
The influence of social media on adolescent suicide is a fairly new phenomenon and is reported to be increasing.11 Understanding the role of social media in terms of suicide-related behaviors can provide insight into adolescents' perspectives.
Adolescents can be exposed to both detrimental influences and supportive resources through numerous forms of social media and networking opportunities. Cyberbullying and harassment increase the risk of self-harm by intensifying feelings of lack of connectedness, hopelessness, and emotional distress.11,12 An association has been noted between visiting negative social media sites that encourage self-harm/suicide and an increased rate of self-harm behaviors.13 Parents, counselors, and teachers need to be aware of the sites that adolescents visit and educate them about safe engagement in any online platform. Assessment of adolescents with suicide risk should include peer and cyber connections.14
Supportive social network sites for suicide prevention, such as the Facebook pages for the National Suicide Prevention Lifeline and American Foundation for Suicide Prevention, offer crisis help and educational resources. Positive social media sites like these increase social connectedness among others and provide support that may decrease suicide risk.11
Misperceptions about suicide
Many nurses are unsure how to approach a potentially suicidal patient, wondering if simply raising the issue increases the risk. The evidence says no; in fact, as discussed below, encouraging patients to talk about their thoughts and feelings may lessen the risk.15
Although many adolescents do not openly talk about how bad they are feeling, those who do are just as likely to carry out a suicide attempt.16 Comments such as “I'd be better off dead,” “You'd be better off without me,” “I hate my life,” or “I wish I were dead” should be taken seriously and evaluated by a professional trained to interpret the seriousness of these comments. Be especially concerned if adolescents are making efforts to get their affairs in order or giving away personal items.16
There is a common perception that suicide happens without warning, but patients thinking about suicide frequently give clues. There is often a sense of ambivalence in suicidal patients, right up until they engage in self-destructive behavior. Suicidal patients may not actually want to die but cannot see any way to continue because of their intolerable pain. This is why patients who have made the decision to end their lives often seem at peace and less distressed. They now have a plan to escape the pain.
Reports of changes, positive as well as negative, in baseline behavior of suicidal patients should alert nurses to be extra vigilant with assessments and supervision. These changes should also be discussed with patients. Let them know that although you are glad they are more interactive with others and seem to be less depressed, you are concerned that these changes can sometimes occur when patients have a plan to end their suffering.
Do not be afraid to ask patients if that is how they are feeling at this time. Regardless of their response, supervise them based on the institutional suicide protocol and Joint Commission standards.17 All checks must include observing patients visually and knowing what they are doing.9,16
Avoid the misperception that asking patients to talk about suicidal feelings and ideas or trying to redirect their thinking is harmful. On the contrary, it is important to reflect what you are hearing because patients are less likely to act on feelings if they can discuss them openly with a caring person.16 Bringing up hopelessness or discussing suicidal thoughts does not plant the idea. Most patients are comforted when someone is willing to try and understand what they are going through. This decreases the isolation they may be feeling and increases the chance of finding alternatives to the stresses they are experiencing.9,16
Be aware that the time of day, the day of week, and the time of year can influence those who are contemplating suicide. The beginning of spring and the happiness others experience as a result can leave a patient feeling depressed and even more isolated. The holidays can also increase stress and isolation, especially for those not connected to family or friends. The idea of confronting another day or week of misery is overwhelming to some. If patients are unable to sleep, they may be up all night obsessing about their problems, which makes facing another day less appealing.
Keep in mind that some patients come into the hospital planning to end their lives there in order to spare their families from the trauma of finding them deceased. They can easily figure out when staff members are occupied, so monitor them closely during shift changes and other times when fewer staff are available or are busy, as these are high-risk times.9
Adolescents may express their pain and hopelessness in nonverbal ways such as giving away personal items, acting out in deviant and angry ways, risk-taking behaviors, somatic complaints such as headaches or abdominal pain, and persistent use of drugs and/or alcohol.2 It can be easy to be distracted by such behavior and miss important clues as to the pain adolescents may be feeling.
Although adolescents may exhibit various signs of depression, the persistent presence of five or more signs or symptoms (see Signs and symptoms of depression) represents the most serious concern. Nurses should be aware of the additional risk factors for suicide that have been identified by the American Psychiatric Association (see Risk factors for suicide).
When interacting with adolescents who are depressed or suicidal, assess the level of lethality or how suicidal they may be. Remember that although problems and concerns may seem minimal to others, they may be overwhelming and devastating to the adolescents who experience them. Nurses working with these patients should utilize suicide-screening tools that have been validated for use with adolescents with psychiatric concerns (see Risk of suicide questionnaire and Ask Suicide-Screening Questions).20
Begin an assessment by reflecting any of the patient's behaviors or statements that are concerning. Try statements such as, “I can see how depressed and discouraged you are” or “I can hear how hopeless you feel.” Let the patient respond and follow up with “Have things gotten so bad that you think about hurting yourself?” If the patient says no, ask “What keeps you going?”
Some patients may respond that they think about suicide but would not take action because of religious beliefs or how it would impact their family. However, any patients who report thinking about suicide should be assessed further.9 If patients report they feel like a burden to others and their friends/families would be better off without them, be concerned and increase supervision.
If patients indicate they are having suicidal thoughts, ask if they are having any thoughts or plans to hurt themselves at the present time. Specifically, ask patients if they have thought about how they would end their lives. If patients have a specific plan, ask if they have collected or have access to the materials needed to complete the act.
Even if patients answer “no” to all of the questions, assess how they cope with stress. Adolescents have less life experience handling stress, they may be impulsive, and current life challenges may seem insurmountable. Screening is just the beginning of this process; all adolescents presenting with a psychiatric concern will need further assessment by a skilled psychiatric provider.21
Nursing interventions: Dos and don'ts
When caring for a patient with suicidal ideation, be aware that anything in the environment can be used for self-harm (sharp items, socks, pajama tops and bottoms, sheets, cords, gowns, shoelaces, plastic bags, etc.) Nurses should remove any objects that could be used for self-harm from patients with suicidal ideation. The room itself should meet Joint Commission standards regarding ligature-resistance and safety. All objects that could be used for self-harm should be removed from the room and any visitors.17
Avoid trying to create an artificially cheerful environment and do not offer false or trite reassurances that everything will be better with time. Do not change the topic if you are uncomfortable because doing so will shut down therapeutic interactions. The simple task of listening, sitting with adolescents when they are hurting, and reminding them that they are not alone may offer hope and perspective.9 Explore the need for spiritual support with the patient and arrange for this if desired.
Let patients know that depression, anxiety, hopelessness, and thoughts of suicide are all treatable conditions. Emphasize that medications are available that can help restore brain chemicals that get depleted with stress and that talking things over with a skilled therapist can greatly decrease feelings of isolation and pain. If adolescents are worried that they will be seen as crazy, emphasize that depression is a brain disease that can be regulated just like some people have diabetes and need to make adjustments to keep blood glucose levels stable.22
Warning: Improvement is still a high-risk period
Once suicidal adolescents begin taking antidepressants they may feel more physical energy, which can result in them having the capacity to complete a suicide attempt. They may also experience even more thoughts of suicide. Supervision during this time may need to be increased. If patients exhibit any abrupt changes from what has been their baseline, begin a discussion and ask directly if they have decided to end their life. Even if they say no, continue to monitor them closely. Patients may look peaceful when they have made a decision to alleviate their pain by ending their lives. Educate patients and families about these risks and discuss the boxed warnings noted in all the antidepressant medications. Let them know that it may be several weeks or more before the full effect of the medication can be experienced. Ideally, adolescents should receive mental health counseling along with pharmacotherapy to help them develop strategies for coping and to provide ongoing support and evaluation.9
Evaluate suicidal adolescents for signs and symptoms of psychosis, such as hearing self-depreciatory voices telling them they do not deserve to live. If a patient reports hearing voices, ask what the voices are saying.
Adolescents with psychosis are at higher risk for suicidal ideation and attempts compared with those without psychotic symptoms.23 The presence of psychotic symptoms, such as delusions, hallucinations, paranoia, and disorganized thinking, represents a high-risk situation and requires patients be under constant monitoring. Psychosis controls the mind and no matter how much rapport the nurse has with these patients, the nurse cannot be sure that patients will not act on their thoughts. Early recognition and treatment of depression and psychosis are necessary to prevent suicide attempts.23
Carefully monitor that patients are taking their medications because some may attempt to stockpile their medication for the purpose of overdosing once they have enough. Ask patients to open their mouths so you can check under their tongue and visualize the entire cheek area. Be open with patients about why you are doing this.
When adolescents are identified as at-risk for suicide, maintain safety by closely monitoring the patient and then contact the provider to obtain an order for suicide precautions and implement them per hospital protocol. A provider must make an assessment and write an order before suicide precautions are discontinued.
If the provider discontinues suicide precautions and the patient seems too cheerful or dramatically different, initiate 1:1 monitoring until the provider can conduct further assessments.17,24
Patients and sometimes families should be referred for psychiatric consultation and crisis services as needed. Educating parents or guardians, as well as collaborating with the patient's school and treatment team, is crucial to provide ongoing support in keeping adolescents who are at risk for suicide safe. Families need to remove access to guns or drugs in the home when they have a child with depression or other mental illnesses. Encourage families to seek out support through community resources such as mental health agencies, the American Foundation for Suicide Prevention (http://afsp.org), and the National Alliance on Mental Illness (www.nami.org).
Take care of yourself
Working with emotionally distressed patients can be rewarding but may also create challenges that lead to exhaustion, burnout, and unresolved emotional pain.24 A nurse operating in any of these states may engage in nontherapeutic behaviors such as avoidance and demonstrating callousness or an attitude of superiority. Being self-aware and seeking professional help when necessary will enhance a nurse's ability to intervene in a safe and therapeutic manner.
Collaboration is key
Never underestimate the powerful role nurses have in supporting individuals who are struggling. It is vital for nurses to work collaboratively with patients and colleagues to establish rapport with patients, instill hope, complete assessments, and identify changes in thoughts and behavior. Do not worry about saying exactly the right thing and do not avoid difficult conversations. Patients often respond to the simplest things that give them hope to hang onto when they are suffering. They can be very appreciative of genuinely caring efforts. Kindness and compassion, along with time and willingness to talk openly about the adolescent's pain, can help save a life.
Signs and symptoms of depression18
In general, five or more of the following signs or symptoms that are present for at least 2 weeks' time and indicate a change in previous functional level may indicate a patient is depressed. They cause significant impairment in all areas of functioning.
- depressed mood
- lack of interest in pleasurable activities
- decreased or increased appetite resulting in weight loss or weight gain
- insomnia or hypersomnia
- psychomotor agitation or retardation
- fatigue or loss of energy
- feelings of worthlessness or excessive or inappropriate guilt
- inability to think or concentrate or make decision
- recurring thoughts of death, with or without a specific plan
- somatic complaints (such as headaches, abdominal pain).
Risk factors for suicide2,19
- family history of suicide
- family history of child maltreatment
- family conflict
- past or current suicidal ideation
- previous suicide attempt(s)
- emotional distress
- exposure to violence
- history of mental disorders, particularly clinical depression
- alcohol and substance abuse
- feelings of persistent hopelessness and sadness
- crying spells
- impulsive or aggressive tendencies toward self or others, irritability, anger, hostility, and acting out
- religious or cultural beliefs (such as a belief that suicide is a noble way to resolve a personal dilemma)
- suicide of peers
- isolation, lack of connectedness to school/sense of supportive school environment
- relationship problems
- barriers to accessing mental health treatment
- personal losses (relational, social, work, or financial)
- physical illness, disabilities, and learning differences
- easy access to lethal methods
- extreme weight-control behaviors
- unwillingness to seek help because of the stigma attached to mental health and substance use disorders or to suicidal thoughts
- lack of access to resources/support.
Risk of suicide questionnaire20
This validated questionnaire can help assess suicide risk.
- Are you here today because you tried to hurt yourself?
- In the past week, have you been having thoughts of killing yourself?
- Have you ever tried to hurt yourself in the past (other than this time)?
- Has something very stressful happened to you in the past few weeks (a situation very hard to handle)?
Ask Suicide-Screening Questions21
This is a validated suicide-screening tool to identify adolescents at risk for suicide. A response of yes to any of the four questions below represents a risk.
- In the past few weeks, have you wished you were dead?
- In the past few weeks, have you felt that you or your family would be better off if you were dead?
- In the past week, have you been having thoughts about killing yourself?
- Have you ever tried to kill yourself?
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