Suicide Assessment

Objectives Identify behaviors associated with self-protective response. Analyze predisposing factors, precipitating stressors, and appraisal of stressors related to self-protective responses. Identify suicide precautions that can be implemented in a clinical setting. Assess additional signs of suicide and warning risks. Identify expected outcomes and short-term nursing goals related to self-protective factors.

Suicide statistics Suicide is a leading cause of death worldwide, outnumbering homicide or war-related deaths 1 person every 15 minutes complete suicide in the U.S. Underepresentation (i.e., single vehicle car crashes) In 2008, 8.3 million people reported having suicide

(CDC, 2012, Suicide facts at a glance) Suicide Statistics Fatal Outcomes (Suicides) in 2010: 38,364 total for the year, an average of 105 per day In 2010 , suicide was the 10th leading cause of death for all ages (Top 10 causes of death 3rd for ages 15-24 (20% of all annual deaths in this age range) 2nd for ages 25-34 4th for ages 35-54 8th for ages 55-64 Completed suicides are 4 times higher in males than females Rates for males aged 75+ were 16.3 per 100,000 compared to 12.4 per 100,000 for the general population Non-fatal Outcomes (Attempts) 2010: 487,700 people were treated in the ED’s for self-inflicted injuries (CDC, 2012, Suicide facts at a glance)

Per 100,000 people

Factors contributing to suicide in the elderly Recent death of a loved one Physical illness Uncontrollable pain or the fear of a prolonged illness Perceived poor health Social isolation and loneliness Major changes in social roles (e.g., retirement) (American Association of Suicidology, 2012, Elderly Suicide Fact Sheet )

Suicide in the military

Suicide in the Military “Since the start of the Iraq War in 2003, the rate of Suicide among U.S. Army soldiers has soared, according to a new study from the U.S. Army Public Health Command. The study, an analysis of data from the Army Behavioral Health Integrated Data Environment, shows a striking 80 percent increase in suicides among Army personnel between 2004 and 2008. The rise parallels increasing rates of depression, anxiety and other mental health conditions in soldiers, the study said.”

Male – female (10 y.o. +) method comparison (2005-2009) http://www.cdc.gov/ViolencePrevention/suicide/statistics/mechanism01.html

Sociocultural context More common in White than African American persons 2nd leading cause of death in American Indian/Alaskan Natives aged 15-34 (1.8x higher than nat. avg. for this age group) Hispanic, female H.S. students report higher rate of suicide attempts (Stuart, 2013, p. 325, Box 19-1)

Schneidman’s 10 Commonalities of Suicide (Schneidman, Edwin- 1985) I. The common purpose of suicide is to seek a solution. II. The common goal of suicide is cessation of consciousness. III. The common stimulus in suicide is intolerable psychological pain. IV. The common stressor in suicide is frustrated psychological needs. V. The common emotion in suicide is hopelessness-helplessness. VI. The common cognitive state in suicide is ambivalence. VII. The common perceptual state in suicide is constriction. VIII. The common action in suicide is regression. IX. The common interpersonal act in suicide is communication of intention. X. The common consistency in suicide is with lifelong coping patterns.

Suicide Risk Factors (NIMH, 2012) depression and other mental disorders, or a substance- abuse disorder (often in combination with other mental disorders). More than 90 percent of people who die by suicide have these risk factors. prior suicide attempt family history of mental disorder or substance abuse family history of suicide family violence, including physical or sexual abuse firearms in the home, the method used in more than half of suicides incarceration exposure to the suicidal behavior of others, such as family members, peers, or media

Suicide risk and psychiatric diagnoses Condition Estimated lifetime suicide rate Prior suicide attempt 27.5% Bipolar disorder 15.5% Mixed drug abuse 14.7% Major depression 14.6% Dysthymia 8.6% OCD 8.2% Panic d/o 7.2% Schizophrenia 6.0% Personality disorders 5.1% Alcohol abuse 4.2% APA Guidelines for Assessing and treating Suicidal Behaviors (2004) In APA 2010, there is an adapted table on p. 31 from Harris and Barraclough meta-analysis, which includes more conditions and respective rates.

Protective factors Effective clinical care for mental, physical, and substance abuse disorders Easy access to a variety of clinical interventions and support for help seeking Family and community support (connectedness) Support from ongoing medical and mental health care relationships Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes Cultural and religious beliefs that discourage suicide and support instincts for self-preservation Children or others who depend on the person CDC Injury Center. Violence Prevention. Suicide: Risk and protective factors. Accessed 10.15.2012 at http://www.cdc.gov/ViolencePrevention/suicide/riskprotectivefactors.html

Warning Signs of Suicide Pneumonic: : IS PATH WARM? I Ideation S Substance Abuse P Purposelessness A Anxiety T Trapped H Hopelessness W Withdrawal A Anger R Recklessness M Mood Changes

Additional Warning Signs: Recent Loss -- through death, divorce, separation, broken relationship, loss of job, money, status, self-confidence, self-esteem, loss of religious faith, loss of interest in friends, sex, hobbies, activities previously enjoyed Increased substance (alcohol or drug) use No reason for living; no sense of purpose in life Anxiety, agitation, unable to sleep or sleeping all the time Feeling trapped - like there’s no way out Low self esteem -- feeling worthless, shame, overwhelming guilt, self- hatred, "everyone would be better off without me" Hopelessness Withdrawal from friends, family and society Rage, uncontrolled anger, seeking revenge Acting reckless or engaging in risky activities, seemingly without thinking Dramatic mood changes.

Warning Signs of Acute Risk: Threatening to hurt or kill him or herself, or talking of wanting to hurt or kill him/herself; and/or, Looking for ways to kill him/herself by seeking access to firearms, available pills, or other means; and/or, Talking or writing about death, dying or suicide, when these actions are out of the ordinary.

Assessing for suicide risk It is imperative that nurses evaluate patients for the risk of suicide or self-injurious behavior IDEATION, PLAN, INTENT Ideation: Have you had any moments when you felt like giving up? Wished that you were dead or wouldn’t wake up? (passive death wish) Have you thought of suicide? When did you begin to have these thoughts? How often (or how intensely) are you having these thoughts?

Assessing for suicide risk (con’t) Plan: Have you gone so far as to think about how you might kill yourself? Do you have the means to kill yourself? Intent: How likely is it that you might make an attempt? Based on your assessment you may “contract for safety” with the patient but you should be very careful- when in doubt confer with a colleague If you determine or suspect that a patient is at high risk for an IMMINENT suicide attempt, you must place the patient on suicide precautions

Suicide Precautions Inform the patient and staff that you will need to place the patient on 1:1 suicide precautions Have the physician or NP write the order The patient will need to be continuously supervised (1:1, arms length)- families may not take over the supervision The patient will often not be permitted to leave the unit You must assure a safe environment by checking the patients belongings (luggage, purses, etc.) and removing items that may be used in a suicide attempt You will need to frequently re-assess the patient for suicidal ideation/plan/intent It will be up to the treatment team to determine when the patient no longer needs 1:1 SP

Psychiatric Interview of a Depressed Patient with Suicide Assessment Protective factors ? Risk factors ? Do you think this patient is at imminent risk? If risk for suicide, what would you do?