Depression and Suicide

Suicide: Terminology Suicidal ideation (SI) Suicidal ideation (SI) Suicidal threat Suicidal threat Suicidal gesture Suicidal gesture Suicide attempt Suicide attempt Thoughts Thoughts Stated intent to end life Stated intent to end life Non-lethal self-injury Non-lethal self-injury Serious method with intent Serious method with 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= middle-aged white males Highest rate of suicide= middle-aged white males Suicide, not homicide, is the leading cause of gun death-57% Suicide, not homicide, is the leading cause of gun death-57% yr olds use a gun to kill themselves every six hours yr olds use a gun to kill themselves every six hours

Other Risk Populations Elderly single men with health problems Elderly single men with health problems Unemployed professional workers Unemployed professional workers Women make more attempts; males more lethal Women make more attempts; males more lethal Adolescents Adolescents

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 with Examples Escape: from abuse or intolerable situation Escape: from abuse or intolerable situation Relief: of physical, emotional pain or guilt Relief: of physical, emotional pain or guilt Manipulation: way to get attention, or recognition Manipulation: way to get attention, or recognition Retaliation: revenge or punishment Retaliation: revenge or punishment Reunion: with a dead loved one Reunion: with a dead loved one Redemption: for loss of honor, harm done to others (also, to save others from death) Redemption: for loss of honor, harm done to others (also, to save others from death)

Issues in Suicide, cont’d Medical illness is factor, Medical illness is factor, esp. in elderly esp. in elderly Cultural aspects: how acceptable; role of shame Cultural aspects: how acceptable; role of shame

Assessment: 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 Is There a Plan?--the more developed, greater risk Is There a 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)

Other Factors to Consider In Assessing Suicide Potential  History of previous attempts  Lives alone or feels alienated; lacks social support  Recent loss(es) and excessive guilt  Poor physical health  H/o frequent threats of self-harm or suicide  Giving away belongings  Depression  At greater risk as depression lifts  Anger  Co-existing substance abuse, or Mental Illness dx.

Suicide and Mental Illness 90% have Diagnosable Mental Conditions: 90% have Diagnosable Mental Conditions: Substance abuse, Bipolar depression, Major Depression, Schizophrenia Substance abuse, Bipolar depression, Major Depression, Schizophrenia What other diagnoses are also associated with risk? What other diagnoses are also associated with risk?  Use of activating SSRI antidepressants: fluoxetine (Prozac) supply energy before the sertraline (Zoloft) depression is relieved

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 40 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 feels he’d be better off dead, but willingly discusses what has happened recently in his life: broke up with girlfriend, furlough from his job, mother is terminally ill.

Nursing Process Scenario In general, which behaviors indicate a risk for suicide? Able to list support system Able to list support system Able to state method he would use if he tries again Able to state method he would use if he tries again Easily talks about feelings with nurse Easily talks about feelings with nurse Has experienced recent loss Has experienced recent loss Talks about future job plans Talks about future job plans

Scenario: Nursing Process Initial Nursing Diagnoses after interview: Problem 1: Risk for Suicide r/t hopelessness and actual or anticipated personal losses Problem 2: Ineffective Individual Coping r/t substance abuse Write a short-term goal for each of these Write a short-term goal for each of these

Ethical and Legal Aspects One short term goal written for Problem 1 is: Client will sign no-harm contract by end of shift  What is the value of this contract from:  an ethical standpoint?  a legal standpoint?