Suicide

Epidemiology

Currently in the US, there are

slightly more than 30,000 suicides
annually or a suicide every 17
minutes
8th leading cause of death in the
US
The 2 most vulnerable age groups
are the elderly and the youth ages
15-24 years
 Biological Factors
Research with adults has
suggested that irregularities with
the serotonin system are found in
suicidal clients
– Breakdown products of serotonin (5-
HIAA) are exceptionally low in those
who have attempted violent suicide
– Pandy et al., (1995) did a study that
showed a significantly higher number
of 5-HT receptors on the surface of
blood platelets of suicidal pts
 Biological Factors (cont)

Goiler (1995) indicated that males

(and possibly females) with low
cholesterol levels (below 160
mg/dl) have a significantly
increased risk of suicide
 The Elderly

Rates of suicide are highest among

the older population, age 65 and
above
Older adults have suicide rates
50% higher than those of a nation
as a whole
Caucasian men 85 yrs and older
are most at risk for suicide
 The Elderly

High suicide rates among the

elderly have been hypothesized to
be caused by:
– Failure to adapt to significant losses
– The inability to endure emotional pain
– Pessimistic attitudes toward the aging
process that are r/t loneliness, illness,
rejection by family and society,
sudden termination of meaningful
work, disruption of long-standing
relationships, and feelings of
 The Youth

Young people between the ages of

15 to 24 have a suicide rate
approx 200% higher than that in
the 1950s
Suicide ranks as the 3rd leading
cause of death for youth
 Gender and Ethnicity
Older Caucasian men have the
highest suicide rates
African-American young adult men
have the 2nd highest rate of suicide
Males commit suicide at rates 3 to
4 times higher than females
Females have the highest rate of
suicide attempts—female Hispanic
suicide attempt rate is higher than
any other ethnic minority group in
the US
 Familial Influences

Suicidal behavior is frequently a sx

of prolonged and progressive
family disruption and dysfunction
Significant changes in the family
such as divorce, death of a spouse,
parent, or child, and social
isolation contribute to high suicide
rates
 Familial Influences

There is a familial predisposition to

suicide in that many suicidal
adolescents often have histories of
suicide or suicidal behavior among
their immediate or extended
families
 Co-Occurrence with
Related Health Issues
Adjuncts to suicidal events include:
– Psychiatric illness
– Drug and alcohol abuse
– Medical illnesses
 Psychiatric Disorders

The presence of a diagnosable

mental disorder increases the risk
of suicide regardless of age
One study done found that 90.1%
of their research population had an
emotional illness at the time of
their suicide attempt
 Depression

The single best predictor of

suicidal thinking is the presence of
a mood d/o
Research indicates that 30-70% of
all completed suicides are r/t
depression
 Schizophrenia

Suicide is the leading cause of

premature death in this population
– 10% incidence in the 1st 10 yrs of
illness and a 15% lifetime incidence
The high risk period is in the 20-30
yr age group
Other risk factors for suicide
completion include:
– Active psychotic sx
 Borderline Personality
Disorder
DSM IV criteria for BPD include
“recurrent suicidal behavior, gestures,
or threats of self-mutilating behavior”
Often clients with BPD experience
suicidal behavior when there is a loss or
perceived loss
Research has also shown that the trait
of impulsivity is an important risk factor
for suicide attempts
Individuals with a hx of childhood abuse
have a higher possibility for engaging in
self-destructive behaviors
 Alcohol and Other Drugs

Independent of another specific

psychiatric dx, alcohol use and
abuse are highly correlated with
most suicidal acts, especially
among youth
Drug use contributes to poor,
impulsive decisions that can lead
to high-risk, self-injurious
behaviors
 Medical Illnesses
Chronic physical illness contributes to
suicidal behavior
– Physical health problems often enhance the
emotional pain experienced by suicidal
persons and may contribute to their
decision to end their life
Physical health problems, such as heart
disease, HTN, obesity, and diabetes
were found in more than half of the
outpatients who committed suicide in
several studies
A complicating factor is when these pts
 Suicide Assessment

The assessment of suicide is an

important skill for the professional
nurse in all practice settings
The nurse needs to use interviewing
skills to talk directly with the client and
family about suicide during the initial
nsg assessment as well as throughout
the hospital stay
Knowledge of the clients PMH and psych
hx of suicidal behaviors gives the nurse
clues for identifying areas for further
 Suicide Assessment (cont)

Are you experiencing thoughts of

suicide?
Have you ever had thoughts of
suicide in the past?
Have you ever attempted suicide?
Do you have a plan for committing
suicide?
If so, what is your plan for suicide?
 SAD PERSONS Scale
S—Sex
– Men kill themselves 3x more often than
women; women make attempts 3x more
often than men
A—Age
– High risk groups: 19 yrs old or younger; 45
yrs or older, esp the elderly >65
D—Depression
P—Previous attempts
E—ETOH
– ETOH is assoc with up to 65% of completed
suicides
 SAD PERSONS Scale

R—Rational thinking loss

– People with functional or organic psychoses
are more apt to commit suicide than the
general pop
S—Social supports lacking
– A suicidal person often lacks significant
others (friends, relatives), meaningful
employment, and religious supports (assess
all 3 areas)
O—Organized plan
– Presence of specific plan indicates high risk
 SAD PERSONS Scale

N—No spouse
– Repeated studies have shown that
persons who are widowed, separated
or divorced are at greater risk than
those who are married
S—Sickness
 5 Levels of Suicidal
Behavior
Suicidal ideation
– Direct or indirect thoughts or
fantasies of suicide or self-injurious
acts without definite intent or action
expressed
Suicide threats
– Direct verbal or written expressions of
intent to commit suicide but without
action
 5 Levels of Suicidal
Behavior (cont)
Suicidal gestures
– Self-directed actions that result in no
injury or minor injury by persons who
neither intended to end their lives nor
expected to die as a result, but were
done in such a way that others would
interpret the act as suicidal in
purpose
– Ex: minor scratches on wrist done
with a plastic knife
 5 Levels of Suicidal
Behavior (cont)
Suicide attempts
– Serious self-directed actions that may
result in minor or major injury by
persons who intend to end their lives
or cause serious harm to themselves
– Gestures and attempts that are
unsuccessful and of low lethality are
often called parasuicidal behavior
Completed or successful suicides
– Deaths of persons who ended their
lives by their own means with
 Determinants of Lethality

Imminence versus nonimminence

Ideation versus intent
Chosen method and accessibility
 Imminence vs
Nonimminence
If persons are imminently in
danger of killing themselves, rapid
action must be taken
Determination of imminence is
subjective and at best is a clinical
judgment based on:
– Professional’s experience
– Knowledge base
– Intuition
 Imminence vs
Nonimminence (cont)
The following suggest that a
person is at imminent risk for
suicide:
– A specific plan
– Access to lethal measures
– Behaviors that signal a decision to die
– Admission of wanting to die
 Ideation vs Intent
Suicidal ideation or thinking about
suicide without clear intent places
a person at lower risk than a
person who intends to die through
a suicidal act
Nurses should carefully observe
and listen for direct and indirect
communication regarding suicidal
intent
– They should not only listen for words,
 Chosen Method and
Accessibility
The method and its availability
determine the outcome of the
suicidal behavior
– High lethality acts through violent
methods include:
• Using firearms—the most prevalent high-
lethality method used in the US
• Piercing of vital organs
• Hanging
• Jumping from high places
• Carbon monoxide poisoning
 Chosen Method and
Accessibility (cont)
Men who complete suicide are
more likely to select violent means
and use guns or knives or hang
themselves
Women are more likely to jump
from high places or Over Dose
Nonfatal attempters tend to
engage in multiple, low-lethality
acts and use self-poisoning by pill
ingestion (most common method
for suicide attempts) followed by
 Chosen Method and
Accessibility (cont)
Accessibility to dangerous weapons
increases suicide risk
The most rapid increase in firearm
suicides has been in the 15 to 24 yr age
range
Suicidal clients in psychiatric hospitals
are high suicide risks
– The most vulnerable periods for attempts
are within the 1st 24 hrs after admission and
as d/c approaches
– **A sudden brightening of affect or lifting of
depression may signal that the client has
 Chosen Method and
Accessibility (cont)
Hanging is the most prevalent
suicide method used in hospital
settings
It is not possible to prevent all
suicides, even in the most secure
facilities, but close observation and
continued reassessment of suicide
risk minimize the chances of
completed suicides
 Discharge Criteria for the
Suicidal Client
Indications that the client is no longer
imminently suicidal
Determination that the client’s living
condition is safe for his or her return
A consistent support system is available
A commitment by the client to use
therapy to understand the crises that
precipitated the SI or attempt
An agreement by the client to call a
suicide hotline or call a supportive
person if SI is experienced again
Case Study
 Case Study

Jim is a 23 y/o SWM admitted to

the psychiatric unit with suicidal
thoughts. During the initial
assessment, Jim tells you he has
been having these thoughts for the
past weeks, but that they have
gotten much worse in the past 2
days. He endorses plan to hang
self.
 Case Study (cont)

What other information should be

gathered from Jim at this point?
 Case Study (cont)

Assessment
– The observable behavior of the client
– The hx from the client
– Information from friends and relatives
– Hx of suicidal gestures or attempts
– The mental status assessment
– The physical examination
– The nurse’s intuition
 Case Study (cont)

Jim then goes on to tell you that he

does have intent to kill self but
feels safe in the hospital. He also
identifies a precipitant to suicidal
thoughts as the loss of his job. He
reports feelings of hopelessness
and helplessness. He reports
depressed mood, SCD, DFA,
decreased appetite with 10 lb
weight loss, and isolation.
 Case Study (cont)

What are some nursing diagnoses

that can be formulated for Jim?
 Nursing Diagnoses

Violence, risk for: self-directed

Coping, ineffective individual
Hopelessness
Social isolation
Sleep pattern disturbance
Altered nutrition: less than body
requirements
 Case study (cont)

Outcome Identification
– What are the outcomes that we want
Jim to achieve?
 Outcome Identification
Jim will:
– Remain safe and free from self-harm
– Verbalize an absence of SI/plan/intent
– Agree to maintain a signed “no self-harm
contract” with the nsg staff or psychiatrist
– Agree to inform staff immediately if suicidal
thoughts feeling recur
– Display brightened affect with broad range
of expression and spontaneity
– Initiate social interactions with peers
– Use effective coping mechanisms to
counteract feelings of hopelessness
– Make plans for the future that include f/u
therapy and medication compliance
 Case study (cont)

Nursing Interventions
– Identify nursing interventions that we
can use with Jim.
 Nursing Interventions
Maintain q 15 minute checks
– If client is having active suicidal thoughts
with intent and is unable to contract for
safety, he will need to be placed on
constant obs
Provide 1:1 interactions with client to
assess suicidality and allow for
ventilation of feelings
Routinely counting silverware and all
other sharp items before and after
client’s use
Provide a room-mate for the client
Grief and Loss
 Grief and Loss
Grief is the painful psychologic and
physiologic response to loss
Grief is most commonly associated
with the death of a loved one
– Can also occur with any significant
loss such as loss of self-esteem,
identity, dignity, or self-worth
Grief is a normal and inevitable
aspect of life
 Physical Manifestations of
Grief
Weakness Dry mouth
Anorexia GI disturbances
Feelings of Fatigue
choking Exhaustion
SOB Insomnia
Tightness in chest
Cognitive Manifestations
of Grief
Center on preoccupation with the
image and the thoughts of the
deceased
– Preoccupation may take the form of
conversations with the deceased
Difficulty concentrating
Hallucinations
– Usually described as momentary
glimpses of the person who died
– Also can consist of short auditory
messages perceived to be spoken by
the deceased
– In most cases, hallucinations diminish
Behavioral Manifestations
of Grief
The old life and patterns lose
meaning without the lost person or
object
Disruptions in patterns of conduct
ranging from:
– Inability to perform even basic ADLs
– Dragging through daily activities
– Restless, disorganized behavior that
includes “searching” for that which is
lost and obsessive rumination
Affective Manifestations of
Grief
Sadness, anger, loneliness, and
guilt are the most common
Sx of bereavement may meet the
criteria for dx of an affective d/o
– The most common differences
between sx of bereavement vs MDD
are that psychomotor retardation and
SI are less common in bereavement
– Affective d/os are of a longer duration
than bereavement
– Dysfunctional or unresolved grief may
result in major depression
Stages and Process of
Grief
 Stages of Grief

Grief is often times described in

terms of stages
Although there are many different
theories of grief, they can all be
summarized as having 3 basic
stages:
– Avoidance—numbing and blunting
– Confrontation—disorganization and
despair
 Stages of Grief (cont)
Avoidance
– Includes both the initial denial and the
subsequent brief periods of time when the
survivor “forgets” then “remembers” with
shock and pain the losses and grief
Confrontation
– Lengthy period of active mourning
– Includes the acute physical, cognitive,
behavioral, and affective manifestations of
grief
Reestablishment
– Occurs with the gradual decrease of sx
– Adjustment to life begins
 Process of Grief

An essential feature of the process

of grief is its dynamic, changing
nature
Periods of apparently normal
functioning may be interspersed
with periods of psychologic
distress or sx
 Grief Work
First named by Lindemann in 1944
The means by which people move
through the stages or process of
grief
Both a struggle to not give in to
despair and a willingness to
confront the reality of the despair
– Person must continue to move on in
life, but at the same time be able to
express the deep, painful emotions of
Types of Grief
 Types of Grief

Anticipatory grief
Acute grief
Complicated grief
 Anticipatory Grief
Premourning
Defined as grief associated with the
anticipation of a predicted death or loss
Early in the development of the
anticipatory grief model, anticipatory
grief was viewed as an adaptive process
that could help resolve relationships
and prepare survivors, to some extent,
for the anticipated loss
More recently, anticipatory grief has
been seen as being associated with a
high incidence of depression or with
 Anticipatory Grief (cont)

There is general agreement that:

– Grief begins when a serious physical
or mental illness occurs
– This grief may be termed anticipatory
and involves pain
– A lack of emotional response to
serious illness or other loss is an
indication that complicated or
dysfunctional grieving is likely
 Acute Grief

Referred to simply as grief

Acute grief does not have a clear
ending
– Gradually the sadness and pain
lessen
– The mourner moves forward with his
or her life
There are also periods when some
situation or event brings back the
 Complicated Grief
Grief that lasts longer and is
characterized by greater disability
than usual as defined by cultural
values
Types of complicated grief include:
– Traumatic grief
• Occurs when there is traumatic loss such
as a spouse murdered, a child dying
suddenly or unexpectedly
• PTSD is often a concurrent or
complicating factor
 Complicated Grief (cont)
Types of complicated grief include:
– Absent or inhibited grief
• Characterized by minimal emotional
expression of grief and is sometimes
associated with trauma
• Can be converted to delayed grief and
thus be experienced yrs after the loss
– Conflicted grief
• Occur when the relationship with the
deceased is characterized by
ambivalence or conflict
• Initial responses to the loss may be
 Complicated Grief (cont)
Types of complicated grief include:
– Chronic grief
• Unending grief after a loss
• May be related to the survivor having a
highly dependent relationship with the
deceased
• May also result from lack of resources or
support to deal with the loss
Bereavement Care Across
the Life Span
 Prevention—Before the
Loss
Grief is a universal experience that
may come with or without warning
Grief is best addressed by the
primary promotion of mental
health
– Family involvement in the community
and faith activities
– Improved parenting
– Promotion of mental and spiritual
 Prevention—When Loss is
Impending
Health promotion should be
considered in relation to grief work
in the case of terminal illness or
other anticipated loss
Interventions in these situations
could include:
– Assisting individuals and families in
working towards personal,
interpersonal, and spiritual
reconciliation
Prevention—After the Loss
Occurs after the loss and involves:
– Telling the “death story” or describing
in detail events surrounding the death
– Expressing and accepting the sadness
of grief
– Expressing and accepting guilt,
anger, and other feelings perceived
as negative
– Reviewing the relationship with the
deceased
– Exploring possibilities in life after loss
– Understanding common processes
 Problem-Oriented Grief
Therapy
Focuses on emotional responses to
the loss and problem solving
related to moving forward in life
Emotional issues center around:
– Telling and retelling the details of the
death and surrounding issues
– The hx of the relationship
– Emphasis on the experience and
expression of feelings—sadness,
anger, guilt
Case Study
 Case Study
Mrs. Jones is 70 y/o and lives alone in
the apartment she shared with her
husband for the past 17 years since
retirement. Her husband died last
month, after a 2 year struggle with
prostate CA. Since her husband’s
death, she has felt sad and depressed.
She wants to spend time with others but
says, “They are happy, and I’m sad, and
it’s no good for anyone.” For the past
week, Mrs. Jones has spent most of her
time alone in her apartment. She has a
 Case Study (cont)
According to your assessment,
what type of grief is Mrs. Jones
experiencing?
What other information should be
gathered from Mrs. Jones at this
point?
 Case Study (cont)
Assessment
Should include each of the
following domains:
– Physical disturbances
– Cognitive disturbances
– Behavioral and relating disturbances
– Affective disturbances
 Case Study (cont)

Identify some nursing diagnoses

for Mrs. Jones.
 Nursing Diagnoses

Sleep pattern disturbance

Social interaction, impaired
Self-esteem, situational low
Coping, ineffective individual
 Case Study (cont)

Outcome identification
– What are the outcomes that we want
Mrs. Jones to achieve?
 Outcome Identification
Mrs. Jones will:
– Verbalize absence of suicidal
ideations
– Express any guilty/angry feelings r/t
the death of her husband
– Express both + and – feelings about
her husband
– Formulate and implement reasonable
plans for adapting to life
– Participate in at least 1 social or
community activity each week
 Case Study (cont)

Nursing Interventions
– Identify nursing interventions that we
can use with Mrs. Jones.
 Nursing Interventions

Assess suicidality
Facilitate the client’s expression of
feelings r/t the loss and validate
the feelings that are already
expressed
Facilitate a review of Mrs. Jones
relationship with the deceased
Promote interactions with others
The End!