Suicide
-is not a diagnosis or a disorder; it is a behavior
-In the field of psychiatry, suicide is considered an irrational act associated with mental illness and most commonly, but not exclusively, with depression.
-More than 90 percent of all persons who commi
Historical Perspectives
-In ancient Greece, suicide was an offense against the state, and individuals who committed suicide were denied burial in community sites . -In the culture of the imperial Roman army, individuals sometimes resorted to suicide to escape humiliation or abus
Epidemiological Factors
More than 41,000 people committed suicide in 2013, the most recent year for which statistics have been recorded. This is the highest rate of suicide in 15 years. These recent statistics have established suicide as the second-leading cause of death (behind
Risk factors
-Marital status
-Gender
-Age
-Ethnicity
-Socioeconomic status
-Religion
-Psychiatric illness
-Severe insomnia
-Other
Marital Status
The suicide rate for single, never married persons is twice that for married persons, and divorce increases risk for suicide particularly among men, who are three times more likely to take their own lives than are divorced women.
Gender
More women than men attempt suicide, but men succeed more often. Successful suicides number about 70 percent for men and 30 percent for women. This success rate has to do with the lethality of the means. Women tend to overdose; men use more lethal means,
Age
-Suicide risk and age are, in general, positively correlated, particularly with men.
-in 2013, the highest rate of suicide occurred in the 45- to 64-year-old age group (with men at particular risk), and the second-highest rate was for those 85 or older (A
Religion
men and women who consider themselves affiliated with a religion are less likely than their nonreligious counterparts to attempt suicide
Socioeconomic Status
-Individuals in the very highest and lowest social classes have higher suicide rates than those in the middle classes
Socioeconomic Status- Occupation
suicide rates are higher among physicians, artists, dentists, law enforcement officers, lawyers, and insurance agents. There are more suicides among the unemployed than among the employed, and suicide rates increase during economic recessions and depressi
Ethnicity
With regard to ethnicity, statistics show that whites are at highest risk for suicide, followed by Native Americans, African Americans, Hispanic Americans, and Asian Americans
Other Risk Factors
- Although suicide is often thought of as strictly related to depression, there is also a recognized risk of suicide among people with schizophrenia, bipolar disorders, personality disorders, eating disorders, anxiety disorders, and substance use disorder
Theories of Suicide: Psychological
-Anger turned inward
-Hopelessness
-Desperation and guilt
-History of aggresion and violence
-Shame and humiliation
Anger turned inward
Freud (1957) believed that suicide was a response to the intense self-hatred that an individual possessed. The anger had originated toward a love object but was ultimately turned inward against the self. Freud believed that suicide occurred as a result of
Hopelessness and Other Symptoms of Depression
Hopelessness has long been identified as a symptom of depression and as an underlying factor in the predisposition to suicide.
History of Aggression and Violence
A history of violent behavior or impulsive acts has been associated with increased risk for suicide, although recent evidence suggests that impulsive traits are higher in individuals with suicide ideation but not necessarily associated with more attempts.
Shame and Humiliation
Some individuals have viewed suicide as a "face-saving" mechanism�a way to prevent public humiliation following a social defeat such as a sudden loss of status or income. Often, these individuals are too embarrassed to seek treatment or other support syst
Durkheim 1951
He believed that the more cohesive the society and the more that the individual felt an integrated part of society, the less likely he or she was to commit suicide.
Theories of Suicide: Sociological- Durkheim's three social categories of suicide:
-Egoistic suicide
-Altruistic suicide
-Anomic suicide
Egoistic suicide
is the response of the individual who feels separate and apart from the mainstream of society. Integration is lacking, and the individual does not feel a part of any cohesive group (such as a family or a church).
Altruistic suicide
is the opposite of egoistic suicide. The individual who is prone to altruistic suicide is excessively integrated into the group. The group is often governed by cultural, religious, or political ties, and allegiance is so strong that the individual will sa
Anomic suicide
occurs in response to changes in an individual's life (e.g., divorce, loss of job) that disrupt feelings of relatedness to the group. An interruption in the customary norms of behavior instills feelings of "separateness" and fears of being without support
Theories of Suicide: Biological
-Genetics
-Neurochemical
Genetics
Twin studies have shown a much higher concordance rate for monozygotic twins than for dizygotic twins. Some studies with people who have attempted suicide have focused on the genotypic variations in the gene for tryptophan hydroxylase, with results indica
Neurochemical Factors
A number of studies have revealed a deficiency of serotonin (measured as a decrease in the levels of 5-hydroxyindole acetic acid [5-HIAA] in the cerebrospinal fluid) in depressed clients who attempted suicide. These studies, as well as postmortem studies,
Assessment:
-Presenting Symptoms: Medical- psychiatric diagnosis
-Suicidal ideas or acts: Seriousness of intent, Plan, Means, Verbal and behavioral clues.
-Interpersonal support system
-identify and distinguish ideas (thoughts), plans (intentions), and attempts (beha
Nursing Process: Assessment: Demographics:
-Age
-Gender
-Ethnicity
-Occupation
-Socioeconomic status
-Marital status
-Lethality and availability of method
-Religion
-Family history of suicide
Demographics- Age:
Adolescents and the elderly have been generally identified as high-risk groups, but recent statistics demonstrating the highest incidence in the 45- to 64-years age group suggests that nurses should pay close attention to assessing for suicide risk in all
Demographics- Gender:
Males are at higher risk for successful suicide than females, but females attempt suicide more frequently.
Demographics Ethnicity/race:
The CDC reports highest rates of suicide among Caucasians followed by American Indians
Demographics- Marital status:
Single, divorced, and widowed individuals are at higher risk for suicide than are married people.
Demographics- Socioeconomic status:
Individuals in the highest and lowest socioeconomic classes are at higher risk than those in the middle classes.
Demographics- Occupation:
Health-care professionals (especially physicians), law enforcement officers, dentists, artists, mechanics, lawyers, and insurance agents have all been identified as occupational groups incurring greater risks for suicide.
Demographics- Method:
The lethality of the method identified by an individual with suicide ideation or by one who has already made an attempt provides meaningful information about the client's intent to die. Use of firearms, for example, is considered a highly lethal method.
Demographics- Religion:
People with a close religious affiliation may be at less risk for attempting suicide if they believe, for example, that suicide is an unforgivable sin or that within their religious affiliation suicide is strictly forbidden. Conversely, people without clo
Demographics- Family history:
A family history of suicide increases an individual's risk for suicide.
Demographics- Military history:
Suicide rates among military personnel now exceed those of the general population.
Presenting Symptoms and Medical-Psychiatric Diagnosis
Mood disorders (major depression and bipolar disorders) are the most common disorders that precede suicide. Individuals with substance use disorders are also at high risk. Other psychiatric disorders in which suicide risks have been identified include anx
Suicidal Ideas or Acts
-MUST ASK
-Individuals may provide both behavioral and verbal clues as to the intent of their act.
-Verbal clues may be both direct and indirect.
-determining whether the individual has a plan, and if so, whether he or she has the means to carry out that
Interpersonal Support System
Does the individual have support persons on whom he or she can rely during a crisis situation? Lack of a meaningful network of satisfactory relationships may implicate an individual as a high risk for suicide during an emotional crisis.
Assessment: Analysis of the Suicidal Crisis:
-Precipitating stressor
-Relevant history
-Life-stage issues
-Psychiatric /medical/family history
The precipitating stressor
Adverse life events in combination with other risk factors, such as depression, may lead to suicide. Life stresses accompanied by an increase in emotional disturbance include the loss of a loved person either by death or by divorce, problems in major rela
Relevant history
Has the individual experienced numerous failures or rejections that would increase his or her vulnerability for a dysfunctional response to the current situation?
Life-stage issues:
The ability to tolerate losses and disappointments is often compromised if those losses and disappointments occur during various stages of life in which the individual struggles with developmental issues (e.g., adolescence, midlife).
Diagnosis- Nursing diagnoses for the suicidal client may include:
-Risk for suicide
-Hopelessness
Planning/Outcome- Short term:
-Remain safe
-Has experienced no physical harm to self.
-Sets realistic goals for self.
-Expresses some optimism and hope for the future.
Psychiatric, Medical, and Family History
The individual should be assessed with regard to previous psychiatric treatment for depression, alcoholism, or previous suicide attempts. Medical history should be obtained to determine the presence of chronic, debilitating, or terminal illness.
IS PATH WARM?
-I: Ideation
-S: Substance Abuse
-P: Purposelessness
-A: Anger
-T: Trapped
-H: Hopelessness
-W: Withdrawal
-A: Anxiety
-R: Recklessness
-M: Mood
Ideation
Has suicide ideas that are current and active, especially with an identified plan
Substance abuse
Has current and/or excessive use of alcohol or other mood-altering drugs
Purposelessness
Expresses thoughts that there is no reason to continue living
Anger
Expresses uncontrolled anger or feelings of rage
Trapped
Expresses the belief that there is no way out of the current situation
Hopelessness
Expresses lack of hope and perceives little chance of positive change
Withdrawal
Expresses desire to withdraw from others or has begun withdrawing
Anxiety
Expresses anxiety, agitation, and/or changes in sleep patterns
Recklessness
Engages in reckless or risky activities with little thought of consequences
Mood
Expresses dramatic mood shifts
Nursing diagnoses for the suicidal client may include the following:
-Risk for suicide related to feelings of hopelessness and desperation.
-Hopelessness related to absence of support systems and perception of worthlessness.
Outcome Criteria
-include short- and long-term goals
-Has experienced no physical harm to self.
-Sets realistic goals for self.
-Expresses some optimism and hope for the future.
Planning/Outcome- Long term:
-Develop and maintain a more positive self-concept.
-Learn more effective ways to express feelings to others.
-Achieve successful interpersonal relationships.
-Feel accepted by others and achieve a sense of belonging.
Interventions- Guidelines for treatment of the suicidal client on an outpatient basis:
-Do not leave the person alone.
-Establish a no-suicide contract with the client.
-Enlist the help of family or friends.
-Schedule frequent appointments.
-Establish rapport and promote a trusting relationship.
-Be direct and talk matter-of-factly about su
Interventions- Information for family and friends of the suicidal client:
-Take any hint of suicide seriously.
-Do not keep secrets.
-Be a good listener.
-Express feelings of personal worth to the client.
-Important to stress that the person's life is important to you and to others.
-Express concern for individuals who express
Fleener (2013) offers the following suggestions for interacting with people who are suicidal:
-Acknowledge and accept their feelings and be an active listener.
-Try to give them hope, and remind them that what they are feeling is temporary.
-Stay with them. Do not leave them alone. Go to where they are, if necessary.
-Show love and encouragement.
Interventions- Interventions with family and friends of suicide victims:
-Encourage him or her to talk about the suicide.
-Discourage blaming and scapegoating.
-Listen to feelings of guilt and self-persecution.
-Talk about personal relationships with the victim.
-Recognize differences in styles of grieving.
-Assist with develo
Evalution
-Ongoing reassessment
-Ensure Follow-up
-Ensure the client knows who to call if feeling suicidal
-continuous reassessment of the client as well as determination of goal achievement
-A suicidal person feels worthless and hopeless