lOMoAR cPSD| 63316909
Concept: Violence
Suicide: act of taking one’s own life. 10th leading cause of death.
• Suicide attempt: the act of attempting to take one’s own life, but not successful/doesn’t result in
death.
• Suicide ideation (SI) : a person constantly considering, planning, or thinking about suicide.
Etiology (Causes): Depression plays a huge role. Usually, the person feels death is only option to solve the
current problem. Those that don’t really care if they live or die use less lethal options. Those that are intent
on death will use a more lethal option. Assessing lethality is important! Middle age white men have highest
role in suicide (access to guns, PTSD, role expectations, can’t adhere to expectations, midlife crisis,
divorce/lack of support.)
Pathophysiology (reasons for SI/suicidal thoughts)
• Genetics and neurobiology: risk is 5x higher when a family member has committed suicide.
• Interpersonal factors: situations that take away control from someone.
o Any significant disturbance can cause a person to become depressed. People who lose a
partner should be monitored closely. A low sense of belongingness can be described as
feelings linked to isolation and disconnection from others. Joiner concluded that the
element of “acquired ability for lethal self-injury” must be present in addition to these
factors to lead individuals to attempt to take their life. With more painful experiences comes
greater capacity for suicide.
• Comorbid disorders: 90% of those that commit suicide have another behavioral health comorbidity.
o Half the people who kill themselves were either experiencing depression at the time or were in
recovery of depression. Most common co-morbid disorders are bipolar, borderline personality,
conduct disorder, schizophrenia, and drug/alcohol dependency. All these disorders have aspects of
impaired impulse control, depression and altered consciousness. People with bipolar are 15-20x
more likely to commit suicide. Most studied treatment associated with decreased suicide risk was
administration of lithium.
• Social factors: recessions, bullying, social beliefs.
o Recessions: economic recessions can cause financial strain and job loss; both are stressful
events excited as potential indicators of suicidal behavior. Economic recessions, and high
unemployment rates, often lead to individuals defaulting on mortgages or losing homes.
Bullying: bullying and discrimination have been linked to an increase for
suicide among transgender individuals. Social beliefs
• Genetics and Neurobiology: Suicide clusters are seen in families. Some of this is attributed to the
increase in suicide due to exposure or due to stressful family dynamics. Serotonin (5-
hydroxytryptamine; 5-HT) is an important neurotransmitter as it pertains to completed suicide.
Studies of the brains of those who have completed suicide show abnormalities of the serotonin
system in an area of the brain called the ventral medial prefrontal cortex. Biological
responses to stress may also constitute a risk factor for many people. The noradrenergic system
mediates stress response, arousal, alertness, and cognitive function and plays a role in the “fight or
flight” response. A chronically overactive noradrenergic system has been associated with anxiety,
agitation, and increased suicide risk. The hypothalamic–pituitary–adrenal (HPA) axis is another stress
response system. When the HPA axis is overactivated, people have a tendency toward depression,
suicide risk, and somatic symptoms.
Risk factors:
, lOMoAR cPSD| 63316909
• Health: Health issues that lead to suicide include comorbid mental health problems; medical
problems, especially those that are considered terminal, chronic, or painful; and TBIs o Certain
medications may also contribute to symptoms of depression; these include cardiac mediations,
corticosteroids, hormonal medications, chemotherapy, and medications to treat pain. Multiple
medications, including nearly all antidepressants, have the adverse effect of inducing suicide
ideation, and many come with a Black Box warning. This is why the US Food and Drug Administration
(FDA) requires all new drugs to be assessed for the potential to precipitate suicidal feelings. o AIDS,
cancer, cardiovascular disease, stroke, chronic kidney disease, cirrhosis, dementia, epilepsy, head
injury, Huntington’s disease, and multiple sclerosis.
• Environmental: Factors include access to means (guns, poison, lethal doses of medication),
prolonged stress in relationships, bullying, loss of employment, divorce, and exposure to suicide
(either known or through media). Lack of access to mental health care.
• Historical: Factors include previous attempts and family history of suicide or adverse childhood
events.
Clinical manifestations
• Behavioral Changes, Affect, Cognitive Changes, Social Isolation, Biophysical changes (not taking care
of yourself) o: feelings/facial expressions that we observe (observable traits) o patient
tells us Affect how they are feeling.
Mood: • Behavioral : verbal cues indicating desire to die, planning to commit
suicide/buying tools to do so, not participating in once loved activities, loss of interest in
school/work, participating in dangerous behaviors such as drug use, speeding, etc.
• IS PATH WARM (short term identifications of suicidal intention) o Ideation, substance abuse,
purposelessness, anxiety, trapped, hopelessness, withdrawal, anger, recklessness, mood changes.
• Cognition: rigid thinking, fantasies about death/dying, thought disorders, preoccupation with death,
fortune telling and extreme negativity.
• Social Isolation : life stressors, poor support systems, social pressure, feeling no one is there to help,
feeling alienated from society, end of relationship, death of spouse/family/friend.
Age
Children: Increased risk if they’ve lost a parent, been abused, have an unstable family or experience
humiliation at school. Can display depression differently (regression, moody).
Adolescents and Young Adult: Risk is increased. Can be “contagious.” Bullying has led to a rise in attempts.
Frontal lobe not fully developed until 25, so at risk for taking risky behaviors, which can cause accidental
death. OD may not be suicide, sometimes the intent was not death.
Strong risk factors for youth are aggression, disruptive behaviors, depression, and social isolation. The
following additional factors are related to youth suicide: Frequent episodes of running away, Frequent
expressions of rage, Family loss or instability, Frequent problems with parents, Withdrawal from family and
friends, Expression of suicidal thoughts or talk of death or the afterlife when sad or bored, Difficulty dealing
with sexual orientation, Unplanned pregnancy, Perception of school, work, or social failure.
Older Adults: Risk factors to be assessed among older adults include social isolation, solitary living
arrangements, widowhood, lack of financial resources, poor health, and feelings of hopelessness. Attempt
suicide is less but have a higher completion rate. Terminal illness increases risk of depression and suicidal
ideation. Untreated depression, loss of employment and finances, feelings of isolation, powerlessness, prior
attempts at suicide (older adult clients are more likely to succeed), change in functional ability, declining
physical health, alcohol or other substance abuse, loss of loved ones.
, lOMoAR cPSD| 63316909
Cultural Considerations
Catholicism and Islam strongly forbid suicide. In Japan, it is considered socially acceptable to
commit suicide in response to certain problems. Suicide bombings in muslin extremists. o Highest
risk for suicide: American Indians and Alaska natives (poverty, isolation, racism, lack of access,
substance abuse)
o 2nd highest risk: non-Hispanic whites o 2nd
lowest risk: African Americans o Lowest suicide
risk: Hispanics
Gender differences
• Women 45-64 have highest rate of suicide in females (hormonal changes, empty nesters,
isolation/divorce) Middle aged men had highest suicide rate in men.
• Firearms, suffocation, and poisoning are used for 90% of suicides.
SAD PERSONS Scale
S Sex 1 if male
A Age 1 if <19 or >45
D Depression or Hopelessness 2
P Previous attempt or psychiatric 1
care
E Excessive alcohol or drug use 1
R Rational thinking loss (psychotic 1
or organic)
S Separated, Widowed, Divorced 1
O Organized plan or Serious 2
Attempt
N No Social Support 1
S Stated future intent 1
(determined to repeat
ambivalent)
Guidelines for Action
0-5 May be safe to discharge (depending on circumstances). If sent home, have follow-up appointment
arranged and discharge patient with family or friend.
6–8 Probably requires psychiatric consultation.
>8 Probably requires hospital admission, voluntary or involuntary. See Chapter 6 for discussion of
involuntary hospitalization.
Suicide Contagion (safe reporting of suicide)
• Responsible reporting of suicides can reduce the risk of additional suicides.
Ultimately want to dispel myths and “de-stigmatize” it.
• Avoid describing method/location of suicide. Instead report the death as suicide, keep information
about location general. Avoid sharing the content of a suicide note. Instead report that a note was
, lOMoAR cPSD| 63316909
found and is under review. Avoid describing personal details about the person who died. Instead
keep information about the person general.
• Avoid presenting suicide as a common/acceptable response to hardship. Instead report that coping
skills, support, and treatment work for most people who have thoughts of suicide.
• Avoid oversimplifying or speculating on the reason for the suicide. Instead describe suicide warning
signs and risk factors (mental illness, relationship problems) that give suicide context.
• Avoid sensationalizing details in headline or story. Instead report on the death using facts and
language that are sensitive to a grieving family. Avoid glamorizing/romanticizing suicide. Instead
provide facts to counter perception that suicide was tied to heroism, honor, or loyalty to an individual
group. Avoid overstating the problem by suicide using descriptors like “epidemic” or “skyrocketing.”
Instead, research best available date and use words like “increase” or “rise.”
• Avoid prominent placement of stories related to a suicide death in print/newscast. Instead place a
print article inside the paper or magazine and later in a newscast.
Treatment & IVC
• Most common and effective treatment is medications/therapy. Treat underlying causes.
• Involuntary commitment:
o Client is held against their will in hospital. Must have a mental illness, pose a danger to self
or others, demonstrates a severe inability to meet basic needs, require treatment but unable
to seek it out on their own. o Must have mental illness/seeming to have mental illness,
pose a danger to self/others, severe inability to meet basic needs, requires treatment but
unable to seek it out on their own. o Can’t IVC for substance abuse disorder but can IVC for
depression and substance abuse disorder.
Pharmacologic
o Antidepressants—SSRI’s
Fluoxetine (Prozac), citalopram (celexa), sertraline (Zoloft), paroxetine (paxil),
escitalopram (lexapro) o Mood stabilizers and Antipsychotics: ketamine treatment for acute
suicidality; provide brief psychological therapy and ketamine treatment.
• Nonpharmacologic: Group therapy, individualized therapy, and family therapy. All of these can be
combined to help the patient. Establish a trusting therapeutic relationship.
• Therapeutic Communication: When questioning the client about suicide, always use a follow-up
question if the first answer is negative. For example, the client says, “I’m feeling completely
hopeless.” The nurse says, “Are you thinking of suicide?” Client: “No, I’m just sad.” Nurse: “I can see
you’re very sad. Are you thinking about hurting yourself?” Client: “Well, I’ve thought about it a lot.”
Apply Nursing Process:
Assessment
• Be direct but respectful. Talking about suicide does NOT put the idea into their head.
• Obtain a full client and family history.
• Assess suicidality: consider risk factors and protective factors, suicidal? Plan? Intent? Assess lethality,
CSSRS is a common assessment tool. The “ask suicide screening questions” (ASQ) is a tool set of four
brief suicide screening questions that takes 20 seconds.
o 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 of killing yourself? Have you tried to kill yourself? Are you having
thoughts of killing yourself right now?
Concept: Violence
Suicide: act of taking one’s own life. 10th leading cause of death.
• Suicide attempt: the act of attempting to take one’s own life, but not successful/doesn’t result in
death.
• Suicide ideation (SI) : a person constantly considering, planning, or thinking about suicide.
Etiology (Causes): Depression plays a huge role. Usually, the person feels death is only option to solve the
current problem. Those that don’t really care if they live or die use less lethal options. Those that are intent
on death will use a more lethal option. Assessing lethality is important! Middle age white men have highest
role in suicide (access to guns, PTSD, role expectations, can’t adhere to expectations, midlife crisis,
divorce/lack of support.)
Pathophysiology (reasons for SI/suicidal thoughts)
• Genetics and neurobiology: risk is 5x higher when a family member has committed suicide.
• Interpersonal factors: situations that take away control from someone.
o Any significant disturbance can cause a person to become depressed. People who lose a
partner should be monitored closely. A low sense of belongingness can be described as
feelings linked to isolation and disconnection from others. Joiner concluded that the
element of “acquired ability for lethal self-injury” must be present in addition to these
factors to lead individuals to attempt to take their life. With more painful experiences comes
greater capacity for suicide.
• Comorbid disorders: 90% of those that commit suicide have another behavioral health comorbidity.
o Half the people who kill themselves were either experiencing depression at the time or were in
recovery of depression. Most common co-morbid disorders are bipolar, borderline personality,
conduct disorder, schizophrenia, and drug/alcohol dependency. All these disorders have aspects of
impaired impulse control, depression and altered consciousness. People with bipolar are 15-20x
more likely to commit suicide. Most studied treatment associated with decreased suicide risk was
administration of lithium.
• Social factors: recessions, bullying, social beliefs.
o Recessions: economic recessions can cause financial strain and job loss; both are stressful
events excited as potential indicators of suicidal behavior. Economic recessions, and high
unemployment rates, often lead to individuals defaulting on mortgages or losing homes.
Bullying: bullying and discrimination have been linked to an increase for
suicide among transgender individuals. Social beliefs
• Genetics and Neurobiology: Suicide clusters are seen in families. Some of this is attributed to the
increase in suicide due to exposure or due to stressful family dynamics. Serotonin (5-
hydroxytryptamine; 5-HT) is an important neurotransmitter as it pertains to completed suicide.
Studies of the brains of those who have completed suicide show abnormalities of the serotonin
system in an area of the brain called the ventral medial prefrontal cortex. Biological
responses to stress may also constitute a risk factor for many people. The noradrenergic system
mediates stress response, arousal, alertness, and cognitive function and plays a role in the “fight or
flight” response. A chronically overactive noradrenergic system has been associated with anxiety,
agitation, and increased suicide risk. The hypothalamic–pituitary–adrenal (HPA) axis is another stress
response system. When the HPA axis is overactivated, people have a tendency toward depression,
suicide risk, and somatic symptoms.
Risk factors:
, lOMoAR cPSD| 63316909
• Health: Health issues that lead to suicide include comorbid mental health problems; medical
problems, especially those that are considered terminal, chronic, or painful; and TBIs o Certain
medications may also contribute to symptoms of depression; these include cardiac mediations,
corticosteroids, hormonal medications, chemotherapy, and medications to treat pain. Multiple
medications, including nearly all antidepressants, have the adverse effect of inducing suicide
ideation, and many come with a Black Box warning. This is why the US Food and Drug Administration
(FDA) requires all new drugs to be assessed for the potential to precipitate suicidal feelings. o AIDS,
cancer, cardiovascular disease, stroke, chronic kidney disease, cirrhosis, dementia, epilepsy, head
injury, Huntington’s disease, and multiple sclerosis.
• Environmental: Factors include access to means (guns, poison, lethal doses of medication),
prolonged stress in relationships, bullying, loss of employment, divorce, and exposure to suicide
(either known or through media). Lack of access to mental health care.
• Historical: Factors include previous attempts and family history of suicide or adverse childhood
events.
Clinical manifestations
• Behavioral Changes, Affect, Cognitive Changes, Social Isolation, Biophysical changes (not taking care
of yourself) o: feelings/facial expressions that we observe (observable traits) o patient
tells us Affect how they are feeling.
Mood: • Behavioral : verbal cues indicating desire to die, planning to commit
suicide/buying tools to do so, not participating in once loved activities, loss of interest in
school/work, participating in dangerous behaviors such as drug use, speeding, etc.
• IS PATH WARM (short term identifications of suicidal intention) o Ideation, substance abuse,
purposelessness, anxiety, trapped, hopelessness, withdrawal, anger, recklessness, mood changes.
• Cognition: rigid thinking, fantasies about death/dying, thought disorders, preoccupation with death,
fortune telling and extreme negativity.
• Social Isolation : life stressors, poor support systems, social pressure, feeling no one is there to help,
feeling alienated from society, end of relationship, death of spouse/family/friend.
Age
Children: Increased risk if they’ve lost a parent, been abused, have an unstable family or experience
humiliation at school. Can display depression differently (regression, moody).
Adolescents and Young Adult: Risk is increased. Can be “contagious.” Bullying has led to a rise in attempts.
Frontal lobe not fully developed until 25, so at risk for taking risky behaviors, which can cause accidental
death. OD may not be suicide, sometimes the intent was not death.
Strong risk factors for youth are aggression, disruptive behaviors, depression, and social isolation. The
following additional factors are related to youth suicide: Frequent episodes of running away, Frequent
expressions of rage, Family loss or instability, Frequent problems with parents, Withdrawal from family and
friends, Expression of suicidal thoughts or talk of death or the afterlife when sad or bored, Difficulty dealing
with sexual orientation, Unplanned pregnancy, Perception of school, work, or social failure.
Older Adults: Risk factors to be assessed among older adults include social isolation, solitary living
arrangements, widowhood, lack of financial resources, poor health, and feelings of hopelessness. Attempt
suicide is less but have a higher completion rate. Terminal illness increases risk of depression and suicidal
ideation. Untreated depression, loss of employment and finances, feelings of isolation, powerlessness, prior
attempts at suicide (older adult clients are more likely to succeed), change in functional ability, declining
physical health, alcohol or other substance abuse, loss of loved ones.
, lOMoAR cPSD| 63316909
Cultural Considerations
Catholicism and Islam strongly forbid suicide. In Japan, it is considered socially acceptable to
commit suicide in response to certain problems. Suicide bombings in muslin extremists. o Highest
risk for suicide: American Indians and Alaska natives (poverty, isolation, racism, lack of access,
substance abuse)
o 2nd highest risk: non-Hispanic whites o 2nd
lowest risk: African Americans o Lowest suicide
risk: Hispanics
Gender differences
• Women 45-64 have highest rate of suicide in females (hormonal changes, empty nesters,
isolation/divorce) Middle aged men had highest suicide rate in men.
• Firearms, suffocation, and poisoning are used for 90% of suicides.
SAD PERSONS Scale
S Sex 1 if male
A Age 1 if <19 or >45
D Depression or Hopelessness 2
P Previous attempt or psychiatric 1
care
E Excessive alcohol or drug use 1
R Rational thinking loss (psychotic 1
or organic)
S Separated, Widowed, Divorced 1
O Organized plan or Serious 2
Attempt
N No Social Support 1
S Stated future intent 1
(determined to repeat
ambivalent)
Guidelines for Action
0-5 May be safe to discharge (depending on circumstances). If sent home, have follow-up appointment
arranged and discharge patient with family or friend.
6–8 Probably requires psychiatric consultation.
>8 Probably requires hospital admission, voluntary or involuntary. See Chapter 6 for discussion of
involuntary hospitalization.
Suicide Contagion (safe reporting of suicide)
• Responsible reporting of suicides can reduce the risk of additional suicides.
Ultimately want to dispel myths and “de-stigmatize” it.
• Avoid describing method/location of suicide. Instead report the death as suicide, keep information
about location general. Avoid sharing the content of a suicide note. Instead report that a note was
, lOMoAR cPSD| 63316909
found and is under review. Avoid describing personal details about the person who died. Instead
keep information about the person general.
• Avoid presenting suicide as a common/acceptable response to hardship. Instead report that coping
skills, support, and treatment work for most people who have thoughts of suicide.
• Avoid oversimplifying or speculating on the reason for the suicide. Instead describe suicide warning
signs and risk factors (mental illness, relationship problems) that give suicide context.
• Avoid sensationalizing details in headline or story. Instead report on the death using facts and
language that are sensitive to a grieving family. Avoid glamorizing/romanticizing suicide. Instead
provide facts to counter perception that suicide was tied to heroism, honor, or loyalty to an individual
group. Avoid overstating the problem by suicide using descriptors like “epidemic” or “skyrocketing.”
Instead, research best available date and use words like “increase” or “rise.”
• Avoid prominent placement of stories related to a suicide death in print/newscast. Instead place a
print article inside the paper or magazine and later in a newscast.
Treatment & IVC
• Most common and effective treatment is medications/therapy. Treat underlying causes.
• Involuntary commitment:
o Client is held against their will in hospital. Must have a mental illness, pose a danger to self
or others, demonstrates a severe inability to meet basic needs, require treatment but unable
to seek it out on their own. o Must have mental illness/seeming to have mental illness,
pose a danger to self/others, severe inability to meet basic needs, requires treatment but
unable to seek it out on their own. o Can’t IVC for substance abuse disorder but can IVC for
depression and substance abuse disorder.
Pharmacologic
o Antidepressants—SSRI’s
Fluoxetine (Prozac), citalopram (celexa), sertraline (Zoloft), paroxetine (paxil),
escitalopram (lexapro) o Mood stabilizers and Antipsychotics: ketamine treatment for acute
suicidality; provide brief psychological therapy and ketamine treatment.
• Nonpharmacologic: Group therapy, individualized therapy, and family therapy. All of these can be
combined to help the patient. Establish a trusting therapeutic relationship.
• Therapeutic Communication: When questioning the client about suicide, always use a follow-up
question if the first answer is negative. For example, the client says, “I’m feeling completely
hopeless.” The nurse says, “Are you thinking of suicide?” Client: “No, I’m just sad.” Nurse: “I can see
you’re very sad. Are you thinking about hurting yourself?” Client: “Well, I’ve thought about it a lot.”
Apply Nursing Process:
Assessment
• Be direct but respectful. Talking about suicide does NOT put the idea into their head.
• Obtain a full client and family history.
• Assess suicidality: consider risk factors and protective factors, suicidal? Plan? Intent? Assess lethality,
CSSRS is a common assessment tool. The “ask suicide screening questions” (ASQ) is a tool set of four
brief suicide screening questions that takes 20 seconds.
o 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 of killing yourself? Have you tried to kill yourself? Are you having
thoughts of killing yourself right now?
