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Course: Mental Health Nursing

Topic: Suicide Prevention and Treatment Part II

The Nurses International Community

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Module Goals

Learners will be able to:

Discuss the current evidence based treatment of suicide ideation.
Discuss the factors associated with the prevention of suicide.
Discuss the nurse’s role in prevention of suicide and treatment of suicide ideation.

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Assessment of Suicidal Risk

Assess for presence of:

Mental health disorder
Serious adverse childhood events
A family history of suicide
Discrimination associated with being lesbian, gay, bisexual
Access to lethal means
Possibly a history of being bullied
Sleep disturbances
Chronic medical conditions

O'Rourke, Jamil, & Siddiqui, 2021

Contact info: info@nursesinternational.org

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Interviewing to Assess Suicidal Ideation (SI)

Characteristics of Current SI:

Onset, frequency, duration, intensity, triggers, associated factors, ability to control, attribution, passive or active SI thoughts.
Suicidal Ideation:

Ask questions to elicit thoughts on living and dying.
Distinguishing between passive and active SI is typically done to identify if an imminent short-term risk.

Harmer et al., 2021

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Interviewing to Assess Suicidal Ideation

Plan: Ask about the suicidal plan

Inquire thoughts of possible options? (e.g., overdose)
Inquire about previous plans
Has the person taken steps to put a plan in place? (e.g. identified a location)
Have they done anything to prepare? (e.g., hoarding medications, purchased rope, etc.)
Have they rehearsed the plan mentally or role played?

Harmer et al., 2021

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Interviewing to Assess Suicidal Ideation

Access to Means

Does the person have access to the chosen method?
Does the individual have career-based knowledge? (e.g.,anesthesiologist,)
Is the chosen plan plausible? How easy would it be for the client to access such means?

Intent

What is the primary reason for self-harming thoughts?
What is the intensity of the person's desire to die?
Has the person made preparations for death?

Harmer et al., 2021

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Interviewing to Assess Suicidal Ideation

Lethality:

Did the person believe that the chosen method and plan would be lethal?
Would the chosen method and plan allow for discovery and lifesaving intervention?

Protective factors

Are there any people or circumstances that would have a positive influence on the client’s desire to go on living?

Harmer et al., 2021

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Interviewing to Assess Suicidal Ideation

Previous attempts or aborted/interrupted attempts?

Ask about past or aborted suicide attempts? (When?)
What were the precipitants?
What was the method?
What was the medical severity?
Were alcohol or drugs involved?

Harmer et al., 2021

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Assessment of Suicidal Risk

Present/Past Risk factors:

Anxiety symptoms and panic attacks
Impulsivity
Psychotic thoughts
Anger/aggression
Mood - depression, hopelessness
Prior history of a psychiatric hospitalization
Health and psychosocial stressors - Painful, chronic, terminal medical illness.

Harmer et al., 2021

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Screening for Suicidal Ideation

Available Screening Tools:

Beck Fast scan: has seven long questions that can help determine the intensity and severity of the depression.
Suicide risk screen: is a 10-item questionnaire that is often used to screen for suicide, especially in young people.
The Patient Health Questionnaire (PHQ): consists of 9 items that ask various questions about self-harm.

O'Rourke, Jamil, & Siddiqui, 2021

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Screening for Suicidal Ideation

The SAFE-T: can be used in an outpatient setting

The SAFE-T explores the following:

What is the suicidal ideation and its intensity, frequency, and duration within the past 48 hours and over the past 4 weeks?
Determines the most serious or worst harmful thought.
Planning of the suicide, location, time, availability, and if any preparations have been made.
Provides information on past behaviors such as past suicide attempts and any aborted attempts.

O'Rourke, Jamil, & Siddiqui, 2021

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Screening for Suicidal Ideation

The Columbia-Suicide Severity Rating Scale (C-SSRS):

Assesses any known suicide attempts and also assesses suicide ideations and behaviors
Like the SAFE-T, it can be used as an initial screen
For the detail of the tool, follow the below given link:
https://suicidepreventionlifeline.org/wp-content/uploads/2016/09/Suicide-Risk-Assessment-C-SSRS-Lifeline-Version-2014.pdf

O'Rourke, Jamil, & Siddiqui, 2021

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Treatment/Management

Involves a 2-phase process.
First and foremost: the client’s safety.

Intervention is based on the application of risk factors coupled with a clinical inquiry.

The second step:

Treatment aimed at diagnosing and treating the underlying mental disorder.

Soreff, Basit & Attia, 2021

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Management of Suicidal Ideation

First Phase:

If the person is indeed suicidal:

The individual must not be left alone.
Involve family or friends.
Ask the client for any weapon, such as knives or pills, and secure them away from the client.
Enlist the help of a support person while at home.
The suicidal individual must be treated in a safe and secure place.

Soreff, Basit & Attia, 2021

Contact info: info@nursesinternational.org

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Management of Suicidal Ideation

Second Phase:

After the initial intervention (Hospitalization)

The focus on addressing the underlying cause of the self-destructive behavior.
If the client has selected suicide to escape physical pain:

A comprehensive pain management program must be initiated.

Example: If the client is depressed, then the depression must be treated.

Soreff, Basit & Attia, 2021

Contact info: info@nursesinternational.org

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Management of Suicidal Ideation

If the client is sent home:

Help develop internal coping strategies (e.g., exercise, journaling, reading, developing a hobby).
Promote social support (call a family member, social worker).
Healthcare professionals to follow up on therapy.
Provide the client with the National Suicide Prevention Lifeline.
Tell the client to call 911 if he or she develops the desire to die.

O'Rourke, Jamil, & Siddiqui, 2021

Contact info: info@nursesinternational.org

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Management of Suicidal Ideation

Psychotherapy

Essential for long-term management
Cognitive behavior therapy and
Other related therapies:

Problem-solving therapy
Dialectical behavior therapy, and
Developmental group therapy

O'Rourke, Jamil, & Siddiqui, 2021

Contact info: info@nursesinternational.org

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Critical Thinking Question

In which stage of management of suicidal ideation would the psychiatrist focus on identifying the causes suicidal behavior?

First phase
Second Phase

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Protective Factors for Suicidal Ideation

Overall Resilience
Problem Solving Skills
Awareness and Access to Mental Health Care
Cultural and Religious Belief that Discourage Suicide
Positive Peer Relationship
Interpersonal and Community Connectedness
Safe Environment
Positive Adult Relationship

Substance Abuse and Mental Health Services Administration, 2020

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Prevention of Suicidal Ideation

Preventing trauma and adverse childhood experiences
Promoting parenting skills training
Establishing positive family supports
Strengthening positive coping norms
Implementing policies and laws that reduce binge drinking

Substance Abuse and Mental Health Services Administration, 2020

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Critical Thinking Question

Which of the following are the protective factors for suicidal ideation? (Select all that apply)

Awareness to mental health
Access to Mental Health care
Positive relationship
Good problem solving skills

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Practice Recommendations for Nurses

The nurse should take seriously all cient statements that indicate, a wish to die by suicide

Assess for suicide risk:

“Are you thinking about ending your life?”
“Are you suicidal?”
“Do you have a plan to take your own life?”
“Do thoughts of death or suicide enter your mind?”

The assessment is documented and communicated to the appropriate members of the health care team.

RNAO, 2009

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Practice Recommendation for Nurses

Establish a therapeutic relationship
Minimize the feelings of shame, guilt and stigma
Provide care with the principles of cultural competence
Assess and manage factors that impact physical safety
Potentially hazardous items include, but are not limited to:

Clothing (e.g. belts, shoelaces), cords,lighters,linens
Sharp or glass objects, toxic substances

RNAO, 2009

Contact info: info@nursesinternational.org

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Practice Recommendation for Nurses

Recognize key indicators that put a client at risk:

Assess for protective factors for suicide prevention.
Obtain collateral information from all sources:

Family, friends, community supports, medical records.

Mobilize resources based upon the client’s level of suicide risk.
Ensure that observation and therapeutic engagement reflects the client’s changing suicide risk.

RNAO, 2009

Contact info: info@nursesinternational.org

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Practice Recommendation for Nurses

Work collaboratively with clients to meet their needs.
Use a mutual problem-solving approach to facilitate the client’s understanding.
Foster hope in the suicidal client.
Be aware of current treatments to provide advocacy, referral, monitoring and health teaching interventions.
Identify persons affected by suicide that may benefit from resources and supports, and refers as required.

RNAO, 2009

Contact info: info@nursesinternational.org

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Responses When Client Says They Want to Kill Themselves

Listen and encourage them to talk about their situation.
Show empathy for their situation and let them know that you take them seriously.
Do not leave them alone.
Offer to get them help (e.g. contact their doctor or call a mental health centre or crisis hotline for advice).
If the person does not want help, inform them that you you are legally obliged to help them and that you are concerned for their safety.

NSW, 2020

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Nursing Actions when Caring for Suicidal Client

Act immediately if there is a risk.
Provide opportunities for a client to talk openly.
Demonstrate empathy and willingness to listen.
Ensure a safe environment for self and the client.
Record details of the interactions with the client.
Maintain a professional approach.
Be mindful of the possible impact of the client’s cultural background, and seek advice from relevant people.

Queensland Government, n.d

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Actions to avoide with suicidal risk clients

Don’t:

Dismiss threats of suicide.
Agree to keep a client’s suicide ideation a secret.
Feel pressured to have the ‘right answer’.
Be judgmental or dismissive towards the client.
Be afraid to ask about a client whether they are thinking about suicide or self-harm.

Queensland Government, n.d

Contact info: info@nursesinternational.org

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What Would the Nurse Do?

A nine (9)-year-old boy is admitted to a psychiatric treatment unit accompanied by his parents. Which action should the nurse take to establish trust and position of neutrality?

Encourage parents to leave while the child is being interviewed.
Interview the child with his parents together, observing their interaction.
Provide diversion for the child and interview the parents alone.
Review the clinical record prior to interviewing the parents

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Red Flags

Be alert to situations

When someone says they want to kill themselves
When someone exhibits suicidal behaviors

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References

Harmer B, Lee S, Duong TvH, et al. [Updated 2021 Aug 6]. Suicidal Ideation. In: StatPearls [Internet]. StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK565877/

NSW Government. (2020). How do I respond if someone says that they want to kill themselves?. https://www.health.nsw.gov.au/mentalhealth/psychosocial/strategies/Pages/communicating-response.aspx

O'Rourke MC, Jamil RT, Siddiqui W. Suicide Screening and Prevention. [Updated 2021 Jun 15]. In: StatPearls [Internet]. StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK531453/

Queensland Government, (n.d). Caring for a Person who is suicidal. https://www.health.qld.gov.au/__data/assets/pdf_file/0024/444534/suicidal.pdf

Contact info: info@nursesinternational.org

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References

RNAO. (2009). Assessment and Care of Adults at Risk for Suicidal Ideation and Behaviour. Nursing Best Practice Guideline Shaping the Future of Nursing. https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0.pdf

Soreff SM, Basit H, Attia FN. Suicide Risk. [Updated 2021 Jul 25]. In: StatPearls [Internet]. StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441982/

Substance Abuse and Mental Health Services Administration, (2020). Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth. EVIDENCE-BASED RESOURCE GUIDE SERIES. https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-06-01-002.pdf

Contact info: info@nursesinternational.org

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