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SUICIDE PREVENTION: ASSESSMENT AND TREATMENT Part I DANA BARTLETT, BSN, MSN, MA, CSPI Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years of as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevire, Lippincott, and Thieme. He has written widely on the subject of toxicology and was recently named a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center and is actively involved in lecturing and mentoring nurses, emergency medical residents and pharmacy students. Abstract Suicide is a leading cause of death in the United States. The literature on suicidology and large-scale studies conducted over the years suggest that there continues to be high rates of suicide among youth, men, and individuals with a mental illness as well as members of ethnic and social groups. The prevalence, risk and protective factors for suicidal thought and actions are discussed in this course. A general approach to highlight key studies and theories on suicidal risk factors and behaviors including an emphasis on modifiable risk and prevention is offered. Specifically, caring for family members and clinician self-care following a patient suicide is 1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com highlighted in this 2-part series. Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning Need Health clinicians need to know how to work with a patient in suicidal crisis. This includes knowing the guidelines on suicide assessment, treatment and management, including ethical and legal considerations. Additionally, clinicians should be aware of the prevalence of suicide, issues related to atrisk or vulnerable populations, and protective factors among various ethnic and racial groups to better evaluate patients for suicide risk. Clinicians that are aware of suicide myths, and common warning signs of a patient at risk for suicide, are better able to assess patients, develop a therapeutic alliance with patients, recommend various treatment approaches; and, an informed clinician is better able to incorporate professional recommendations of selfcare while dealing with a suicidal patient. 2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Course Purpose To provide health clinicians with knowledge of the guidelines on suicide prevention, including assessment and treatment of the patients and families, for individuals of all age groups in varied civilian and military roles, as well as observing professional guidelines for clinicians to care for themselves while caring for a suicidal patient or in the event of a patient suicide. Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Dana Bartlett, BSN, MSN, MA, CSPI, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. 3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. The CDC estimates _____ attempted suicides occur per every suicide death. a. b. c. d. 4 7 11 18 2. Suicide is the _____ leading cause of death among teenagers. a. b. c. d. number one second third fourth 3. Which of the following is defined as “nonlethal intentional selfinjurious behavior”? a. b. c. d. Contagion Parasuicide Suicidal ideation Cluster 4. Which of the following is defined as “a phenomenon whereby susceptible persons are influenced toward suicidal behavior through knowledge of another person’s suicidal acts”? a. b. c. d. Contagion Parasuicide Suicidal ideation Cluster 5. The increased suicide rate in the United States is especially pronounced in a. b. c. d. teenagers. middle aged adults. older adults. middle aged women. 4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Introduction One of the most challenging and prevalent issues clinicians can face is a patient’s suicidal crisis. Suicide is defined as self-inflicted death with evidence (either explicit or implicit) that the person intended to die. Although many patients experience major depressive episodes, training on how to manage suicidality is often not a component of training curriculums. Many recommendations are impractical to manage an emerging crisis. Working with a patient in suicidal crisis can be difficult and evoke strong feelings in the clinician. This course will provide discussion and highlight guidelines on suicide assessment, treatment and management. Overview Of Suicide Prevention In a 2014 American Psychology Association (APA) Monitor publication, Nadine Kaslow, APA President, sent an alarming message to clinicians to continue to focus on developing a public health perspective to reduce suicide. She stated that such an agenda must address diverse populations and span the continuum of suicidal behavior. Some of Kaslow’s suggestions included: 1) standardizing and providing training to psychologists and trainees on suicide assessment and treatment, 2) training community members as gatekeepers for identifying and referring those at risk, and 3) creating, assessing and disseminating programs that have a broad impact.1 Such services are most assuredly needed. The prevalence of suicide needs to be understood by clinicians. The National Institute of Mental Health has termed suicide as a major public health problem.2 According to the Centers for Disease Control and Prevention (CDC) statistics, suicide was the tenth leading cause of mortality in the 5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com United States, accounting for 41,149 deaths in 2013.3 Many people attempt suicide, but do not actually complete the attempt. These statistics estimate 11 attempted suicides occur for every suicide death.3 Most people who die by suicide have risk factors of depression and other significant mental health issues, a substance use disorder, or a combination of risk factors. In addition to the numbers quoted above, suicide is a growing concern for clinicians treating adolescents. A CDC study found that 16% of adolescents in grades 9-12 had seriously considered suicide and 8% attempted to do so.4 As these statistics suggest, health clinicians may often see suicidal ideation and suicidal behaviors among their patients. The identification of suicide risk remains among the most important, complex, and difficult task performed by clinicians. Research has confirmed that most mental health professionals have experienced at least one patient suicide.6 Patient suicide can have profound personal and professional effects, including increased levels of anxiety and stress, isolation and withdrawal,5 and damage to the therapists’ personal relationships. There may also be evidence of depression, a protracted grieving process, symptoms of posttraumatic stress or vicarious traumatization. Therapists working with suicidal patients have many responsibilities. These include developing a skill set and protocols for: 1) Treating clients who may be at risk for suicide, 2) Accurately assessing suicidal risk, 3) Responding to a client’s suicide attempt, and 4) Implementing self-care activities. It is important for clinicians to be knowledgeable when asking patients about suicidal ideation and behavior. It may be challenging for clinicians to balance their own comfort level with the need to obtain accurate and clear information. 6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Terminology Prior to looking at assessment and treatment of suicidal behavior, the following terms should be reviewed. Suicide: Self-inflicted death with evidence that the person intended to die. Suicide attempt: Self-injurious behavior with a nonfatal outcome and accompanied by evidence that the person intended to die. Parasuicide: Any nonlethal intentional self-injurious behavior that is intended to express suicidal feelings but not to cause harm. This is often called a suicide gesture. Suicidal ideation: Thoughts of suicide. They can vary in seriousness depending on how specific a suicide plan is, and the degree of intent. Suicidal intent: The seriousness or intensity of a person’s wish to terminate his or her life. Lethality of suicidal behavior: Objective danger to life associated with a suicidal method; lethality may not always coincide with an individual’s expectation of what is medically dangerous. Contagion: A phenomenon whereby susceptible persons are influenced towards suicidal behavior through knowledge of another person’s suicidal acts. There is evidence that suggests suicide is socially contagious, but there is also doubt that this is true and a lack of clarity regarding the definition of contagion as it pertains to suicide. Cluster: A suicide cluster is defined as a higher number of suicides occurring in a space and/or time than what is normally. Resilience: Capacities within a person that promote positive outcomes, such as mental health and wellbeing, and provides protection from 7 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com factors that might otherwise place that person at risk for adverse health outcomes and suicide. Suicide Prevalence Selected suicide data from the CDC and other noted sources are summarized below.3 In 2013, suicide was the 10th leading cause of death for Americans. From 1999 to 2014 the age-adjusted suicide rate in the United States increased 24%. Suicide death rates vary considerably among demographic variables including age, sex, race/ethnicity, and geographic region/state. Other variables that may also affect suicide rates are socioeconomic status, employment, occupation, sexual orientation, and gender identity. Whites, Native Americans, and Alaska natives are particularly at risk for suicide. Men commit suicide at four times the rate of women, but women are more likely to have suicidal thoughts. Men typically commit suicide by using a firearm, women by self-poisoning. A significant number of people who commit suicide will have a positive test for the presence of alcohol, anti-depressants, or opioid analgesics. In 2013, 494,169 people were treated in emergency rooms for selfinflicted injuries. Sexual and gender minorities are at a higher risk for suicide than heterosexuals. The increased suicide rate in the United States is especially pronounced in older adults, and older adults have more completed suicides. 8 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com It is important to note that these prevalence statistics are estimates, and it is difficult to know exactly how common suicidal behavior is in the general population and in subgroups. Suicides are often underreported, in part because it may be difficult to determine intent. Existing data collection instruments may also fail to include questions that would determine the prevalence of suicidal behaviors in specific groups. For example, because death certificates do not indicate sexual orientation and gender identity, rates of deaths by suicide in lesbian, gay, bisexual, and transgender (LGBT) populations are unknown and many of the research studies provide estimates only. Theories Of Suicidal Behavior Many of the current theories of suicidal behavior are based on a stressdiathesis model. In this model, suicidal behavior involves an interaction of trait-dependent/constant risk factors (diatheses) and a state-dependent trigger or stressor that is only present during certain periods of time. When both are in place the likelihood of suicidal behavior is increased; if only one is present the risk is less. Cognitive Stress Diathesis Model The cognitive stress diathesis model of suicide evaluates suicidality as a result of a combination of neuropsychological deficits in areas of memory, attention or problem solving along with stressors that result in perceptions of hopelessness, immovability, or esteem issues. The three primary components of this model are discussed below.5 Oversensitivity to Signals of Defeat: Researchers used the emotional Stroop task (measuring response time of 9 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com the participants to name colors of negative emotional words), and isolated attentional biases/perceptual pop-outs in association with suicidal behavior; hypersensitivity to stimuli signaling “loser” status increases the risk that the defeat response will be triggered. Perceived No Escape: Researchers theorized that problems with autobiographical memory limit the ability to problem-solve and when an individual is faced with stress, he or she may feel as if there is no escape from problems or life events. An individual may also think in an overly general way that prevents focusing on the details that could help problem solving. Perceived No Rescue: Suicidal behavior may be associated with limited fluency, and an inability to come up with positive events that might happen in the future. Thus, people may feel as if there is no rescue from the current life situation. They may also be unable to generate positive future events, causing significant levels of hopelessness, a core clinical predictor of suicidal behavior. Clinical Stress Diathesis Models The McGirr and Turecki model is based on the idea that psychopathology is a necessary, but not sufficient, factor for suicide. The authors noted that people who attempt or commit suicide might have a predisposition to do so because of aggressive and impulsive personality traits. Individuals with suicidality engage in behaviors without consideration of consequences, behaviors that are risky or inappropriate to the situation, and are accompanied by undesirable outcomes. 10 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Neurobiological Stress Diathesis Model Another example of a stress diathesis model of suicide uses neurobiological data. Some research included the use of PET studies to compare young men with a history of attempted suicide to young men with no suicide history. Groups involved in studies were shown pictures of angry, happy, and neutral faces. The young men with a suicide history demonstrated significant differences in brain activity. Those attempting suicide were distinguished from non-suicidal patients by their responses to angry and happy faces, suggesting increased sensitivity to others’ disapproval, higher propensity to act on negative emotions, and reduced attention to mildly positive stimuli. The authors concluded that these patterns of neural activity and cognitive processes might represent vulnerability markers of suicidal behavior in men with a history of depression, which was supported by later studies. Interpersonal Model of Suicidal Behavior The interpersonal theory of suicidal behavior holds that there are two factors that must be present for a person to commit suicide:6 1) Perceived burdensomeness, or the feeling that one is a liability, and 2) Thwarted belongingness or a feeling that there are no meaningful social connections. These feelings along with hopelessness, increased pain tolerance, and reduced fear of death, are the proximal causes of dangerous suicidal behavior. For example, the capability for suicidal behavior emerges in response to repeated exposure to physically painful and/or fear-inducing experiences. Such repeated exposure results in habituation and ultimately a higher tolerance for pain and a sense of fearlessness about death. Some researchers have suggested that clinicians should be cognizant of their patients’ levels of belongingness, burdensomeness, and acquired capability 11 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com (especially previous suicide attempts), in assessing suicide risk and in targeting therapeutic interventions. Research in Suicidology Suicidology is the scientific study of suicide. Suicide research is aimed at understanding and preventing suicide. The primary fields involved in suicide research are psychology and sociology. The following approaches help to shed light on the research. Psychological research focuses on the psychological states experienced by the person attempting or completing suicide. This can include the cognitive, behavioral or emotional components and states. Psychodynamic researchers focus on the role of anxiety and inner conflicts, postulating that suicide is how people express anger and hostility, generally as a way of turning these emotions inward. Rage, hopelessness, despair, and guilt are important affective states leading to suicide. The meanings of suicide can be usefully organized around the conscious and unconscious meanings given to death by the suicidal patient, for example, death as retaliatory abandonment, death as revenge, death as self-punishment or atonement. Biological, biochemical and constitutional research looks at how genetics, neurotransmitters, hormones, and biochemistry influence suicide. 12 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Biological suicide research has developed as an offshoot of biological depression research. Many of the studies are conducted after a person has committed suicide or are twin studies. Sociocultural research assesses the degree to which someone's surroundings exert a positive or negative influence; whether an individual's family, community and country are supportive or stressful. Psychiatric and mental illness researchers look at the connections between mental illness and suicide. Epidemiological and demographic research identifies populations most at risk for suicide. Some of the demographic factors studied are gender, race, sexual orientation, health issues, seasonal factors, and trends. Prevention, intervention and post-intervention research looks at how to prevent suicide from occurring (usually in specific at-risk groups), how to intervene in cases of active suicidality, and how to respond following completed suicide (alleviating the effects in family members and community). Key Research Findings/Risk Factors Case Vignette I Emma is a 24-year-old survivor of multiple traumas and recently diagnosed with a dissociative disorder. She is overwhelmed by the diagnosis and the need to start to work on her past trauma. She expresses that “this is too hard,” and “I don’t want to live like this anymore.” Her therapist expresses an understanding of the difficulty of the diagnosis and task and assumes that her expression of suicidal ideation is a communication of this difficulty. Her therapist is upset 13 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com when she receives a call indicating that Emma has been admitted to a hospital following a serious suicide attempt. Fortunately, Emma will be okay. Case Vignette II Kevin is a 35-year-old man who has struggled with depression and alcoholism for many years. While he is attending therapy groups, his level of commitment to them appears minimal. He does not appear actively suicidal, but his group therapist is alarmed by disclosures in the group that indicate Kevin does not feel he has a reason to live. The therapist does an assessment, which indicates that Kevin’s level of suicidal ideation is high; he has a plan, and he fully intends to kill himself. She can persuade Kevin to consider hospitalization and is hopeful that the situation will resolve. The situations discussed above are common in clinical practice. In understanding why some clients consider and follow through with suicide attempts, it is helpful to look at the research literature. The effectiveness of clinicians in the prevention of suicide depends on understanding how and why suicide occurs. Related factors or triggers for suicide attempt or completion identified in the literature are reviewed below.7-17 Previous Suicide Attempts and Suicidal Ideation The data from the United States and abroad has found a positive correlation between suicide attempts and subsequent completed suicide, and suicidal ideation is a risk factor for suicide attempts and completed suicide. There are approximately 10-40 suicide attempts for every completed suicide, 14 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com and adolescents make far more suicide attempts (100 to 200) than complete the act. Age and Gender Older adults are more likely to complete suicide than younger adults. Women have more suicidal ideation and make more suicide attempts than men, but more men than women complete suicide. Family History Family history and by implications genetics can be a risk factor for suicidal behavior and suicide. The heritability of suicide has been estimated to be 30-50%, and a national registry study showed that risk of suicide was significantly increased if a sibling had committed suicide. Another interesting approach is the social model thesis. This model says that exposure to completed and attempted suicide in the family can increase suicide risk among other family members by providing a social model of selfharm behavior. The researchers suggested containment of information regarding suicidal behaviors in prevention of suicidality. Medical Conditions Patients with serious medical conditions may be at increased risk for suicide. These include but are not limited to chronic pain, cancers, HIV/AIDS, lupus, headache, traumatic brain injury, fibromyalgia, and diseases of the central nervous system such as Alzheimer’s disease, epilepsy, Huntington’s disease, and multiple sclerosis. 15 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Environmental Stressors Personal stress is a significant risk factor for suicidal behavior and suicide. Acute and chronic stressors that increase the risk of suicidal behavior and suicide include bullying, intimate partner violence, financial stress, and death of a spouse or relative. Access to Lethal Methods/Impulsivity Many suicide attempts are impulsive or unplanned and occur during an acute period of ambivalence, and impulsivity and aggression have been shown to be risk factors for suicide. Access to a lethal means of suicide such as firearms or highly toxic pesticides are recognized as risk factors for suicide. Biological Bases of Suicide Researchers have studied the brains of people who have died by suicide, looking for visible differences from brains of those who died by other causes. Most frequently studied have been the serotonergic system, adrenergic system, and the hypothalamic-pituitary axis (HPA), all of which influence mood, thinking and stress response. A key challenge of neurobiological studies is determining the abnormalities in genes, brain structures, or brain function that differentiate depressed people who died by suicide from depressed people who died by other causes. Summary of risk factors Previous suicide attempts Family history of suicidal behavior Medical conditions and chronic pain Contagion (local epidemics of suicide) Access to lethal methods Isolation, a feeling of being cut off from other people Previous suicide attempt(s) 16 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Loss (relational, social, work or financial) Unwillingness to seek help due to stigma Protective Factors For Suicide Protective factors for suicide are characteristics or conditions that may help to decrease a person’s suicide risk. It is important to note that these factors have not been well studied, and that while they do not eliminate the possibility of suicide, especially in someone with risk factors, these protective factors may help reduce the risk. Protective factors for suicide have been identified as:18,19,44 Effective mental health care Connectedness to individuals, family, community, and social institutions Problem-solving skills Contacts with caregivers The most consistent protective factors found in suicide research are social support and connectedness and hopefulness. Marital status is also linked with suicide risk. Married individuals are less likely to commit suicide than divorced or separated people, and divorce has been associated with an increased risk of suicide. Among females, another protective factor appears to be parenting, which provides a sense of purpose and reason for women to not give up despite having depression or suicidal thoughts. Some researchers have looked at protective factors against suicidal acts in major depression. Researchers assessed inpatients with major depression, 17 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com general psychopathology, suicide history, and hopelessness. Of the 84 patients, 45 had attempted suicide and 39 had not. The depressed patients who had not attempted suicide expressed more feelings of responsibility toward family, more fear of social disapproval, more moral objections to suicide, greater survival and coping skills, and a greater fear of suicide than the depressed patients who had attempted suicide. Linehan, et al. developed the Linehan Reasons for Living Inventory (LRFL). This is a 48-item self-reported assessment tool that reflects adaptive beliefs and expectations that help people resist suicidal urges, and it may be used to explore differences in the reasons for living with individuals who engage in suicidal behavior and those who do not.21 The LRFL consists of six subscales and a total scale. The subscales include: survival and coping beliefs (24 items), responsibility to family (7 items), child-related concerns (3 items), fear of suicide (7 items), fear of social disapproval (3 items), and moral objections (4 items). Examples from the six subscales are provided below. Each item is rated on a 6-point scale ranging from 1 (not at all important) to 6 (extremely important). 1. I care enough about myself to live. 2. It would hurt my family too much and I would not want them to suffer. 3. The effect on my children could be harmful. 4. I am a coward and do not have the guts to do it. 5. Other people would think I am weak and selfish. 6. I believe only God has the right to end a life. Linehan, et al. classified respondents into four categories: 1) those never considering suicide in any way, 2) those who considered suicide only briefly 18 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com or non-seriously, 3) those who seriously considered suicide, or 4) those having made a suicide attempt. They found that the respondents who had never considered suicide had more self-reported reasons for living, and better coping and survival skills. Religion appears to play a protective role in suicide due to the strict sanctions against suicide in most major religions, and religiosity has been shown to be associated with reduced risk of suicidality.64 Christianity, Hinduism, Islam, and Judaism all condemn suicide, although the strictness of this condemnation varies. Research also confirms that more traditional or orthodox religions tend to have lower suicide rates. Fostering a suicidal person’s spiritual or religious faith may contribute to the effectiveness of interventions. An area of emerging research concerns the protective factor of high distress tolerance. Simply put, distress tolerance concerns the accepting, finding meaning for, and tolerating distress. Distress intolerance, on the other hand, is a perceived inability to fully experience unpleasant, aversive or uncomfortable emotions, and is accompanied by a desperate need to escape the uncomfortable emotions. Distress tolerance skills support the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Anestis, et al. studied 93 adult inpatients who were receiving treatment for substance use disorders.22 Each patient completed a structured interview assessing suicide potential. Results indicated that in atrisk populations, the capacity to tolerate aversive physiological and affective arousal might reduce the risk of serious or lethal suicidal behavior. Suicide And Mental Health Diagnoses 19 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Suicidal ideation or attempts are a clear indication that something is very wrong in a person’s life, and most people who die by suicide have a mental or emotional disorder. Suicide research often uses a method termed psychological autopsy in which researchers conduct interviews with family members and friends, who provide information on their understanding of the likely factors that contributed to the person’s death. Most suicide events occur in people who have a psychopathology such as bipolar disorder or depression, and although the great majority of people who have a mental disorder do not commit suicide, the results of several studies suggest that the vast majority of those who committed suicide had a psychiatric diagnosis at the time of death. In particular, people who have bipolar disorder, borderline personality disorder, a substance use and addiction disorder, eating disorders, major depression, post-traumatic stress disorder, psychotic disorders, or schizophrenia have an increased risk of suicide behavior.23 Throughout history, mental illness has been associated with stigma and seen as a sign of weakness or deficiency. There is also the sense that those affected by mental illnesses may be dangerous or unpredictable. This sense of stigma increases the risk of suicide by increasing secrecy and precipitating shame and self-blame, all of which discourage affected individuals from seeking treatment. This is especially true among certain ethnic and racial groups. Prior to looking at the connections between suicide and specific mental illnesses, it is helpful to briefly explore here the connections between mental illness and stigma as a causal factor of suicide.3,24-41,86-89 Mood Disorders and Suicide Mood disorders, especially bipolar disorder and depression, are significant risk factors 20 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com for suicide. A key aspect of risk among people with mood disorders is the presence of hopelessness, as indicated by negative attitudes, or pessimism, about the future. Hopelessness theory, first proposed by Abramson, Metalsky, and Alloy in 1989, postulated that people with depression tend to make internal, stable, and global attributions to explain the causes of negative events, and external, unstable, and specific attributions about positive events. This attributional style results in the individual taking personal blame for negative events in his or her life. Hopeless can be measured using the Beck Hopelessness Scale. This is a 20item self-report inventory that measures negative and positive attitudes about the future in terms of affective, cognitive, and motivational factors. An example is that an affective statement would be “I look forward to the future with enthusiasm.” A ‘yes’ would score 0, a ‘no’ would score 1, and of the possible results of 0 - 20, a score of 0 – 3 indicates a minimal level of hopelessness; 4 – 8 a mild level; 9 – 14 a moderate level; and, 15 – 20, a severe level. The Beck Hopelessness Scale has been shown to have a strong predictive value for suicide and suicide behavior. Other risk factors for suicide among people with mood disorders include (but are not limited to) previous suicide attempts, family history of depression/suicidal behavior, lack of social support, impulsive or aggressive behavior, severity of depression, a history of sexual abuse, and comorbid states of anxiety, panic disorder, or substance use. Substance Use/Alcohol Use Disorders and Suicide As mentioned earlier, a significant number of people who commit suicide will have a positive test for the presence of alcohol, antidepressants, or opioid analgesics. Alcohol use disorder and substance use have been consistently 21 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com identified as risk factors for, and strongly associated with suicide, suicide ideation, suicidal behavior, and suicide. Concurrent substance use and bipolar disorder or major depressive disorder is very common and associated with greater functional, psychological and social impairment, increased resistance to treatment, poorer prognosis, and more severe depressive symptoms. Alcohol use disorder increases aggression and impulsivity, another risk factor for suicide. Specific factors in people who have concurrent depression and substance use disorder that can increase the risk of suicide are age (older people are at greater risk), dysfunctional attitudes, feelings of hopelessness, male gender, the age at which the psychiatric illness began, and the severity of the psychiatric illness. People who have an alcohol use disorder may be more vulnerable to suicide if they are over 50 and are male, unemployed, living alone, experience a major depressive episode, experience a stressful life event, have poor social support, or have a substance use disorder or a serious medical illness. An emerging area of study involves the connection between addictive disorders such as pathological gambling and suicidality. In pathological gambling, multiple financial, occupational and relationship problems and losses can occur, and people who are pathological gamblers have an increased risk of suicide, suicidal ideation, and suicidal behavior. Thon et al., reviewed questionnaires that had been completed by 862 pathological gamblers; the rate of attempted suicide in this group was 4-20% and 12-92% of the respondents had suicidal ideation. Schizophrenia and Suicide 22 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Suicide is one of the most common causes of death in people who have schizophrenia, and the risk of suicide in this population is significantly higher than in the general population. Accurate and reliable assessment for the risk of suicide in schizophrenic patients has been reported to be very difficult, but research and clinical experience suggest that there are psychological and social factors that increase risk in this population. These factors include feelings of agitation, depression, and hopelessness, insomnia, male gender, poor compliance with treatment, previous suicide attempts, and social isolation. Protective factors include delivery of and adherence to treatment, the use of antipsychotics (particularly clozapine), antidepressants, and psychosocial treatments. Suicide in schizophrenic patients is especially common in the first years after onset of the disease, and if a patient has been recently diagnosed with severe psychotic symptoms, social impairment, substance use disorder, and many of the risk factors previously listed this increases the risk of suicide. Anxiety Disorders and Suicide Anxiety disorders, including panic disorder, agoraphobia, social phobia, specific phobia, generalized anxiety disorder, and posttraumatic stress disorder have been associated with suicide and suicidal ideation and identified as predictors for suicide attempts and ideation. However, studies have found that anxiety posed a statistically significant, yet weak, predictor of suicide ideation, attempts, but not deaths. Researchers have also found that findings do not translate into clinically practical information ... (and) anxiety and its disorders, at least as these constructs have been studied to date, are unlikely to serve as powerful actual or real-world indicators of risk for suicidal thoughts and behaviors. Nepon, et al. pointed out that there are 23 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com high levels of comorbidities in people who have anxiety disorders and these comorbidities, not the anxiety, may explain the suicidal behavior in these patients. Sleep Disorders and Suicide Insomnia and other sleep disorders are common in people who have a psychiatric illness that predisposes them to suicide. Research of the link between insomnia, sleep disorders, and suicide has often had methodological problems (i.e., failure to account for presence of psychopathology as a confounder, definitions and measurements of insomnia and sleep disorders) that limited the findings. However, recent studies and meta-analyses indicate that sleeping problems and certain aspects of sleep problems such as sleep duration and the need for soporifics have a significant association with suicide risk that is independent of confounders and variables. Violence and Trauma Violence and trauma, emotional, physical, and sexual, have been associated with an increased risk of suicidal behavior, suicidal ideation, and suicide. These include bullying and cyber-bullying, exposure to interpersonal violence, intimate partner violence, dating violence, post-traumatic stress disorder, childhood abuse and maltreatment, and sexual assault. Borderline Personality Disorder and Suicide Borderline personality disorder is defined (in part) by the DSM-5 as: A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity... People who have borderline personality disorder have a high risk for suicidal behavior and suicide, and the risk may be increased by comorbidity with alcohol misuse, anxiety disorder, bipolar 24 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com disorder, major depressive disorder, post-traumatic stress disorder, and substance use and addiction disorders. Eating Disorders and Suicide The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes eight eating disorders and notes that: Feeding and eating disorders are characterized by a persistent disturbance of eating or eatingrelated behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning. Three of the eight eating disorders, anorexia nervosa, bulimia nervosa, and binge eating are of specific interest here for two reasons: 1. Eating disorders are relatively common. The lifetime prevalence of anorexia nervosa and bulimia nervosa in women in the U.S. has been estimated to be 4% and 2%, respectively, and similar figures have been reported in other areas of the world. Binge eating is the most common of the three, but it appears that suicide issues are less common with this eating disorder. 2. Eating disorders and suicide are closely related. Suicidal ideation, suicidal behavior, and suicide are common in people who have an eating disorder even after adjusting for comorbid conditions such as anxiety disorder, major depressive disorder, and substance use. Potzky, et al. noted that 11.8% of patients with an eating disorder had attempted suicide and 43% had experienced suicidal ideation. Behaviors, comorbidities, demographic characteristics, and life experiences that may increase the risk of suicide in people who have an eating disorder 25 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com include (but are not limited to): adolescence, alexithymia (inability to recognize or describe one's emotions), borderline personality disorder, childhood physical or sexual abuse, depressive symptoms, excessive exercise, the use of laxatives and other purging behaviors, previous suicide attempts, and substance use. Research using the Australian Twin registry suggest that in women who have an eating disorder there is a genetic influence relative to suicidality. The association of binge eating with suicidal ideation, suicidal behavior, and suicide has been less well studied. Sheehan and Herman’s literature search, covering 2003-2014 identified three articles that had pertinent information. One study found 6.7% of women with a binge eating disorder had made a suicide attempt. A sample of an adult outpatient population who had binge eating disorder found that 28% of the patients had had suicidal ideation; and, a study of Swedish twins found that women who had binge eating disorder and major depressive disorder had a higher suicide attempt and completion rates than women who had binge eating disorder but not major depressive dsorder. Traumatic Brain Injury and Suicide Traumatic brain injury (TBI) is a common injury that is caused by violent external force to the head. Blunt trauma, acceleration or deceleration, or exposure to a blast (as in a war zone) causes injury to the brain, resulting in neurologic dysfunction, confusion, and a change in consciousness that is temporary or permanent. Traumatic brain injury can be mild, moderate, or severe. In the U.S. the incidence of TBI is between 18 and 250 per 100,000 persons per year, and these are associated with significant morbidity and mortality. People who 26 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com have had a TBI are at high risk for cognitive, emotional, physical, and psychiatric disorders, including suicide. The link between TBI and the risk for suicide is very strong, and research has consistently shown that people who have a TBI have much higher rates of suicidal ideation, suicidal behavior, and suicide than the general population. The presence of alcohol use disorder, anger and aggression, depression, severity of injury, and substance use in combination with TBI increases the risk for suicide. Suicidal ideation and attempts may be directly associated with the consequences of TBI. These include the physical effects, such as change in eyesight (limiting driving ability and independence), difficulty with balance and coordination, and inability to use certain motor functions, cognitive effects, such as difficulty concentrating, making decisions/judgments, selfexpression, or aphasia, and mood-related changes, including apathy, anxiety, emotional lability, and depression. Emotional Regulation and Suicide Emotional regulation has been defined in technical terms, but for the purposes of this course, emotional regulation can be considered the behaviors and strategies used to cope with emotions. In essence, emotional regulation relates to how individuals control emotions so that emotions do not control them. Simple examples of positive/functional emotional regulation are cognitive reappraisal, emotional awareness and problem solving; and, examples of negative/dysfunctional emotional regulation are emotional suppression and avoidance. Negative emotional regulation is a common feature of anxiety disorder, bipolar disorder, borderline personality disorder, depressive disorder, eating disorders, PTSD, and other psychiatric illnesses that are strongly associated 27 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com with suicide, and studies of some populations have shown that improving emotional regulation can reduce suicidal ideation and suicide attempts. Dysfunctional emotional regulation increases the risk for suicide, suicidal behavior, and suicidal thoughts. The Risk For Suicide In Special Populations The following case vignette highlights the vulnerability of lesbian, gay, bisexual, and transgendered (LGBT) individuals, but there are many specific populations in our society in which the risk of suicide is particularly high. This section will discuss these at-risk populations. Case Vignette Rutgers University made headlines in 2010 due to the suicide of freshman student Tyler Clementi, who killed himself by jumping from the George Washington Bridge. Tyler reportedly was distraught when his roommate broadcast intimate footage of Tyler and another young man. Tyler’s death brought national and international attention to the issue of cyber bullying and the struggles facing LGBT youth. Lesbian, Gay, Bisexual and Transgendered Lesbian, gay, bisexual and transgendered (LGBT) individuals have a far higher risk of suicide than heterosexuals. Researchers found that close to one-fourth of the LGBT adult population surveyed had attempted suicide and that there was an association between sexual minority status and suiciderelated behavior. It is not clear if LGBT individuals complete suicide more than other population groups.15,16 28 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Factors that increase the risk of suicide for LGBT individuals (but are not limited to) include an earlier time of coming out, lack of community and family acceptance, isolation, negative self-image, physical and sexual abuse, a greater incidence of alcohol and PTSD, substance use, victimization, and a higher incidence of anxiety disorder, depressive disorder, and other psychiatric disorders. The higher incidence of significant psychiatric disorders is particularly concerning as these are well known to increase the risk of suicide. Bostwick, et al. (2014) noted that mental health disparities in sexual minorities are well documented and that numerous studies … have demonstrated heightened prevalence of depressive and anxiety disorders among lesbian, gay, and bisexual groups as compared with heterosexuals.87 Haas, et al. opined that … elevated rates of mental disorders, including substance use disorders, have also been reported in one-quarter to one-third of LGB adult respondents in large-scale health surveys that have defined sexual orientation based on self-identity.88 This disparity has been explained by the greater number of personal and social stressors that LGBT individuals must contend with and their relative lack of social support. Childhood Sexual Abuse Childhood sexual abuse is a strong predictor for suicidal behavior and suicide, and victims of childhood sexual abuse are at increased risk for developing behavioral problems and serious psychiatric disorders such as borderline personality disorder, depression, PTSD, and substance use that predispose to suicide. Early onset, duration, severity, and the identity of the perpetrator appear to increase the risk for suicidal behavior and suicide. Elderly 29 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The rates for suicide are highest for middle age and older adults, and the increased suicide rate in the U.S. is especially pronounced in older adults. Older adults and the elderly also have comparatively more completed suicides, one completion for every four attempts, and a much lower ratio than that of the general population. There is also evidence that suggests that suicide in the elderly is underreported, and researchers have found that suicidal behavior in older adults is associated with many factors, including specific illnesses such as COPD and malignancies, pain and functional disabilities.46,47 Factors that increase the risk of suicide for the general population, such as isolation, psychiatric disorders, and substance use are relatively common in older and elderly adults and increase their risk, as well. But older and elderly adults react differently to some of these issues, and aging presents stressors that can increase the risk of suicide specific to this population. Cognitive changes are a common feature of aging, and these may be a factor in the high rates of suicide in older and elderly adults. For example, cognitive impairment and dementia, both relatively common in these populations, have been identified as risk factors for suicide. The early stage of dementia when awareness is less affected and a comorbid condition of depression appear to particularly increase the risk of suicide in older adults. In addition, psychiatric disorders such as depression are common in people who have cognitive impairment, dementia and depression, which is a suicide risk factor. Physical illnesses and functional disability in older and elderly adults have been strongly associated with an increased risk of suicide. Adolescents 30 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Suicide is the third leading cause of death in adolescents and for adolescents 15–19 years of age it is the second leading cause of death. Adolescents are less likely to complete suicide, with the ratio of attempts to completed suicides estimated to be from 50:1 to 100:1, but as with other groups there is evidence that adolescent suicides are unreported therefore the risk and the total numbers may be higher. Adolescents are subject to many of the same risk factors for suicide as other defined groups and the general population. But there are also suicide risk factors that are specific to this age group and some that are common to all populations but appear to be particularly dangerous for an adolescent.3,41,53,57 Discussed here are bullying and mood disorders and psychotic symptoms.14 Bullying Bullying is consistently mentioned as a factor that increases the risk of suicidal ideation and behavior and suicide in adolescents, and youth bullying has been described by the National Academies of Sciences as a major and preventable public health problem. Bullying can take many forms, i.e., cyberbullying, emotional and relational bullying, and physical bullying but regardless of how it is done, bullying involves aggression in the context a power imbalance. The CDC defines bullying among youth this way: Bullying is any unwanted aggressive behavior(s) by another youth or group of youths who are not siblings or current dating partners that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated. It is not known how often adolescents suffer from bullying, but researchers have found that a significant percentage of the adolescent population have been victims of cyber-bullying as well as victims of traditional bullying. 31 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Factors that increase the risk of bullying victimization in adolescents include (but are not limited to) depression, low self-esteem, obesity, real or perceived differences, sexual minority status, and social isolation increase the risk of being bullied. Mood Disorders and Psychosis Mood (affective) disorders, particularly bipolar disorder and depression, are significant risk factors for suicide, and these psychiatric illnesses are very common in adolescents who commit suicide. Psychotic symptoms are not uncommon in adolescents. Kelleher, et al. in a meta-analysis found that in adolescents 13–18 there was a 7.5% median prevalence of psychotic symptoms in adolescents 13–18 years of age. These symptoms are intensely troubling and dangerous for anyone, and perhaps more so for adolescents. Kelleher, et al. interviewed 423 adolescents in two separate studies, one group being 11–13 years of age, and the other being 13-15 years of age. The authors reported that the presence of psychotic symptoms greatly increased the risk of suicidal behavior, and the risk for suicidal behavior in adolescents who had suicidal ideation. The authors also opined that when directly questioned, most adolescents with suicidal plans and acts reported psychotic symptoms, in particular auditory hallucinations. Kelleher also confirmed the seriousness of psychotic symptoms in adolescents, noting that adolescents with psychopathology who reported psychotic symptoms had a nearly 70-fold increased odds of acute suicide attempts. Homelessness Homeless Americans are especially vulnerable to suicide. They have a far greater incidence of many of the risk factors for suicide such as serious 32 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com psychiatric illnesses, chronic illnesses, unemployment, traumatic life events, and alcohol and substance use. In addition, the homeless appear to be less resilient to these issues, and the multitude and intensity of these stressors has a predictable and tragic result. Homeless individuals have a much higher rate of suicidal thoughts and behavior and suicide itself than the general population; researchers have found that homeless individuals were twice as likely as the non-homeless to kill themselves and a significant percentage of adults living in a homeless shelter had attempted suicide.51,90,148 Incarceration Suicidal ideation and behavior and suicide are common in people who are, or have been incarcerated. Casiano, et al. found that suicide was the number one cause of death among incarcerated youth.149 Research on factors that influence and/or increase the risk has produced (somewhat) conflicting results. A combination of individual and environmental factors likely accounts for the higher rates of suicide in correctional settings. Jails and prisons contain vulnerable groups that are traditionally among the highest risk for suicide, including young males, persons with mental disorders, people who are socially disenfranchised or socially isolated, people with substance use problems, and those who have had previous suicidal behaviors. Another common factor was that many of the inmates who had committed suicide had been held on or convicted of violent charges. However, depression and previous inpatient psychiatric treatment have consistently been identified in incarcerated individuals who have suicidal ideation and behavior or have completed suicide.52 There are also contextual issues that could influence suicidality among incarcerated individuals. Some of these include overcrowding, lack of 33 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com possibility of purposeful activity, sanitation, broad sociocultural conditions, the prevalence of HIV/AIDS, levels of stress, and access to basic health or services for mental health or substance use issues. Prisons are also characterized by social isolation and violence. Youth in Foster Care There is also concern that youth in the foster care system may be at an increased risk for suicidal behaviors and other related problems. Each year millions of children are abused at home and by necessity placed into the foster care system. Adolescents who have been in foster care are much more likely to have seriously considered suicide or attempted suicide than other youth. Anxiety, depression, and substance use, strong risk factors for suicide, and emotional and behavioral problems are more likely to be present in children and adolescents who are in foster care.53 While the home environment is not a positive one for youth in foster care, many youth in the system still struggle with separation from their other caregivers and supports (friends, school supports such as teachers, and neighbors). They may also experience further maltreatment in foster care, and may frequently be moved from home to home. These experiences may result in a sense of loss. They may also carry the shame of being placed in foster care. These experiences of loss, isolation, and lack of social support are all risk factors for suicide. Other common risk factors among youth in foster care include:53 Mental illness including substance use Access to medications Prior suicide attempt 34 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Self-injury Parental mental illness and substance use Family conflict and dysfunction Family history of suicidal behavior Poor coping skills Social alienation Exposure to suicides and attempts Suicide means availability (access to lethal means) Other risk-taking behaviors (promiscuous sex, driving recklessly, petty theft, vandalism) Minority sexual orientation or gender identity Violence and victimization Bullying Physicians It has traditionally been reported (and there is evidence to support this) that physicians and physicians in training have a high risk for suicide, higher than the risk of suicide in the general population. The risk is particularly high for female physicians.56 The factors that increase the risk of suicide for physicians are often the same as for the general population, i.e., depression, alcohol and substance use, but as with many of the other specific groups discussed in this course, these stressors are more common in physicians and physicians in training than in the general population. But physicians also have two stressors that increase the risk of suicide, stressors that are not unique to this group but are especially pronounced for them; burnout and stigma. 35 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The rate of professional burnout is very high in physicians and the stigma of having mental illness or suicidal ideation is also very high in this group. It is a dangerous combination; high levels of stress and burnout, higher than average incidence of risk factors for suicide, shame and stigma at having a mental illness and/or suicidal thoughts, and a natural reaction to the shame and stigma and unwillingness to seek help. Culture And Ethnicity As Risk Factors For Suicide While prevalence data outlines the increased vulnerability of certain ethnic and cultural groups, it does not necessarily provide insight into culturally relevant risk and protective factors. It is important that clinicians treat suicidality from a culturally competent perspective. Additionally, there are many myths associated with various ethnic groups and suicide risk, (for example, a belief that because Hispanics are predominately Catholic, suicide is not a problem) that may incorrectly influence therapists. This section provides an overview of suicidality among certain ethnic groups.3,61-74 American Indians American Indians have a higher rate of suicide than other ethnic groups in the U.S. The risk is especially high for adolescents and young adults but unlike other groups, suicide in older American Indian adults is less prevalent. Interestingly, suicidal ideation appears to be less common for this group. 36 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Suicide risk factors for American Indians are much the same as for the general population and for other ethnic groups; alcohol and substance use, bullying, economic stress, personal loss, poor or no access to mental health services, previous suicide attempts, psychiatric illnesses, sexual abuse, social isolation, and racism. Other individual risk factors that apply to both youth and adults in Native American families include feeling disconnected from family, feeling that one is a burden, unwillingness to seek help because of stigma attached to mental and substance use disorders and/or suicidal thoughts, and concerns associated with suicide contagion or cluster suicide. However, as with other specific populations and ethnic groups, some of these risk factors are more common in American Indians than in the general population, explaining in part why American Indians have a high rate of suicide. The role of historical trauma is one that is affects American Indians and merits additional consideration. Broadly defined, historical trauma is defined as an event or events that affect multiple generations of a culture. For American Indians, there has been the historical trauma of forced relocation known as the Trail of Tears. The Indian Removal Act of 1830 mandated relocation of members of the Cherokee, Muscogee, Seminole, Chickasaw, and Choctaw nations from their ancestral homelands in the southeastern U.S. to an area west of the Mississippi River that had been designated as Indian Territory. This is one widespread example of such actions. A related trauma was the removal of children who were sent to boarding schools during the late 19th and early 20th centuries. Originally established by Christian missionaries, these Boarding Schools immersed children in European-American culture through appearance changes with haircuts, a 37 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com ban on speaking their native languages, and traditional names being replaced with new European-American names. In numerous ways, children were encouraged or forced to abandon their Native American identities and cultures. While today tribal nations have increasingly insisted on communitybased schools and have also founded numerous tribal colleges and universities, these memories are still fresh for many Native American families. These experiences may be part of the challenges of help-seeking behaviors among these groups who may believe these services represent the “white man’s” system and culture, or that the professionals will not understand Native ways. Another aspect in recognizing suicidal ideation in Native American people concerns the politeness theory. In this culture, people considering suicide may not be direct in making their personal pain known to avoid placing a burden on others. Additionally, vague or indirect calls for assistance help protect them from their own embarrassment if others fail to respond. There is a cultural stigma against suicide and following a suicide attempt. Protective factors that have been found to prevent suicide in American Indians include, but are not limited to: access to mental health case findings and intervention, services, emotional regulation, family cohesion, respect for help-seeking behavior, screening, survivor groups, and taboos against suicide. Spirituality has also been shown to be a buffer against suicidality in Native Americans. Due to experiences of assimilation, many Native Americans try to achieve a spiritual balance between what may be Christian religious practices while others may be grounded in traditional spiritualism. Researchers have found that it is important to integrate traditional 38 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com spirituality into the therapy, including the use of traditional healing practices, sacred rituals, and ancestral knowledge. Examples include the use of the medicine wheel, the sacred pipe, sweat lodges, the sun dance, the seeking of a vision, the womanhood ceremony, the throwing of the ball, the keeping of a spirit, and the making a relative. While there have been many organized efforts to include these ideas, one that provides a good example is called Native H.O.P.E. (Helping Our People Endure). Aimed at youth, Native H.O.P.E. is a curriculum based on the theory that suicide prevention can be successful in Indian Country when Native youth become committed to breaking the ‘code of silence’ that is prevalent among all youth. The program also is premised on the foundation of increasing strengths among Native youth as well as increasing their awareness of suicide warning signs. The program supports the full inclusion of Native culture, traditions, spirituality, ceremonies, and humor. The 3-day Native H.O.P.E. youth leadership curriculum takes a proactive approach to suicide prevention. Clinicians may seek more information on Native American client support, including the American Indian Community Suicide Prevention Assessment Tool developed by the One Sky Center, a national resource center for American Indians and Alaska Natives, at the One Sky Center Web site, www.oneskycenter.org. African Americans African Americans are much less likely to have suicidal ideation and to commit suicide than white Americans. The risk factors for suicide that affect African Americans are much the same as for the general population but suicide in the African American population is disproportionately clustered in adolescents, and racism is a prominent aggravating factor. Racial stereotypes and negative images can be internalized, denigrating individuals’ self-worth and adversely affecting their social and psychological functioning. 39 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Racism and discrimination have resulted in minorities’ lower socioeconomic status and poorer living conditions in which poverty, crime, and violence are persistent stressors that can affect mental health. Additionally, racism and discrimination are stressful events that can directly lead to psychological distress and physiological changes affecting mental health. African Americans are also significantly overrepresented in the most vulnerable segments of the population and those previously discussed for being at high risk for suicide. More African Americans than Caucasians or members of other racial and ethnic minority groups are homeless, incarcerated, or are children in foster care or otherwise supervised by the child welfare system. African Americans are especially likely to be exposed to violence-related trauma, as were the large number of African American soldiers assigned to war zones in Vietnam. Access to mental health services and service utilization also appears to play a role. African Americans who reported suicidal thoughts or attempts were less likely than whites to seek or receive psychiatric services. Lack of health insurance is a barrier to seek mental health care at local health centers. Significant protective factors found for all populations apply for African Americans as well, for example, effective and accessible mental health care, connectedness to individuals, family, community, and social institutions, problem-solving skills, and contacts with caregivers. Adaptive traditions have sustained African Americans through long periods of hardship imposed by the larger society and this resilience is an important protective resource. Additionally, research has shown significant protective factors in African American populations, particularly the role of spirituality and religious beliefs. 40 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Neeleman, et al. found that the comparatively low level of suicide among African-Americans involved high levels of orthodox religious beliefs and personal devotion, evaluated to be protective against suicide, and other researchers have mirrored these findings. Assari, et al. noted that religiosity delayed the age of onset and the number of psychiatric disorders. The role of family support, peer support, and community connectedness have been shown to help protect African American adolescents from suicidal behavior. Matlin, et al. studied the relationship between various types of social support and suicide, and the extent to which support moderates the relationship between depressive symptoms and suicidality. The researchers asked 212 African American adolescents to rate three types of social support: family support, peer support, and community connectedness. The survey also addressed depressive symptoms and suicidality, as measured by reasons for living, a cognitive measure of suicide risk. The results indicated that increased family support and peer support are associated with decreased suicidality; and, peer support and community connectedness moderated the relationship between depressive symptoms and suicidality. Similarly, positive interactions and social and family support have been shown to significantly reduce risk for suicide attempts among African American adults. Hispanic/Latinos There is a common perception that Hispanic Americans do not commit suicide due to the strong Catholic restrictions against it. Religiosity is an important protective factor, but Hispanic Americans are a diverse group and while suicide rates are lower than other ethnic groups they are not negligible. 41 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Compared to white Americans Hispanic Americans are much less likely to commit suicide. The risk for suicide however is particularly high for Hispanic American adolescents, particularly girls. Alcohol and substance use are relatively high among Hispanic youth compared to white and African American youth, which can certainly be an aggravating factor. The stresses of acculturation and discrimination have also been found to contribute to the risk for suicide in Hispanic Americans. Some researchers have proposed that suicidal behavior among Hispanics may be connected to a cultural expectation that family needs are placed above individual needs; suicidality in young Hispanic females may be related to the stress caused by the expectation of obligation to the family. Access to and utilization of healthcare resources are also risk factors that affect Hispanic Americans and may influence the suicide rate in this group, especially in adolescents. In some research outcomes, it was noted that Hispanic adolescents were less likely than other ethnic youths to be identified as suicidal; and, Hispanic adolescents who had emotional, family, or social issues that might cause suicidal ideation tended to get help from family and friends. The immigration status of Hispanic Americans has a somewhat complicated effect on a suicide. Hispanic immigrants were reported to have a higher suicide risk that Hispanics born in the U.S., but the risk for suicide was influenced by population size: immigrants have higher rates overall, this difference was conditioned by the relative size of the Hispanic immigrant community; in areas with smaller immigrant populations, immigrants were at a higher risk of suicide than their native-born counterparts, while in areas 42 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com with larger immigrant populations, the opposite was true — natives were at a higher risk. While these barriers are daunting, there are also many protective factors in Hispanic American culture. The cultural role of familism, which emphasizes close family relationships and extended family, is crucial to many Hispanics, and these connections can be very important for protection against suicide. Moral objections to suicide have also been identified as a protective factor. Asian Americans/Pacific Islanders The last U.S., census was done in 2010 and it estimated there were 17.3 million people of Asian descent and people who identified as Pacific islander ethnicity living in the U.S. This is a very diverse group that includes individuals of Cambodian, Chinese Filipino, Laotian, Korean, Asian Indian, Vietnamese, Japanese, and Pacific Islander, and other Asian descent. The risk of suicide in this population has usually been determined to be less than that of white Americans and American Indians and approximately equivalent to African Americans and Hispanic Americans/Latinos; however, an unfortunate exception is Asian American adolescents. Like Native American and Hispanic/Latino adolescents, Asian American adolescents have a disproportionately high risk for suicide. The 2016 Youth Risk Survey found that the self-reported incidence of suicide attempts in Asian American adolescents was 9.5%, or 1.5 times that of white American adolescents. Risk factors for suicide that appear to be specific to Asian Americans include: low comparative utilization of mental health resources, lack of culturally appropriate mental health resources; expressing emotional distress through physical problems (somatization) and believing that that physical problems 43 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com cause emotional disturbances, cultural stigma of mental illness, financial or professional failures, real or perceived, that engenders feelings of shame and failure to meet family and social obligations, cultural norms that inhibit and discourage expression of suicidal ideation, and interpretation of mental illness as a personal weakness and as an obstacle that prevents meeting social and family responsibilities. Immigration can also be a stressor that increases the risk for suicide. Zhang, et al. (2013) compared depression, anxiety, and suicidal ideation among Chinese Americans, looking at immigration-related factors. The researchers found that U.S. born Chinese and those who immigrated to the U.S. at 18 years or younger were at higher risk for lifetime depressive or anxiety disorders or suicidal ideation than were their China-born counterparts who arrived in the country at or after 18 years of age. For Chinese Americans, immigration-related factors were associated with depression and anxiety disorders and suicidal ideation. The researchers concluded that the higher prevalence of these disorders might be attributed to the psychological strains experienced by those who are at higher risk of cultural conflicts. Protective factors for Asian Americans include the desire to maintain interpersonal and social relationships, an emphasis on self-reliance, and social support from family and community. Immigrants The groups we have discussed to this point have primarily been assimilated into the U.S. for many years. But in every year since 1990, approximately one million new immigrants have entered the United States. Immigrants typically demonstrate strengths and resiliencies, and research suggests that among these is the motivation to learn English and engage in the labor 44 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com market. However, the act of moving to another country is a stressful life event. Recently arrived immigrants face many risks, including potential poverty, discrimination, employment problems and social isolation. Also, immigration has been found to have many stressors that can heighten the risk for suicide. Additional challenges may be connected to the immigration process (separation from country of origin and families, and navigation of unfamiliar cultural contexts), and acculturation (language, cultural and ethnic identity, customs, gender roles, etc.). Intergenerational and familial conflicts may result from the acculturation process. Many immigrants have also faced traumatic experiences within their countries of origin. These factors result in immigrants being at higher risk for mental health problems including depression and anxiety disorders and posttraumatic stress disorder (PTSD), all potentially related to suicidality. Kposowa, et al. looked at the impact of immigration on suicide using an unmatched case-control design. Data on cases were obtained on suicides in one county in California from 1998 to 2001. Information on controls was obtained from the 2000 U.S. Census, and the researchers found that immigration increased suicide risk. Immigrant divorced persons were over 2 times more likely to commit suicide than natives. Single immigrants were nearly 2.6 times more likely to kill themselves than the native-born Californian. Shorter duration of residence was associated with higher suicide risk. The authors suggested that integration of immigrants in receiving societies is important to decrease suicide and that policies aimed at reducing suicide should target more recent immigrants. While more formal research is needed, clinicians should consider the effects of immigration as a risk factor for suicidality. 45 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Assessing Suicidal Risk There are many risk factors for suicide, but no single one by itself increases or decreases risk. Population-based research suggests that the risk for suicide increases with an increase in the number of risk factors present; the greater the number of risk factors that are present the more likely there an increased risk for suicidal behaviors.3,82,115-121,124,143 Acute signs of suicide risk include: Actively looking for ways to commit suicide such as buying a firearm, researching suicide methods, and making a plan. Making threats to commit suicide. Persistently and actively talking about death and suicide. Talking, writing or posting on social media about death, dying and suicide. Expanded warning signs of suicide include: Dramatic mood changes Hopelessness Increased alcohol and/or drug use Making arrangements for those who will be left behind Rage, intense anger Reckless behavior Saying goodbye Social withdrawal 46 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Chronic/ongoing risk involves feelings and behavior that is experienced over an extended period. The five key feelings and behaviors are identified in the Table below. Feelings No reason for living, or no sense of purpose in life Feeling trapped, like there’s no way out Hopelessness Dramatic mood changes Behaviors Increased substance use Withdrawal from friends, family and/or society Rage, anger, revenge-seeking behavior Reckless or risky decision making and actions Anxiety/agitation Unable to sleep or sleeping all the time Myths and Misconceptions About Suicide Among clinicians and laypersons a number of myths exist relating to suicide. Some researches and authors have described some of these myths. People who want to kill themselves will not talk about suicide: Research on this idea has yielded mixed results. While some people actively considering suicide do not seek help, others do. It is always important to take people seriously when they express suicidal ideation. It is important not to dismiss talk of suicide as a cry for attention. 47 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Suicides increase in fall and winter: There does appear to be an association between increased suicide risk and the fall and winter seasons, but research has found that the association of season to suicide changes with geographical region and several climatic variables. An unsuccessful attempt means that the person wasn't serious about ending his or her life: Some people are naive about how to kill themselves. The attempt in and of itself is the most important factor, not the method or outcome. People who commit suicide always leave notes: Some people do, while others do not leave a suicide note. The so-called birthday blues lead to an increase in suicide: Some researchers have found evidence supporting the idea of birthday blues increasing the risk of suicide, while some have not; and others have found it to be true only for certain groups of people. Using the word suicide with a client will increase the likelihood that he/she will attempt suicide. Assessment Process Suicide assessment for an at-risk client should be an individualized process. There are many standardized suicide assessment tools that have been 48 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com validated as accurate and can be very helpful, but they are not substitutes for clinical evaluation. The information collected during the assessment process allows the clinician to: 1) Identify specific factors and features that increase or decrease the risk for suicide or other suicidal behaviors and that can be modified by acute and ongoing interventions, 2) Address the patient's immediate safety and determine the most appropriate setting for treatment, and 3) Develop a diagnosis that will guide treatment. Goals of the assessment are: Ask the patient about past suicide attempts and suicidal ideation. Get the details of the patient’s current suicidal thoughts and plans. Find out what, if any, comorbid psychiatric illnesses the patient has. Determine the patient’s level of impulsivity and self-control. Find out if the patient has ready access to firearms, dangerous prescription medications, or other means of causing self-harm. Evaluate for the presence of other risk factors, i.e., alcohol and/or substance use, recent stressful events, social isolation. Evaluate for protective factors. Find out what past medical history (if any) the patient has and if he/she has any acute or chronic long-term medical problems being treated. Ask about basic socio-demographic characteristics as many of these are factors that can increase the risk for suicide: age, gender, ethnicity, immigration status, financial health information and determine if any of these are specific risk factors for suicide. 49 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The core questions include: Are you thinking about killing yourself? Are you planning on killing yourself? Some authors have recommended that these questions be asked with a neutral tone, and view them as an opening for further dialogue. Some of the possible things that may emerge following the questions include: 1) A clear denial of suicidal feelings, thoughts, and plans, 2) A clear endorsement of suicidal feelings, thoughts, and plans, or 3) A vague response that neither endorses or denies suicidality. Clinicians should be aware that studies have shown that approximately 50%-80% of people who are thinking about and/or planning suicide will deny this when asked. Current Presentation of Suicidality In assessing current presentation of suicidality/self-harming behaviors, there are critical considerations. These include suicidal ideation, planning or feasibility and intent, lethality of proposed plan, timing, impulsivity and risk factors, hopelessness, and reasons for living. Ideation: Have you ever felt that life is not worth living? When did these thoughts occur? What led up to these thoughts? Have you discussed these thoughts with anyone? Planning/Feasibility: Do you have a specific plan? What is it? When are you considering carrying it out? Do you have the means to carry it out? Have you ever tried to carry out the plan? Rehearsed it in any way? 50 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Are you engaging in behaviors such as getting your affairs in order, saying goodbyes, writing notes, giving things away? Is there anything that stops you from carrying out this plan? Intent: On a scale of 1-10, how likely are you of carrying out this plan? If there were another solution to your problem(s) would you take it? How often are these thoughts occurring? Do they occur in specific instances? Do you have a will? Lethality of Proposed Plan: Elicit plan details, and determine degree of lethality associated with method. Assess: Is death likely to result? How completely have they researched the method (i.e., Internet, books)? If intervention occurs, will the person still die? Protective factors: What would be a deterrent to killing yourself? Why? Assess for specific factors: Morality, fears of death, family/children, friends, job, and importance to others, and cultural or religious beliefs about death or suicide Suicidal History The clinician should ask about previous suicide attempts, suicidal ideation, and self-harming behaviors. In assessing previous attempts, the number of attempts, severity/lethality, circumstances/precipitants, and what happened 51 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com should be documented. Additionally, post-intervention, feelings after the attempt, and any information about support, including family/friends, previous therapy should be determined. Multi-Association Assessment Guidelines The American Psychiatric Association, the International Association for Suicide Prevention, the Substance Abuse and Mental Health Services Administration (SAMHSA), and the World Health Organization has suicide assessment guidelines and information that are free and on-line. Recommendations for Conducting a Suicide Assessment As mentioned previously, suicide assessment is something that is highly individual to each clinician and to each clinical case. There are some guidelines that can be used to support and facilitate the information gathering process. The clinician should adopt a neutral, nonjudgmental stance to encourage honesty and openness on the part of the client. Developing and maintaining a good therapeutic alliance enhances risk assessment. The clinician should avoid an interrogational style when asking questions. Encourage a comfortable conversation. The therapist should strive to instill hope, especially in the future. It is important to convey that the assessment is only the first step in the overall process. 52 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The clinician should commend the client for honesty in thoughts and feelings. During a crisis situation, the clinician should be mindful of actions to avoid: Marginalizing the client through adopting a stance of power and authority. Contributing to the stigma of suicide by shaming a client. Superficial reassurance and minimization of intense affect. While it is important to be hopeful, it is equally important not to minimize difficult and intense emotions. Avoid passivity. The best therapeutic approach is active and direct. Documentation It is important to thoroughly document the assessment. Suicide assessment is an ongoing process and its documentation will occur after an initial evaluation or, for patients in ongoing treatment, when suicidal ideation or behaviors begin or when there is significant worsening or unanticipated improvement in the patient's condition. Estimation of Suicide Risk Following the assessment, the clinician must make an estimate of suicide risk. While a portion of this assessment certainly rests on sound clinical judgment, the following factors are helpful to consider. The following factors in the Table below have been found to increase suicide risk. Suicidal Thoughts/Behaviors 53 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Suicidal ideas (current or previous) Suicidal plans (current or previous) Suicide attempts (including aborted or interrupted attempts) Lethality of suicidal plans or attempts Substance abuse Suicidal intent Psychiatric illnesses Chronic suicidality or manipulative suicidality Psychiatric diagnoses associated with a high suicide risk include: Major depressive disorder Bipolar disorder (primarily in depressive or mixed episodes) Schizophrenia Anorexia nervosa Alcohol use disorder Panic disorder Eating disorder (particularly connected to weight gain) Other substance use disorders Cluster B personality disorders (particularly borderline personality disorder) Comorbidity of mental health disorders Physical illnesses and factors associated with suicide risk include: Diseases of the nervous system HIV/AIDS Lupus Pain syndromes Functional impairment High utilization of medical care 54 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Psychosocial features to consider when evaluating suicide risk include: Recent lack of social support (including living alone) Unemployment Drop in socioeconomic status Poor relationship with family Recent stressful life event Childhood traumas, as well as genetic and familial considerations are generally needed when evaluating for suicide risk, which include: Sexual abuse Physical abuse Family history of suicide (particularly in first-degree relatives) or suicide attempts Family history of mental illness, including affective disorders and substance use disorders Psychological features often encountered when a patient reports suicidal thoughts or intent include: Depression Hopelessness Loss of pleasure or interest in life Severe anxiety Acute agitation Decreased self-esteem Increased self-hatred/self-loathing Extreme narcissistic vulnerability Impulsiveness Aggression 55 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Cognitive features encountered in a suicidal patient may include: Loss of executive function Thought constriction/inability to see alternatives to present situation Polarized thinking Thought patterns in a high-risk suicide patient involve: Idea that death may be a “way out” of terrible psychological pain Fantasies of death as an escape Feeling that he/she is a source of shame to his/her family Having suffered a recent humiliation Demographic features of higher risk patients for suicide include: Male Widowed, divorced, or single marital status, particularly for men Elderly age group (age group with greatest proportionate risk for suicide) Adolescents and young adults White race GBLT orientation Additional features when considering suicide risk should include: Access to or availability of lethal means (purchasing or having available a gun, rope, poison) Substance intoxication Recent discharge from a psychiatric hospital (many suicides occur within 3 months of discharge) Unstable or poor therapeutic relationship 56 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Absence or limited meaningful supportive relationships Be sure to screen for positives, i.e., “What is keeping you alive right now?” Therapeutic Rapport And Patient Alliance One of the challenging aspects of suicide prevention is that people who consider suicide do not always seek counseling. Earlier researchers found that people who took their lives often did not directly communicate their suicide intent to anyone. Older adults, a group that has a high risk for suicide, are comparatively less likely to express suicidal ideation. The relationship between the clinician and the patient is probably the most important factor in the assessment and treatment of suicidal behavior. In Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors, the American Psychiatric Association acknowledges that a positive and cooperative psychotherapeutic relationship can be an invaluable and even life-sustaining force for suicidal patients.77-82 It is helpful to communicate an empathic but clinically sound path during the 57 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com assessment process. The clinician begins to develop therapeutic rapport from the first moment he or she meets the client. Some rapport building strategies include: Explain the purpose of the assessment Ask the client for their preference on how they would like to be addressed (especially a culturally diverse client) Use a calm, neutral and reassuring tone of voice Listen deeply Initial Care Patient safety is the first priority, and the first step in the management of suicidal patients is to determine the intensity and the immediacy of risk. If outpatient treatment strategies are unsuccessful or suicide risk is imminent, the clinician should consider hospitalizing the patient in a secure inpatient setting. For example, if the patient has attempted suicide, if he/she has a detailed plan and the means to carry it out, hospitalization is warranted, or if the patient has psychosis and made a suicide attempt and/or has a detailed plan, he/she should be hospitalized. Additional considerations that indicate the need for hospitalization include: Suicide threats are escalating and the patient is determined to be a risk to self or others. The patient is on psychotropic medications and has previously used medications with intent to cause self-harm. The suicidal patient is not responding to outpatient treatment and there is severe depression or disabling anxiety. The patient is in an overwhelming crisis and cannot cope without the risk of serious harm to him or herself and no other safe environment 58 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com can be found. The risk of suicide outweighs the risk of hospitalization. While inpatient hospitalization is needed in these situations, it is important to note that for some patients there is an increased risk of suicide following inpatient care. This may be due to a short length of stay, lack of continuity of care after discharge, non-adherence with the treatment plan, and patient factors present on admission such as a relatively high level of depression, hopelessness, and impulsivity. Somewhat paradoxically, suicide completers also evidenced fewer previous suicide attempts and less suicidal ideation compared with living subjects who had attempted suicide at the time of index assessment. Thus, it is important not to assume that a person does not require further monitoring and assessment following discharge. Outpatient Treatment Hospitalization also carries the added burdens of increased financial costs and social stressors resulting from missed work, inability to take care of personal responsibilities, and possible stigma. If the patient is not considered to have a high or immediate risk for suicide, outpatient treatment is an option. Outpatient Management of Suicidality The clinician should conduct an evaluation for suicidal ideation/plans, address factors that directly contribute to risk, get a medication referral (if needed) to treat underlying disorder(s), encourage increased social support from the patient’s friends and family, and provide individual and family (where indicated) therapy. Concurrent substance use can greatly increase the risk of suicide so if the patient has a substance use problem, addressing this should be a priority. Keep accurate and current records and carefully 59 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com and continually document all findings. Arrange for emergency coverage for evenings and weekends. Other important points include: When imminent risk does not dictate hospitalization, intensity of outpatient treatment should increase. This should include more frequent appointments or telephone contacts. If the target is reduction of suicide attempts and behaviors, treatment should focus on identified skill deficits such as difficulties with problem-solving, effectiveness, anger management, or emotional regulation. Follow up should be employed to avoid the patient dropping out of treatment prematurely. Extended evaluation may be necessary, and suicide risk should be monitored on an ongoing basis. A strong therapeutic alliance should be developed with the suicidal patient. Use the clinical relationship to support safety during times of crisis. Involvement of family members, including parents or guardians in treatment is important. Their contribution should be acknowledged and they should be empowered to have a positive influence on the patient. Therapy There are many treatment approaches that are helpful for treating suicidal patients. In working with acutely suicidal clients, a dual approach of psychotherapy and medications is most helpful. Psychopharmacology And Therapeutic Models Lithium 60 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Lithium carbonate has been used since the late 1940s to treat people who have bipolar disorder, and it can reduce the number and severity of the depressive and manic episodes that characterize this disease. There is also good evidence that lithium can prevent suicide in people who have unipolar and bipolar mood disorders, and although this is not a labeled use for lithium, it is often recommended for this purpose. Recent literature reviews and a meta-analysis of 48 randomized controlled trials found that lithium was an effective treatment for reducing the risk of suicidal behavior in people who have mood disorders, possibly by its effect as a mood stabilizer and by reducing aggressiveness and impulsivity.156,158 Antidepressants Depression is a risk factor for suicide and although the magnitude of its effect is unclear, antidepressants have been shown to be effective at treating depressive disorders. A logical and intuitive inference from those facts would be that antidepressants might help to prevent suicide. But can they? There is evidence that antidepressants are associated with a slightly higher risk for suicide in adolescents and young adults. Antidepressants are associated with a protective effect against suicide in older adults; and, pharmacoepidemiologic studies have shown that antidepressants have a protective effect against suicide. However, the up-to-date literature is unequivocal on the issue; the current data cannot be used to conclude that antidepressants decrease or do not increase the risk for suicide.158 Antipsychotics, Anticonvulsants and Sedative-hypnotics 61 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The antipsychotics, anticonvulsants, and sedative-hypnotic drugs have been used to treat suicidal patients. The evidence indicates that their effect for this purpose is weak and inconsistent and based on limited research.158 Psychotherapy: Models of Therapy Edward Shneidman was a seminal researcher and theorist in the field of suicidology. Shneidman felt that the primary cause/causes of suicide was not psychiatric illnesses such as depression or schizophrenia but a condition he called psychache. Psychcache is the hurt, anguish, soreness, aching psychological pain on the psyche – the pain of excessively felt shame, or guilt, or humiliation, or loneliness, or fear, or angst, or dread of growing old or of dying badly, or whatever. People commit suicide, according to Shneidman, when someone can no longer bear the burden of his/her psychache; suicide is then the logical choice to reduce the tension and pain. Campos, et al. discussed psychache as a distinct construct ... a mental pain that is deeper, more primal, and more savage than general distress or depression, although general distress or depression may also be present.157 Shneidman opined that suicide prevention is primarily a matter of addressing and partially alleviating those frustrated psychological needs that are driving the person to suicide. In retrospect, in almost every case I have ever seen, it appears that suicide is pushed by pain, and that suicidal fantasies and suicidal acts are efforts to escape or put a stop to the pain that flows through the mind. Shneidman identified many needs associated with psychache and suicide. He felt the most important ones are: Counteraction: The need to atone for failure. 62 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Affiliation: The need to belong. Defense: The need for self-protection against harm and threats. Inviolacy: The need for autonomy and independence. Shame-avoidance Succor: The need to be loved and valued. Order and understanding: The need to understand the inner and outer world. The concept of psychache has been identified as an accurate identifier of suicide risk, and research has shown a strong link between the presence or strength of psychache and suicidal behavior.157,160 Collaborative Assessment and Management of Suicidality (CAMS) The Collaborative Assessment and Management of Suicidality (CAMS) is an evidence-based clinical intervention for suicidal patients. The basic framework of CAMS is a patient-clinician relationship that emphasizes collaboration and understanding.153,154 The therapist and the patient work together - collaborate - on an assessment of the patient’s suicidal ideation and behaviors using an assessment tool called the suicide status form. When the level of risk has been established, an appropriate therapeutic intervention is applied and the patient is actively included, or collaborates, as a co-author of the treatment process. Essential to the success of CAMS is a strong therapeutic relationship based on understanding. Suicide is not a desirable response or one that a therapist would like to see occur. But it should be emphasized to the client that he/she understands and empathizes with suicidal feelings. When therapists understand how suicide is in a sense functional for the patient – as an escape from psychic pain - they are better positioned to propose alternative 63 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com and less life-threatening ways of coping. During therapy sessions, the therapist tracks the patient’s suicidal ideation, and if after a certain period there are no suicidal thoughts, feelings, or behaviors the suicide risk is considered absent. Clinical trials have shown that CAMS can be effective. Cognitive Behavioral Therapy Cognitive-behavioral therapy (CBT) is a problem solving and action oriented approach to therapy. It is based on the principle that cognitive characteristics such as rigidity, poor problem solving and coping skills, and thought distortions are the source of the troublesome and maladaptive behavior; and the CBT therapist uses this framework as a way to reduce suicidal ideation and related symptomatology such as depression, hopelessness, and loneliness.153,154 People who are suicidal often have a negative view of themselves and the future, and they have irrational beliefs and ways of viewing the world that lead to hopelessness. The goal of CBT is identifying these issues and developing coping strategies that are specific to the cognitive distortions and deficits that drive suicidal ideation and behavior. In CBT, patients are actively challenged on their negative beliefs and their tendency to view themselves, their circumstances and their future in unrealistically negative terms. Patients focus on skills such as problem solving, coping, assertiveness, and interpersonal communication. In this approach, therapists actively educate patients about suicide, and the therapists teach them to recognize and understand their own self-limiting and negative beliefs. 64 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Clinical guidelines for CBT in suicidality are like those for depression or anxiety, and include targeting automatic thoughts, summarizing, and providing homework assignments to practice strategies and techniques outside of session. Additionally, guidelines state that CBT treatments target suicidality directly, rather than as a symptom of another presenting disorder. Thus, treatment needs to be implemented around the client's suicidality. Many of these guidelines have been applied to adult populations. Several researchers/clinicians have looked at adolescents with suicidal behaviors to assess the efficacy and develop treatment protocols for this population. For example, a manualized CBT approach for adolescents who had attempted suicide was designed to help adolescents use more effective means of coping when faced with stressors and problems that trigger suicidal crises, and the primary focus was reducing suicidal risk factors, enhanced coping, and preventing suicidal behavior. Parental involvement was included, as well, in family sessions focused specifically on suicide risk reduction strategies. A central focus of the manualized approach is the identification of risk factors and stressors, including emotional, cognitive, behavioral, and family processes active just prior to and following the adolescent’s suicide attempt or recent suicidal crisis. These include deficits in the adolescent’s abilities or motivations to cope with suicidal crises. Family issues become addressed to the extent that they are relevant to the case conceptualization and the prevention of future suicide attempts. The initial phase of acute treatment occurs during the first three sessions and consists of five main components: Chain Analysis, Safety Planning, Psychoeducation, Developing Reasons for Living and Hope, and Case Conceptualization. During the middle phase of acute treatment and after the immediate suicidal crisis has resolved, the primary area of intervention is behavioral and/or cognitive skills training 65 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com using individual or family sessions. The final component of the acute intervention phase includes a relapse prevention task. Dialectical Behavior Therapy Dialectical behavioral therapy (DBT) was developed as a therapeutic approach for treating people who have borderline personality behavior, and it has been adapted and used successfully for suicidal and parasuicidal behavior. Dialectical behavioral therapy includes simultaneous individual and group treatment modalities, and is based on the principles of cognitive, behavioral, and interpersonal therapy.153,154 Among chronically suicidal clients, distress tolerance tends to be low and coping resources and responses are limited. Dialectical behavioral therapy targets identified skills deficits such as inability or reduced ability for emotion regulation, distress tolerance, managing impulsivity, problem-solving, interpersonal assertiveness, and anger management. One of the key driving concepts of DBT is mindfulness. The patient is encouraged to be aware of internal and external experiences, how they affect mood and influence behavior, and to use this information to change troublesome behavior. Treatment strategies that guide the DBT process are: dialectical strategies, problem-solving, group therapy, learning and improving social skills, individual therapy, validation, capability enhancement, relationship strategies, and contingency strategies. Dialectical behavioral therapy was developed as a treatment for borderline personality disorder, but as previously mentioned, it has been shown to be effective at reducing suicidal ideation and behavior. For example, Linehan, et al. used DBT to treat 99 women who had borderline personality disorder who had previously made several suicide attempts or at least one recent (within 66 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com eight weeks) suicide attempt prior to the study. Dialectical behavioral therapy or DBT plus or minus some of its standard components was found to significantly reduce the frequency and severity of suicide attempts and suicidal ideation, the frequency of non-suicidal self-injury, and increase reasons for living and the use of crisis services.21 Alliance-Based Therapy (ABT) Alliance-based therapy (ABT) focuses on the therapeutic alliance with patients to treat suicidal behavior. Alliance-based therapy is guided by a set of principles that allows therapists to notice, engage and verbalize the interpersonal meaning of suicide. Through this process, and if there is a strong therapeutic alliance, suicidality shifts from symptom to interpersonal communication between the therapist and patient and becomes something under the patient’s conscious control.153,154 Some of the principles of ABT include: Differentiate lethal from non-lethal self-destructive behaviors Offer a non-punitive interpretation of the patient’s aggression Metabolize the countertransference Assign responsibility of the preservation of treatment to the patient Provide an opportunity for repair Interpersonal Psychotherapy (IPT) The Interpersonal Psychological Theory of Suicide (IPTS) informs interpersonal psychotherapy, and the IPTS has been shown to be a useful and accurate tool for understanding suicide. The IPTS theory states that suicidal ideation is caused by thwarted belongingness (i.e., lack of social 67 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com contact, loneliness) and perceived burdensomeness (self-hate, a feeling that one is a burden on others). The act of suicide and suicide behavior occur, according to ITP, when an individual acquires the capability to commit suicide. Specifically, the patient has a lowered fear of death because over time risk factors for suicide have become constant, intense, and unrelieved. In simpler terms, IPTS states that people commit suicide because they are lonely, feel that they are a burden, and suicide is preferable to their pain.153,154 The IPTS principles guide clinicians to look for interpersonal stressors that may be present in a client’s life. Examples of these stressors include grief, role transitions, interpersonal disputes, and interpersonal sensitivity (i.e., skills deficits). The theory suggests that clinicians be cognizant of their patients’ levels of belongingness, burdensomeness, and acquired capability (especially previous suicide attempts), which may aid clinicians in the task of suicide risk assessment and of target interventions. Summary The prevalence of suicide needs to be understood by health clinicians. Many people attempt suicide, but do not actually complete the attempt. Most people who die by suicide have risk factors of depression and other significant mental health issues, a substance use disorder, or a combination of risk factors. In addition, suicide is a growing concern for clinicians treating adolescents. The identification of suicide risk remains among the most important, complex, and difficult tasks performed by clinicians. Patient suicide can have profound personal and professional effects, including increased levels of anxiety and stress, isolation and withdrawal, and damage to clinicians’ 68 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com personal relationships. There may also be evidence of depression, a protracted grieving process, symptoms of posttraumatic stress or vicarious traumatization. Therapists working with suicidal clients have many responsibilities. These include developing a skill set and protocols for treating clients who may be at risk for suicide, accurately assessing suicidal risk, responding to a patient’s suicide attempt, and, importantly, implementing self-care activities. It is important for clinicians to be prepared and to continuously improve their skills to screen patients for suicidal ideation and behavior. While it may be challenging for clinicians to balance their own comfort level with the need to obtain accurate and clear information, with the varied approaches raised here to help evaluate patient risk, clinicians may focus on developing a public health perspective to reduce suicide. 69 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. 1. The CDC estimates _____ attempted suicides occur per every suicide death. a. b. c. d. 4 7 11 18 2. Suicide is the __________ leading cause of death among adolescents 15-19 years of age. a. b. c. d. number one third second fourth 3. Which of the following is defined as “nonlethal intentional selfinjurious behavior”? a. b. c. d. Contagion Parasuicide Suicidal ideation Cluster 4. Which of the following is defined as “a phenomenon whereby susceptible persons are influenced toward suicidal behavior through knowledge of another person’s suicidal acts”? a. b. c. d. Contagion Parasuicide Suicidal ideation Cluster 5. The increased suicide rate in the United States is especially pronounced in 70 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com a. b. c. d. teenagers. middle aged adults. older adults. middle aged women. 6. Which of the following is NOT one of the three primary components of the Cognitive Stress Diathesis Model? a. b. c. d. Oversensitivity to signals of defeat Perceived “no escape” Perceived “no rescue” A present/past orientation 7. In the Clinical Stress Diathesis Models, the primary proposed genetic factors are a. b. c. d. aggressive and impulsive. aggressive and anxious. anxious and depressive. depressive and impulsive. 8. _____________ research assesses the degree to which someone’s surroundings exert a positive or negative influence depends on individual factors. a. b. c. d. Psychological Sociocultural Psychodynamic Epidemiological 9. The presence of ____________ appears to confer an increased risk for suicidal behavior. a. b. c. d. marital discord financial Stressors mental illness chronic pain 10. ___________ typically commit suicide by poisoning. a. Students 71 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com b. Older males c. Men d. Women 11. In addition to hopefulness, the most consistent protective factors found in suicide research are a. b. c. d. employment and physical health. physical health and social support. social support and connectedness. connectedness and employment. 12. Which of the following is a perceived inability to fully experience unpleasant, aversive or uncomfortable emotions, and is accompanied by a desperate need to escape the uncomfortable emotions? a. b. c. d. Distress intolerance Emotional myopia Dysemotiva Distress tolerance 13. Several studies suggest that __________ of those who committed suicide had a psychiatric diagnosis at the time of death. a. b. c. d. over 90% 40% over half 70% 14. Which of the following is a measure of hopelessness that is a 20-item self-report inventory? a. b. c. d. Beck Hopelessness Scale Rey Hopelessness Inventory Lawrence Hopelessness Schedule Brief Hopelessness Checklist 15. A person who has an alcohol use disorder may be more vulnerable to suicide if that person, among other things, is 72 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com a. b. c. d. female. an adolescent. male, and over 50. elderly. 16. _________________ was developed as a therapeutic approach for treating people who have borderline personality behavior and it has been adapted and used successfully in treating suicidal and parasuicidal behavior. a. Alliance-based therapy (ABT) b. Cognitive-behavioral therapy (CBT) c. Rational emotive behavior therapy (RET) d. Dialectical behavioral therapy (DBT) 17. Homeless individuals were _______ likely as the non-homeless individuals to kill themselves. a. b. c. d. less just as 4 times more twice as 18. Demographic features of higher risk patients for suicide include a. b. c. d. African Americans. Native Americans. Caucasians. Hispanics. 19. One challenging aspect in recognizing suicidal ideation in Native American people concerns a. b. c. d. the politeness theory. machismo. spirituality. a strong sense of individuality. 20. True or False: Hispanic Americans tend NOT to commit suicide due to the strong Catholic strictures against it. a. True 73 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com b. False 21. The risk of suicide for Asian Americans/Pacific Islanders has usually been determined to be less than or equal to other groups, except for _________________, who have a disproportionately high risk for suicide. a. b. c. d. elderly Asian Americans Asian American adolescents elderly men Asian American women 22. Which of the following is NOT an acute warning sign of suicide risk? a. b. c. d. Hopelessness Threatening to hurt self Looking for ways to kill self Persistently talking or writing about death 23. Which of the following is/are a myth or misconception about suicide? a. Using the word “suicide” with a client will increase the likelihood that they will make an attempt b. Suicide contracts are the best way to ensure safety c. Suicides increase in fall and winter d. All the above 24. Which of the following is NOT a cognitive feature that increases suicide risk? a. b. c. d. Loss of executive function Thought constriction Mental retardation Polarized thinking 25. True or False: Dialectical Behavior Therapy includes simultaneous individual and group treatment modalities. 74 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com a. True b. False 26. Which of the following is NOT a principle of Alliance-Based Therapy? a. b. c. d. Identify and dispute negative cognitions Differentiate lethal from non-lethal self-destructive behaviors Metabolize the countertransference Provide an opportunity for repair 27. Which of the following is a school-based prevention program? a. b. c. d. SAMHSA NAMI SOS IASP 28. Concern for suicide among adolescents a. b. c. d. is a growing concern. has leveled off. is in decline because of programs like SOS. generally affects children over the age of 12. 29. Resilience describes capacities within a person that promote a. b. c. d. 30. adverse health outcomes. positive outcomes. persistence in suicide attempts. discourse on suicide ideation. True or False. Lithium is an effective treatment for reducing the risk of suicidal behavior in people who have mood disorders, possibly by its effect as mood stabilizer and but has NO effect on aggressiveness and impulsivity. a. True. b. False. 75 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com CORRECT ANSWERS: 1. The CDC estimates _____ attempted suicides occur per every suicide death. c. 11 “Per the Centers for Disease Control and Prevention (CDC) statistics, suicide was the tenth leading cause of mortality in the U.S., accounting for 41,149 deaths in 2013. Many people attempt suicide, but do not actually complete the attempt. These statistics estimate 11 attempted suicides occur for every suicide death.” 2. Suicide is the __________ leading cause of death among adolescents 15-19 years of age. c. second “Suicide is the third leading cause of death in adolescents and for adolescents 15–19 years of age it is the second leading cause of death.” 3. Which of the following is defined as “nonlethal intentional selfinjurious behavior”? b. Parasuicide “Parasuicide: any nonlethal intentional self-injurious behavior that is intended express suicidal feelings but not to cause her. This is often called a suicide gesture.” 4. Which of the following is defined as “a phenomenon whereby susceptible persons are influenced toward suicidal behavior through knowledge of another person’s suicidal acts”? a. Contagion 76 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com “Contagion: A phenomenon whereby susceptible persons are influenced towards suicidal behavior through knowledge of another person’s suicidal acts.” 5. The increased suicide rate in the United States is especially pronounced in c. older adults. “The rates for suicide are highest for middle age and older adults, and the increased suicide rate in the United States is especially pronounced in older adults.” 6. Which of the following is NOT one of the three primary components of the Cognitive Stress Diathesis Model? d. A present/past orientation “This model looks at suicidality as resulting from a combination of neuropsychological deficits in areas of memory, attention or problem solving along with stressors that result in perceptions of hopelessness, immovability, or esteem issues. The three primary components of this model are… Oversensitivity to Signals of Defeat…. Perceived No Escape…. Perceived No Rescue.” 7. In the Clinical Stress Diathesis Models, people who attempt or commit suicide may have a pre-disposition to do so because of _________________ personality traits. a. aggressive and impulsive “Clinical stress diathesis models…. is based on the idea that psychopathology is a necessary, but not sufficient, factor for suicide. The authors noted that people who attempt to, or do commit suicide may have a predisposition to do so because of aggressive and impulsive personality traits.” 8. _____________ research assesses the degree to which someone’s surroundings exert a positive or negative influence depends on individual factors. b. Sociocultural 77 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com “Sociocultural research assesses the degree to which someone's surroundings exert a positive or negative influence whether an individual's family, community and country are supportive or stressful.” 9. The presence of ____________ appears to confer an increased risk for suicidal behavior. d. chronic pain “Patients with serious medical conditions may be at increased risk for suicide. These include but are not limited to chronic pain, cancers, HIV/AIDS, lupus, headache, traumatic brain injury, fibromyalgia, and diseases of the central nervous system such as Alzheimer’s disease, epilepsy, Huntington’s disease, and multiple sclerosis.” 10. ____________ typically commit suicide by poisoning. d. Women “Men commit suicide at four times the rate of women, but women are more likely to have suicidal thoughts. Men typically commit suicide by using a firearm, women by self-poisoning.” 11. In addition to hopefulness, the most consistent protective factors found in suicide research are c. social support and connectedness. “The most consistent protective factors found in suicide research are social support and connectedness and hopefulness.” 12. Which of the following is a perceived inability to fully experience unpleasant, aversive or uncomfortable emotions, and is accompanied by a desperate need to escape the uncomfortable emotions? a. Distress intolerance “Distress intolerance, on the other hand, is a perceived inability to fully experience unpleasant, aversive or uncomfortable emotions, 78 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com and is accompanied by a desperate need to escape the uncomfortable emotions.” 13. Several studies suggest that __________ of those who committed suicide had a psychiatric diagnosis at the time of death. a. over 90% “Most suicide events occur in people who have a psychopathology such as bipolar disorder or depression, and although the great majority of people who have a mental disorder do not commit suicide, the results of several of studies suggest that over 90% of those who committed suicide had a psychiatric diagnosis at the time of death.” 14. Which of the following is a measure of hopelessness that is a 20-item self-report inventory? a. Beck Hopelessness Scale “Hopeless can be measured using the Beck Hopelessness Scale. This is a 20-item self-report inventory that measures negative and positive attitudes about the future in terms of affective, cognitive, and motivational factors.” 15. A person who has an alcohol use disorder may be more vulnerable to suicide if that person, among other things, is c. male, and over 50. “People who have alcohol use disorder may be more vulnerable to suicide if they are over 50, male, unemployed and living alone, experience a major depressive episode, experience a stressful life event, have poor social support, or have a substance use disorder or a serious medical illness.” 16. _________________ was developed as a therapeutic approach for treating people who have borderline personality behavior and it has been adapted and used successfully in treating suicidal and parasuicidal behavior. 79 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com d. Dialectical behavioral therapy (DBT) “Dialectical behavioral therapy (DBT) was developed as a therapeutic approach for treating people who have borderline personality behavior, and it has been adapted and used successfully for suicidal and parasuicidal behavior. Dialectical behavioral therapy or DBT plus or minus some of its standard components was found to significantly reduce the frequency and severity of suicide attempts and suicidal ideation, the frequency of non-suicidal selfinjury, and increase reasons for living and the use of crisis services.” 17. Homeless individuals were _______ likely as the non-homeless individuals to kill themselves. d. twice as “Homeless individuals have a much higher rate of suicidal thoughts and behavior and suicide itself than the general population; researchers have found that homeless individuals were twice as likely as the non-homeless to kill themselves….” 18. Demographic features of higher risk patients for suicide include c. Caucasians. “Demographic features of higher risk patients for suicide include: … White race.” 19. One challenging aspect in recognizing suicidal ideation in Native American people concerns a. the politeness theory. “Another aspect in recognizing suicidal ideation in Native American people concerns the politeness theory. In this culture, people considering suicide may not be direct in making their personal pain known to avoid placing a burden on others. Additionally, vague or indirect calls for assistance help protect them from their own embarrassment if others fail to respond. There is a cultural stigma against suicide and following a suicide attempt.” 80 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20. True or False: Hispanic Americans tend NOT to commit suicide due to the strong Catholic strictures against it. b. False “There is a common perception that Hispanic Americans do not commit suicide due to the strong Catholic strictures against it. Religiosity is an important protective factor, but Hispanic Americans are a diverse group and while suicide rates are lower than other ethnic groups they are not negligible.” 21. The risk of suicide for Asian Americans/Pacific Islanders has usually been determined to be less than or equal to other groups; an exception within this community is _____________, who have a disproportionately high risk for suicide. b. Asian American adolescents “Asian Americans/Pacific Islanders: ... The risk of suicide in this population has usually been determined to be less than that of white Americans and American Indians and approximately equivalent to African Americans and Hispanic Americans/Latinos; however, an unfortunate exception is Asian American adolescents. Like Native American and Hispanic/Latino adolescents, Asian American adolescents have a disproportionately high risk for suicide; the 2016 Youth Risk Survey found that the self-reported incidence of suicide attempts in Asian American adolescents was 9.5%, 1.5 times that of white American adolescents.” 22. Which of the following is NOT an acute warning sign of suicide risk? a. Hopelessness “Acute signs of suicide risk include: Actively looking for ways to commit suicide such as buying a firearm, researching suicide methods, and making a plan. Making threats to commit suicide. Persistently and actively talking about death and suicide. Talking, writing or posting on social media about death, dying and suicide.” 81 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23. Which of the following is/are a myth or misconception about suicide? a. Using the word “suicide” with a client will increase the likelihood that they will make an attempt b. “Birthday Blues” lead to an increase in suicides c. An unsuccessful suicide attempt meant the person was not serious about suicide d. All the above [correct answer] “Among clinicians and laypersons a number of myths exist relating to suicide… authors have described some of these myths following myths... An unsuccessful attempt means that the person wasn't serious about ending his or her life: Some people are naive about how to kill themselves. The attempt in and of itself is the most important factor, not the method or outcome. The so-called birthday blues lead to an increase in suicide... Using the word suicide with a client will increase the likelihood that he/she will attempt suicide.” 24. Which of the following is NOT a cognitive feature that increases suicide risk? c. Mental retardation “Cognitive features: Loss of executive function; Thought constriction/inability to see alternatives to present situation; Polarized thinking” 25. True or False: Dialectical Behavior Therapy includes simultaneous individual and group treatment modalities. a. True “Dialectical behavioral therapy includes simultaneous individual and group treatment modalities, and is based on the principles of cognitive, behavioral, and interpersonal therapy.” 82 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26. Which of the following is NOT a principle of Alliance-Based Therapy (ABT)? a. Identify and dispute negative cognitions “Some of the principles of ABT include: Differentiate lethal from non-lethal self-destructive behaviors; Offer a non-punitive interpretation of the patient’s aggression; Metabolize the countertransference; Assign responsibility of the preservation of treatment to the patient; Provide an opportunity for repair.” 27. Which of the following is a school-based prevention program? c. SOS “SOS is a school-based prevention program that incorporates two prominent suicide prevention strategies into a single program...” 28. Concern for suicide among adolescents a. is a growing concern. “… suicide is a growing concern for clinicians treating adolescents. A CDC study found that 16% of adolescents in grades 9-12 had seriously considered suicide and 8% attempted to do so.” 29. Resilience describes capacities within a person that promote b. positive outcomes. “Resilience: Capacities within a person that promote positive outcomes ...” 30. True or False. Lithium is an effective treatment for reducing the risk of suicidal behavior in people who have mood disorders, possibly by its effect as mood stabilizer and but has NO effect on aggressiveness and impulsivity. b. False. “…controlled trials found that lithium was an effective treatment for reducing the risk of suicidal behavior in people who have mood 83 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com disorders, possibly by its effect as mood stabilizer and by reducing aggressiveness and impulsivity.” References Section The References below include published works and in-text citations of published works that are intended as helpful material for your further reading. [Please see the Suicide Prevention Resources in the Appendix attached below]. 1. Kaslow N. Our opportunity to reduce suicide. APA Monitor. 2014;45(4):2014. http://www.apa.org/monitor/2014/04/pc.aspx. 2. The National Institute of Mental Health (2016). Retrieved online @ https://www.nimh.nih.gov/health/topics/suicideprevention/index.shtml. 3. Centers for Disease Control and Prevention. Suicide: Facts at a Glance, 2015. https://www.cdc.gov/violenceprevention/pdf/suicide-datasheeta.pdf. 4. Centers for Disease Control and Prevention. Youth Suicide. March 10, 2015. https://www.cdc.gov/ViolencePrevention/suicide/youth_suicide.html. 5. van Heeringen, K. (2012). Stress-Diathesis Model of Suicidal Behavior. The Neurological Basis of Suicide. Retrieved online at https://www.ncbi.nlm.nih.gov/books/NBK107203/. 6. Van Orden, K.A.; Witte, T.K.; Cukrowicz, K.C.; Braithwaite, S.R.; Selby, E.A.; Joiner Jr., T.E. (2010). The interpersonal theory of suicide, Psychological Review,117(2), 575-600. 7. Lowry, F. (2013). Chronic, non-cancer pain boosts suicide risk. JAMA Psychiatry. Published online May 22, 2013. 8. Kanzler, K.E. et al., (2012). Suicidal ideation and perceived burdensomeness in patients with chronic pain. 9. Yamuchi, T., et al. (2014). Death by suicide and other externally caused injuries following a cancer diagnosis: the Japan Public Health Center-based Prospective Study, Psycho-oncology. 10. Mock, C.C., Chan, K.L., Cheung, E.F., Yip, P.S. (2014). Suicidal ideation in patients with systemic lupus erythematosus: incidence and risk factors. Rheumatology, 53(4), 714-721. 11. Rozen, T.D. & Fishman, R.S. (2012). Cluster headache in the United States of America: demographics, clinical characteristics, triggers, suicidality, and personal burden. Headache, 52(1), 99-113. 12. Carroll, L.J., et al. (2014). Systematic review of the prognosis after mild traumatic brain injury in adults: cognitive, psychiatric, and mortality outcomes: results of the international collaboration on mild 84 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. traumatic brain injury prognosis. Archives Physical and Medical Rehabilitation;95(3 Suppl):S152-73. Wolfe, F., Hassettm, A,L., Walitt, B., & Michaud K. (2011). Mortality in fibromyalgia: a study of 8,186 patients over thirty-five years. Arthritis Care Research, 63, 94–101. Shireen et al. (2014). Trauma experience of youngsters and Teens: A key issue in suicidal behavior among victims of bullying? Pakistan Journal of Medical Sciences, 30(1), 206-210. Carney, A. (2014). Lesbian, gay, and bisexual adolescent suicidality: the impact of social stigma. Kentucky Nurses Association, 62(1), 4. Stone, D.M. et al. (2014). Sexual orientation and suicide ideation, plans, attempts, and medically serious attempts: evidence from local Youth Risk Behavior Surveys, 2001-2009. American Journal of Public Health, 104(2), 262-71. Mustanski, et al. (2014). A syndemic of psychosocial health disparities and associations with risk for attempting suicide among young sexual minority men. Kleiman, E.M., Riskind, J.H., Schafer, K.E. (2014). Social Support and Positive Events as Suicide Resiliency Factors: Examination of Synergistic Buffering Effects. Archives of Suicide Research, March, 2014. Goldfarb, S., Tarver, W.L., Sen, B. (2014). Family structure and risk behaviors: the role of the family meal in assessing likelihood of adolescent risk behaviors. Psychology research and behavior management, 7,53-66. Bryan, C., Andreski, S.R., McNaughton-Cassill, M., & Osman, A. (2014). Agency is Associated with Decreased Emotional Distress and Suicidal Ideation in Military Personnel. Archives of Suicide Research Linehan, M. et al. (2012). Assessing and Managing Risk With Suicidal Patients. Cognitive and Behavioral Practice 19 (2012) 218-232. Retrieved online at http://www.nadorff.psychology.msstate.edu/SuicideClass/Readings/Lin ehan%202010%20Assessing%20and%20Managing%20Risk%20in%2 0Suicidal%20Individuals.pdf. Anestis, M.D. et al. (2013). The importance of high distress tolerance in the relationship between nonsuicidal self-injury and suicide potential. Suicide and Life Threatening Behavior, 43(6), 663-675. Niederkrotenthaler, T. et al. (2014). Characteristics of U.S. suicide decedents in 2005-2010 who had received mental health treatment, Psychiatric Services, 65(3), 387-390. Karch, D.L., Logan J., Patel, N. (2011). Surveillance for violent deaths—National Violent Death Reporting System, 16 states, 2008. MMWR Surveillance Summary. 60,1-49. 85 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25. Kaley, Mancino, & Messias (2014). Sadness, suicide, and drug misuse in Arkansas: results from the Youth Risk Behavior Survey 2011. Journal of the Arkansas Medical Society, 110(9), 185-186. 26. Thon, N. et al. (2014). Prevalence of suicide attempts in pathological gamblers in a nationwide Austrian treatment sample. General Hospital Psychiatry, 36(3):342-346. 27. Dvorak, R., Lamas, D., & Malone, P., (2013). Alcohol use, depressive symptoms, and impulsivity as risk factors for suicide proneness among college students, Journal of Affective Disorders, 149(1-3), 326-34. 28. Hor, K. and Taylor, M. (2010). Suicide and schizophrenia: a systematic review of rates and risk factors. Journal of Psychopharmacology, 24(supplement), 81–90. 29. Kasckow. J., Felmet, K. & Zisook, S. (2011). Managing suicide risk in patients with schizophrenia. CNS Drugs, 25(2):129-143. 30. Nepon, J. et al. (2011). The Relationship Between Anxiety Disorders and Suicide Attempts: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Depression and Anxiety, 27(9), 791–798. 31. Bernert, R. & Nadorff, M. (2015). Sleep Disturbances and Suicide Risk, Sleep Medicine Clinics, 10(1), 35-9. 32. Williams, J. and Nieuwsma, J. (2017). Screening for depression in adults. UpToDate. Retrieved online at https://www.uptodate.com/contents/screening-for-depression-inadults?source=search_result&search=beck%20depression%20scale&s electedTitle=1~150. 33. Pawlak, J., et al. (2016). Suicide behavior as a quantitative trait and its genetic background. J Affect Disord. 2016;206:241-250. 34. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013). 35. Garland EL, Riquino MR, Priddy SE, Bryan CJ. (2016). Suicidal ideation is associated with individual differences in prescription opioid craving and cue-reactivity among chronic pain patients. J Addict Dis. 2016 Aug 12:1-7. [Epub ahead of print] 36. Hooten WM. (2016). Chronic pain and mental health disorders: Shared neural mechanisms, epidemiology, and treatment. Mayo Clin Proc. 2016;91(7):955-970. 37. Fegg M, Kraus S, Graw M, Bausewein C. (2016). Physical compared to mental diseases as reasons for committing suicide: a retrospective study. BMC Palliat Care. 2016 Feb 9;15:14. doi: 10.1186/s12904-0160088-5. 38. Yamuchi T, Inagaki M, Yonemoto N, et al. (2015). Death by suicide and other externally caused injuries following a cancer diagnosis: the Japan Public Health Center-based Prospective Study, Psychooncology. 2014; Sep;23(9):1034-41.Sheehan and Herman (2015). 86 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39. Goehringer F, Bonnet F, Salmon D, et al. (2016). Causes of death in HIV-infected individuals with immunovirologic success in a national prospective survey. AIDS Res Hum Retroviruses. 2016 Dec 16. [Epub ahead of print] 40. Lyness, J.M. (2017). Unipolar depression in adults: Clinical features. UpToDate. Retrieved online at https://www.uptodate.com/contents/unipolar-depression-in-adultsclinicalfeatures?source=search_result&search=stigma%20and%20suicide&sel ectedTitle=5~150. 41. Jacobson, C., Batejan, K., Kleinman, M., Gould M. (2013). Reasons for attempting suicide among a community sample of adolescents. Suicide and Life Threating Behavior, 43(6), 646-62. 42. Schlebusch L, Govender RD. (2015). 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BMJ Open. 2014 Mar 21;4(3) 96 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Appendix Suicide Prevention Resources Air Force Suicide Prevention Program http://afspp.afms.mil American Association of Suicidology http://www.suicidology.org/home American Association of Suicidology Clinician Survivor Task Force http://mypage.iu.edu/~jmcintos/basicinfo .htm This website offers an Air Force description of their suicide prevention program and offers communities a model with elements that can be adapted for communities. This organization advance Suicidology as a science; encouraging, developing and disseminating scholarly work in suicidology. Many clinical resources are available. Develops and provides postvention for clinicians who had lost a patient to death by suicide Charting the future of suicide prevention: A 2010 progress review of the national strategy and recommendations for the decade ahead http://www.sprc.org/sites/sprc.org/fi les/library/ChartingTheFuture_Full book.pdf This document reviews developments in the field of suicide prevention since the National Strategy for Suicide Prevention was published. Depression Screening http://www.mentalhealthamerica.ne t/llw/depression_screen.cfm Mental Health America has a Depression Screening site as part of their Campaign for America’s Mental Health. The webpage educates people about clinical depression, offers a confidential way for people to get screened for symptoms of the illness, and guides people toward appropriate professional help if necessary. IASP is dedicated to preventing suicidal behavior, to alleviate its effects, and to provide a forum for academics, mental health professionals, crisis workers, volunteers and suicide survivors. The National Suicide Prevention Lifeline provides confidential support to people in suicidal crisis 24 hours a day, 7 days a week (1-800-suicide). It also operates a Veterans Crisis line (1-800-273-TALK). A nonprofit, grassroots, self-help, support and advocacy organization of consumers, families, and friends of people with severe mental illnesses, such as schizophrenia, International Association for Suicide Prevention (IASP) http://www.iasp.info/ National Suicide Prevention Lifeline http://www.suicidepreventionlifeline.org/ National Alliance on Mental Illness http://nami.org 97 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com major depression, bipolar disorder, obsessive-compulsive disorder, and anxiety disorders S.O.S (Signs of Suicide) http://www.mentalhealthscreening.o rg/programs/youth-preventionprograms/sos/ Suicide Prevention Resource Center http://www.sprc.org/ Substance Abuse and Mental Health Services Administration (SAMHSA ) http://www.samhsa.gov/ SOS is a school-based prevention program that incorporates two prominent suicide prevention strategies into a single program, combining a curriculum that aims to raise awareness of suicide and its related issues with a brief screening for depression and other risk factors. The educational component is expected to reduce suicidality by increasing middle or high school students’ understanding of and promoting more adaptive attitudes toward depression and suicidal behavior. The self-screening component enables students to recognize depression, suicidal thoughts and behaviors in themselves, and to find assistance. Promotes a public health approach to suicide prevention and includes suicide prevention basics, news and events, a training institute, best practices registry, and a library of resources. There are additional training documents specific to different ethnic groups and vulnerable populations. A division of the U.S. Department of Health and Human Services, SAMHSA provides leadership in promoting quality behavioral health services to local communities throughout the country, through grants and funding for research and programs. 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