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SUICIDE PREVENTION:
ASSESSMENT AND
TREATMENT
Part II
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 self1
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care following a patient suicide is 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 at-risk 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
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is better able to incorporate professional recommendations of self-care
while dealing with a suicidal patient.
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.
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Opportunity to complete a self-assessment of knowledge
learned will be provided at the end of the course.
1. Key to a veteran’s engagement and adherence to a
treatment program is
a.
b.
c.
d.
the
the
the
the
veteran’s education.
veteran’s understanding of mental illness.
veteran’s agreement to the treatment decision.
veteran knowing the options.
2. True or False: Screening for a medical condition has been
defined as the examination of a person with symptoms of a
condition to determine if the person actually has the
condition.
a. True
b. False
3. Screening for a mental disorder
a.
b.
c.
d.
replaces formal assessment of mental illness.
is used in lieu of diagnosis.
may be done by an untrained clinician.
serve as a decision support tool.
4. When a veteran is referred to a mental health professional
for evaluation,
a.
b.
c.
d.
an initial evaluation should be done within 14 days of referral.
data is maintained on the proportion who begin evaluation.
data is tracked to confirm the veteran completed evaluation.
All of the above
5. Veteran status is not always disclosed to a healthcare
provider because
a.
b.
c.
d.
it is not asked in traditional behavioral health screenings.
a patient’s military service is confidential.
asking a patient about military service is not important.
veterans routinely deny their service.
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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. Veterans have been reported to take their own
lives at more than double the rate of civilians. Often veterans will not
identify themselves as having served in the military and may avoid
bringing up those past experiences. Appropriate evaluation of suicide
risk in the veteran population will often depend on clinicians’ screening
tools and incorporation of specific screening questions related to the
branch of military service, course of duty and whether military combat
was part of veteran duty. Clinicians encountering suicidal thoughts and
behaviors in patients may tend to focus more on patient suffering and
risk than their own rate of stress and emotional burnout. This part 2
course on Suicide Prevention Assessment And Treatment includes a
special focus on the need for the health caregiver to incorporate selfcare into everyday practice.
Veterans At Risk For Suicide:
VA/DoD Clinical Practice Guidelines
Suicide rates among veterans are higher than in the general
population, and the suicide rates in the United States military
dramatically increased after the wars in Iraq and Afghanistan. Suicide
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has become the second highest cause of death in the military (death
by combat was first), and this increased risk of suicide has been found
to continue many years after the end of active service.
Military service and combat experience are associated with depression,
isolation, post-traumatic stress disorder (PTSD), substance use, and
other behavioral, psychiatric, and social conditions that are associated
with an increase in the risk of suicide. There are also specific personal
and service factors that increase the risk for suicide in military
personnel. Research about these factors is at times contradictory, but
it appears that female gender, an age of less than 25 years when
entering service, depression, alcohol or substance use disorders,
Caucasian race, low educational level, enlisted status versus officer
status, and (possibly) deployment history and status increase the risk
of suicide.
Veterans from recent conflicts have or will be diagnosed with PTSD,
major depression, or both PTSD and major depression at a significant
rate. Since 2001, 2.4 million active duty and reserve military
personnel were deployed to the wars in Iraq and Afghanistan. Thirty
percent of this group, nearly 730,000 men and women, have or will be
diagnosed with a mental health condition requiring treatment. These
issues arise during deployment, as well as when veterans and their
families confront reintegration into their communities.
Current and former members of the military may not always volunteer
information about their military service. Furthermore, veterans may
not be willing to share their experiences, especially when memories of
military action cause them mental anguish. Deployment may have a
profound effect on military personnel, and an understanding of mental
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illness and how to screen, diagnose and treat mental illness is
important for health clinicians.
Mental Health Disorders in Veterans
The most common medical and mental health issues affecting veterans
include PTSD, suicide, depression, grief, drug and alcohol use, and
intimate partner violence or child abuse. It is important for a health
clinician to talk to patients and their family members about military
involvement to assess the risk of mental health conditions, as well as
the stress, depression, grief, and risk of suicide that may be present.
With the right screening questions, health professionals have the
opportunity to begin early intervention to mitigate the impact of these
conditions.
Screening for Military Service
Screening has been defined as the examination of a generally healthy
population to identify people as likely or unlikely to have a particular
condition.91 Because screening is not without cost or potential adverse
effects, six criteria have been proposed to determine the acceptability
of any given screening procedure.

The identified condition should be an important health problem.

The test should be clinically, socially, and ethically acceptable

The test should be simple, precise, and valid.

The test should lead to reduced morbidity.

Staffing and facilities for all aspects of the screening program must
be adequate.

Benefits of screening should outweigh potential harms.
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It is generally accepted that screening for PTSD, depression, and other
mental health problems is ineffective unless it is integrated into a total
management program with adequate follow-up to confirm or refute a
positive screening result and adequate capability to provide
appropriate treatment.
Screening is not meant to replace assessment or diagnosis, but it can
serve as a decision support tool. A person who has a positive
screening result should undergo a clinical assessment that can be used
by a trained clinician to make appropriate diagnoses, including
comorbid conditions, such as depression or traumatic brain injury
(TBI), and to acquire additional information that is required to plan
treatment. Such an assessment should take into account symptoms
that the person is experiencing and the severity of and functional
impairment associated with the symptoms.
Although it is widely believed that screening for PTSD among current
and former service members is important to identify affected
individuals as early as possible for direction to appropriate treatment
planning, there is no strong evidence to support the belief that this will
prevent chronic suffering and maladjustment.92
Why Screen for Military Service?
The major psychological conditions currently screened for in activeduty military personnel and veterans are PTSD, depression, alcohol
use disorders, sexual trauma, suicidality, and mild TBI. Traumas
associated with military service, such as combat and sexual assault,
have been associated with a high prevalence of PTSD in this
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population, and several factors should be considered when
implementing broad screening directives in this group.
For a screening program to be
effective, adequate resources need
to be in place to support it, such as
appropriate personnel and time.
There are important factors to
designing a screening program,
such as the choice of instrument,
method of delivery (self-report
versus clinician-administered),
place of delivery (in the theater of
war versus on the home front),
and intended use of the results of
the screen.92,93
In the Veterans Health Administration (VHA), positive screenings for
PTSD, depression, suicidality, or military sexual trauma (sexual assault
or extreme harassment that occurred during service in the military)
result in referral of the veteran to a mental health professional for
evaluation. Patients referred are to receive an initial evaluation within
24 hours and a full evaluation within 14 days after referral. However,
no data is available to track what happens after referral; for example,
what proportion engage and complete evaluations, enter and complete
treatment, continue or return to active duty, or are discharged.94
Veteran Status
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Veterans and service members may not self-identify as such to their
health professionals. Assessing veteran status should be integrated
into the behavioral health screening process. The American Medical
Association (AMA) has urged health clinicians to ask patients if they
have served in the military and to include that experience in their
records. The American Academy of Nursing (AAN) launched an
awareness campaign in 2013 to encourage health professionals to ask
patients if they are veterans or family members of veterans. Health
clinicians do not routinely ask this question. Only a small percentage of
veterans receive services through the Veterans Health Administration.
Many more veterans receive health care through community health
professionals.94,95
The AAN program provides screening and intake questions and
information on general areas of concern for all veterans, such as posttraumatic stress, military sexual trauma, and blast concussions or
traumatic brain injury, as well as health concerns for veterans of
specific conflicts or deployment conditions. The initiative aims to
ensure that individuals have appropriate access to services and to
increase health clinicians’ awareness of service-related healthcare
issues.95
Assessing veteran status is not included in traditional behavioral health
screenings. Since patients may not volunteer this information, asking
patients if they have served in the military has important implications
for the available benefits and care. Screening for veteran status
includes 1) ensuring that veterans have access to healthcare and
support services that they have earned, 2) informing treatment
planning, and 3) increasing awareness of the extraordinary strengths
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that veterans often possess and unique challenges that they may
face.96
Family Member of Veteran
Finding out if patients have close family members who are veterans
can help health clinicians understand the patient’s family context and
determine if the family could benefit from connection to veteran
resources. In addition, individuals working with veteran family
members must take their mental health into account. It is important to
provide mental health assessments to the family members of veterans
on a regular basis to ensure their needs are being met.97
Screening Questions
The American Academy of Nursing suggests the following screening
questions for determining military service of patients or family
members of patients.98

Have you or has someone close to you ever served in the military?

When did you serve?

Which branch did you serve?

What did you do while you were in the military?

Were you assigned to a hostile or combative area?

Did you experience enemy fire, see combat, or witness casualties?

Were you wounded, injured, or hospitalized?

Did you participate in any experimental projects or tests?

Were you exposed to noise, chemicals, gases, demolition of
munitions, pesticides, or other hazardous substances?
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
Have you ever used the VA (Veterans Administration) for
healthcare? (When was your last visit to the VA? Do you have a
service-connected disability or condition? Do you have a VA
primary care provider?)
Mental health screening is an important part of patient evaluation and
intake in both the outpatient and inpatient setting. Screening for a
mental health condition, such as anxiety or depression, allows the
mental health professional to identify a condition and intervene early
to avoid a serious outcome and to help the patient begin the
appropriate treatment needed. Research has shown that identifying
primary psychiatric symptoms early helps to formulate an effective
treatment plan and leads to improved mental health outcomes.
Moreover, when a mental health condition is identified early, long-term
distress and disability may be prevented. The following sections
discuss specific psychiatric diagnoses and screening instruments to
early identify a mental health condition for appropriate treatment and
follow-up care.
Post-traumatic Stress Disorder in Veterans
Post-traumatic stress disorder is a condition that can occur at any age,
including childhood. PTSD is seen in war veterans and survivors of
physical and sexual assault and abuse, accidents, disasters, and many
other serious events. PTSD can cause many symptoms. These
symptoms may include those listed below.99,100
Re-experiencing or Intrusive Thoughts

Flashbacks, which involve reliving a trauma over and over, with
physical symptoms like a racing heart or sweating
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
Bad dreams

Frightening thoughts
Avoidance or Numbing

Staying away from places, events, or objects that are reminders of
the experience

Feeling emotionally numb

Feeling strong guilt, depression, or worry

Losing interest in activities that were enjoyable in the past

Having trouble remembering the dangerous event

Wanting to avoid thoughts about the trauma, including using
alcohol or drugs
Increased Arousal or Vigilance

Being easily startled

Feeling tense or “on edge”

Having difficulty falling or staying asleep

Irritability or angry outbursts

Difficulty concentrating
Other Criteria for PTSD Diagnosis

Duration of at least one month

Functional impairment (clinically significant)
Not everyone with PTSD has been through a dangerous event. Some
people get PTSD after a friend or family member experiences danger
or are harmed. The sudden, unexpected death of a loved one can also
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cause PTSD. Mentally reliving a traumatic event can be almost as
stressful and frightening to people with PTSD as the original trauma.
People with PTSD often experience frustration, embarrassment, and
confusion, in addition to the physical and psychological symptoms.
PTSD strains relationships because many people with PTSD detach
themselves from friends and loved ones and the activities that they
once enjoyed.101
Screening for PTSD is usually not the sole focus of a clinical
assessment but is combined with screening and assessment of other
conditions. The Veterans Administration with the Department of
Defense (VA/DoD) Clinical Practice Guidelines support assessment of
patients for psychiatric and medical conditions, which includes past
and current psychiatric and substance use problems and treatment,
prior trauma exposure, pre-injury psychological stressors, and existing
social support. 102 The number of deployments that a person has had
should also be considered.
For those who screen positive for PTSD or when evidence suggests the
presence of other disorders or comorbidities, the screening program
should ensure rapid diagnostic evaluation by a trained clinician that
includes the assessment of other possible causes of symptoms and
issues that are important for treatment planning. The use of a
structured interview may improve the validity and reliability of such an
evaluation. Evaluation should address comorbidities, such as TBI,
depression, other anxiety disorders, alcohol or substance use, and the
presence of risky behaviors. In addition, determining the severity of
symptoms, the degree and nature of functional impairments, and
suicide risk are important in selecting treatment. During the
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evaluation, the veteran being evaluated should be educated regarding
PTSD and other relevant diagnoses, have treatment options explained,
and participate and agree with treatment decisions. The latter is key to
later patient engagement and adherence to treatment.
Depression in Veterans
Those that have served in the
military are prone to depression, at
least partially as a result of
exposure to traumatic experiences,
including witnessing combat and
separation from family during
deployment or military trainings.
Consistent with the U.S. Preventive
Services Task Force (USPSTF)
recommendation, screening for a
major depressive disorder (MDD)
and follow-up of a positive screen
should be standard clinical
practice. The current policy for VA and DoD recommends annual
screening for MDD. Screening for major depressive disorder as an
accepted and routine part of primary care practice has depended on a
number of developments, which are illustrative for integrating
screening for and management of PTSD in primary care practice.
These are of particular concern in practices outside the DoD and the
VA systems.103,104
A number of self-administered questionnaires are available to assist
primary care clinicians in the assessment, diagnosis, and ongoing
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management of depression in adults. Both the Patient Health
Questionnaire-2 (PHQ-2) and the Patient Health Questionnaire-9
(PHQ-9) are reliable and valid measures of detecting depression and
identifying the level of depression severity. Moreover, ease of use
makes both the PHQ-2 and PHQ-9 useful and efficacious clinical tools
for the primary care setting.104,105
Grieving in the Veteran Population
Although research into the prevalence and intensity of grief symptoms
in war veterans is limited, clinicians recognize the importance for
veterans to grieve the loss of comrades. Grief symptoms can include
sadness, longing, missing the deceased, non-acceptance of the death,
feeling the death was unfair, anger, feeling stunned, dazed, or
shocked, emptiness, preoccupation with thoughts and images of the
deceased, loss of enjoyment, difficulties in trusting others, social
impairments, and guilt concerning the circumstances of the death.
Complications of Bereavement
Bereavement is a universal
experience. Intense emotions,
including sadness, longing, anger,
and guilt, are reactions to the loss
of a close person. Common in the
first days and weeks of grieving
are intense emotions, usually
experienced as coming in waves
lasting 20 minutes to an hour, with
accompanying somatic sensations
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in the stomach, tightness in the throat, shortness of breath, intense
fatigue, feeling faint, agitation, and helplessness. Lack of motivation,
loss of interest in outside activities, and social withdrawal are also
fairly common. A person experiencing normal grief will have a gradual
decline in symptoms and distress. When grief symptoms remain at
severely discomforting levels, even after two months, a referral to a
clinician can be considered. If intense symptoms persist after six
months, a diagnosis of complicated grief can be made and there is a
definite indication for clinical intervention. Complicated grief prolonged
over time has been shown to have negative effects on health, social
functioning, and mental health.145,146,159
Risk Of Suicide In Veterans
Suicide prevention experts usually
use the term suicide screening to
refer to a procedure in which a
standardized instrument or protocol
is used to identify individuals who
may be at risk for suicide. Suicide
screening can be done
independently or as part of a more
comprehensive health or behavioral
health screening. Screening may be
done orally (with the screener asking
questions), with pencil and paper, or
using a computer.
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Suicide assessment usually refers to a more comprehensive evaluation
done by a clinician to confirm suspected suicide risk, estimate the
immediate danger to the patient, and decide on a course of treatment.
Although assessments can involve structured questionnaires, they also
can include a more open-ended conversation with a patient and/or
friends and family to gain insight into the patient’s thoughts and
behavior, risk factors (i.e., access to lethal means or a history of
suicide attempts), protective factors (i.e., immediate family support),
and medical and mental health history.100
Suicide assessment is characteristically used when there is some
indication that an individual is at risk for suicide; for example, when a
patient has been identified as such by a suicide screening or a clinician
notices some signs that a patient may be at risk. Suicide assessment
is also used to help develop treatment plans and track the progress of
individuals who are receiving mental health treatment because they
have been assessed as being at risk for suicide.
Suicide and other forms of suicidal self-directed violence are a
persistent and growing public health problem in the U.S., and for U.S.,
veterans. Statistics have shown that all veteran men and women are
at greater risk for suicide than the general population. Some study
results show that psychological distress still exists many years after
deployment. For this reason, a suicide risk assessment is vital to
perform in all psychiatric interviews. According to the Nurse
Practitioner (NP) standards of care, assessing a patient requires
effective communication skills for interviewing, behavioral observation,
and comprehensive assessment of the patient and relevant systems.
This enables the clinician to make clinical judgments and plan
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appropriate interventions with the patient. Furthermore, the use of an
assessment tool can only help in evaluating the patient. The treatment
clinician must use every skill and resource available to achieve the
ultimate goal of prevention of suicide attempts and completions.110,111
Whether or not all veterans are at increased risk, suicide rates are
substantially increased among those who use VHA health care
services. Information from the Office of Mental Health Operations on
causes of death for all veterans who use VHA health care services
since 2000 demonstrates that rates among users are higher than those
of the general population. Users of VHA services account for 16001900 suicides per year or about 5 per day with rates of approximately
36 per 100,000 patient years, 38 per 100,000 among men, and 15 per
100,000 among women. Among the deaths from suicide,
approximately half had a diagnosis of a mental health condition
recorded in their medical records in the year prior to their deaths, and
approximately three-fourths within the past five years. For those with
a mental health diagnosis within the past year, the rate of suicide was
noted to be 70 per 100,000.115
Assessment of Suicidal Ideation
Suicidal events often start with suicidal ideations and progress over
minutes, days, or years toward suicidal and potentially injurious
behaviors. Each step along this progression presents an opportunity to
intervene to prevent a suicidal attempt. Suicidal ideations are thoughts
of suicide-related behaviors and/or wanting to die in a self-inflicted
manner. Early identification of suicidal ideations before suicide
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attempts is critical as it provides the greatest opportunity to reduce
risk of suicide injuries and death.100
Important aspects to consider while inquiring about suicidal ideation
include onset, duration, intensity, frequency, active versus passive
nature, plan lethality, recent stressors, relieving and aggravating
factors, association with substance use, and level of comprehension of
potential outcomes of actions. Suicidal intent should also be assessed
and involves explicit or implicit evidence that the person wants to die,
has the ability to act on thoughts, and understands the potential
outcome of the actions.
Factors to consider while evaluating suicidal intent include impulsivity,
amount of determination to act, and strength of desire to die. Suicidal
or preparatory behaviors include any behavior that indicates
preparation for self-directed death. Inquiry may comprise questions
about practicing a suicidal plan, seeking a location for the event,
determining likelihood of rescue, lethality of plan, and making life
changes to prepare for self-directed death. In addition to inquiring
about suicidal ideation, intent, and behavior in a patient at risk for
suicide, risk factors should also be considered.114
Ideally, a patient is identified before any suicidal behavior occurs.
Early identification of suicidal ideation presents the greatest
opportunity to reduce the risk of suicide attempt and death. The
suicide continuum is understood to begin with suicidal thoughts,
evolving into a wish to die, consolidated into an intention to act, and
resulting in a methodology or plan formulated to end one’s life. The
evolution of these steps can occur over minutes or years. Each step
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along the continuum presents an opportunity to intervene and prevent
the act of suicidal self-directed violence. All too often, a patient is
identified after a suicide attempt is made. Often the first opportunity
to assess an individual’s suicide risk occurs because of the
demonstration of warning signs that are identified by a caregiver,
gatekeeper, or loved one. Recognition of warning signs is the key to
creating an opportunity for early assessment and intervention.112
Suicide risk assessment is not absolute. There are no clear, validated
predictive models or risk stratification. For simplicity’s sake, many
guidelines will recommend a three-tier stratification system to define
1) those patients in need of immediate intervention in order to prevent
a suicide attempt, 2) those patients at elevated risk of suicidal
behavior in the future and in need of a clinical intervention, and
3) those for whom the risk of suicide is not significantly elevated, but
may benefit from an intervention. The stratification of an assigned
level of acute risk (high, intermediate, and low) was developed by
consensus, with full recognition that an equally good case could be
made for other terms. The importance of determining the level of risk
is that it will inform the decision made to select a care setting, and the
management and treatment plan to follow. It is worth remembering
that no individual is at “no risk” of suicide, so these strata are an
imperfect attempt to rationalize clear distinctions from within a
continuum of risk with no absolute cutoffs.100
Suicide Risk Factors
Although health professionals have an opportunity to identify at-risk
individuals and engage them in treatment to reduce suicidal self21
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directed violence, many health clinicians are uncertain how to assess
for suicide risk. Several risk factors for suicide and suicidal selfdirected violence have been identified; most notably, older age, male
gender, physical and mental health disorders (including depression
and substance use disorders), familial and genetic influences,
impulsivity, poor psychosocial support, and access to and knowledge
of firearms. Several psychological autopsy studies of the events
leading up to suicide have suggested the majority of individuals who
die by suicide exhibit symptoms of depression or other mental health
issues prior to death.115
The relative importance of some of these traditional risk factors, as
well as the influence of population-specific risk factors, may be unique
among military personnel and veterans. The prevailing male
demographic, along with high rates of post-traumatic stress disorder,
substance use disorders, and other mental health disorders, may
especially contribute to the risk of suicidal self-directed violence in
military and veteran populations. In addition, several aspects of
military experience can increase the risk for mental health and
substance use, which in turn are risk factors for suicide. Other risk
factors unique to the military experience could also contribute to
overall suicide risk, including military rank, combat exposure,
traumatic brain injury, habituation to violence, and deployment-related
stressors (i.e., strained or long distance relationships, relocation, postdeployment adjustment).108,116
Many military and veteran personnel will have one or more of these
individual risk factors, but relatively few of them are truly at-risk for
suicidal self-directed violence. Suicide risk assessment tools need to
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account for the relationship among these different risk factors and
identify risk factors or combinations of risk factors that are particularly
associated with suicidal self-directed violence. To be practically useful,
risk assessment tools would identify a threshold beyond which
preventive action should be taken and be brief enough to be conducted
in primary care settings where many of the at-risk persons may be
seen. Ideally, such tools would identify all persons truly at-risk for
suicidal self-directed violence (i.e., have high sensitivity), while
minimizing misidentification of persons who are not truly at high-risk
(i.e., high specificity) because subsequent, preventive therapies may
be time-consuming and costly.
Risk assessment tools should be able to identify those at high- and
low-risk for suicidal self-directed violence. Given the rarity of suicide,
this can be a difficult task. Estimates suggest that using an
assessment tool with 0.80 sensitivity and 0.70 specificity, applied to
10,000 patients (10 of whom will attempt suicide), has a positive
predictive value of 0.3 percent (8 true-positives, 2 false-negatives and
2,997 false-positives). Using a tool with a sensitivity of 0.89 raises the
positive predictive value to 3.8 percent.97 These challenges require an
enhanced understanding of suicide risk assessment in military and
veteran populations. It is necessary for primary care and mental
health clinicians to review the available evidence for risk factors and
assessment tools developed for use in healthcare and other
community settings that have been tested with veteran and military
populations.114,117,118
Three direct warning signs are particularly indicative of suicide risk.
These are when the patient is communicating suicidal thought verbally
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or in writing, is seeking access to lethal means such as firearms or
medications, and is demonstrating preparatory behaviors such as
putting his or her affairs in order. Presence of one or more of these
warning signs is a strong indication that further assessment is needed.
The evidence is insufficient to recommend a specific suicide risk
assessment tool that can predict those who will commit suicide with
definitive accuracy. In addition, there is a lack of validated predictive
or risk stratification models. However, a comprehensive clinical
assessment informed by identified risk factors in combination with an
assessment of content of suicidal thoughts and behaviors may improve
risk management and allow opportunities for intervention. Although
not intended to be all-inclusive, the aim of the following section is to
discuss key risk factors for suicide, including those that are particularly
applicable to the veteran population.100
Demographic and Family History Factors
Some of the known demographic risk factors for suicide in veteran and
nonveteran populations include Caucasian race, male sex,
adolescence, and old age. Younger age, marital status, lower
education level, and unemployment are also possible risk factors for
suicidal behaviors. Other risk factors include childhood
maltreatment and family history of suicidal behavior and mental
disorders. Demographic and family history factors add a potentially
predictive component to overall suicide risk assessment and may act
as moderating agents for other more modifiable risk factors.120,121
Psychiatric Factors
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Prior suicidal behavior is a strong risk factor for future suicide in
veteran and nonveteran populations. Clinicians should consider
screening for prior suicide attempts and inquiring about the details
surrounding any past suicidal events, including seriousness of intent
and lethality of attempt.114
While a history of suicidal behavior is a clear predictor of suicide risk,
the most common risk factor for suicide is the presence of psychiatric
illness. Detection of certain mental health disorders with subsequent
behavioral health referral or treatment may affect suicide risk.
Depression, PTSD, and substance use disorders have a high
prevalence in veteran populations and in primary care settings.
Depression has been identified as a key risk factor for suicide and, as
mentioned, is prevalent in veteran and nonveteran populations and
commonly encountered in primary care. Studies suggest a need for
improved assessments of depression and suicide risk, detection of
comorbid substance use, optimization of psychiatric management, and
adherence to guideline-based treatment in patients with depression. In
addition, veterans often have difficulty disclosing symptoms of
depression. The use of validated depression screening tools in this
population may be particularly useful; however, veterans have been
reported to have positive depression screens 6 to 12 months after an
initial negative, immediate post-deployment screen, which implies
reassessment for mental health disorders, such as depression, may be
warranted, even after an initial negative screen.108,113
Post-traumatic stress disorder has been described as a clinical
syndrome characterized by various combinations of intrusive
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experiences, avoidance, and hyperarousal behaviors following
exposure to a trauma or stressor. A 2013 literature review of PTSD
and suicide risk among veterans showed a significant association
between PTSD and increased risk for suicidal ideations, attempts, and
completions in veterans. These findings are of particular concern
considering PTSD has been reported in up to 29% of Operation
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans
receiving care at the VA in fiscal years 2002 to 2012. Even subthreshold PTSD symptoms have been found to be associated with
increased expression of hopelessness and suicide ideations.101
Substance use disorders are highly prevalent in the veteran population
and associated with an increased risk for suicide. The prevalence of
drug use and addiction were 5 percent and 3 percent among OEF and
OIF veterans, respectively, receiving care at the VA from 2002 to
2012, and alcohol was reported to be the most commonly used
substance. Comorbid psychiatric disorders may further increase the
risk for suicidal behavior in veterans with substance use disorders. In
addition to routine, repeat assessments for substance use in
individuals at risk for suicide, the VA/DoD guideline recommends that
intoxicated patients at acute risk for suicide should be monitored in an
acute care setting and reassessed after they are sober.
Access to Means
Access to means is another established risk factor for suicide and is
particularly relevant to the veteran population. Male veterans are more
likely to use firearms to complete suicide than the general population,
and guns are the most common means of suicide among male
veterans. Furthermore, higher rates of firearm ownership have been
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associated with higher rates of suicide by firearms. Evidence supports
the effectiveness of means restriction as a suicide prevention
strategy. Veterans Health Administration suicide prevention initiatives
include a gun safety program comprising distribution of gun locks and
safety literature, as well as discussions of safe storage of firearms with
patients and their families, particularly when veterans are experiencing
crises.
Protective Factors
Protective factors are personal qualities and environmental resources
that may buffer the risk for suicide. Examples include good impulse
control, strong bonds to family, responsibilities to others, and spiritual
and religious beliefs. While evidence on protective factors is limited,
clinicians are encouraged to incorporate protective factors in risk
formulations and treatment planning. Once assessment is complete,
clinicians should consider all gathered information to formulate the
patient's level of risk in one of the following categories:123

High risk:
High risk includes patients with a recent suicide attempt, serious
suicidal thoughts or plans and limited impulse control; the
patient requires constant observation and monitoring while
arranging for immediate transfer for psychiatric evaluation or
hospitalization.

Intermediate risk:
Intermediate risk comprises patients with current suicidal
ideations but with good impulse control and no intent or
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preparatory behavior; individuals identified to be at intermediate
risk in primary care settings should be evaluated by a mental
health clinician.

Low risk:
Low risk includes patients with recent suicidal ideations who
have good impulse control and no current suicidal thoughts,
plans, or intent; patients identified as low risk in primary care
should be considered for referral to a mental health clinician.

Not at an elevated risk for suicide.
Suicide Risk Prevention
The VA has adopted a multifaceted approach to develop a
comprehensive suicide prevention program and reduce suicide in the
veteran population. This effort includes an increase in resources and
funding to allow ready access to high-quality mental health treatment,
suicide prevention research and data collection, mandated staff
education, and improved peer-support services. In addition, VA
medical centers have added suicide prevention coordinators, staff
members who are primarily responsible for coordinating mental health
care for veterans at risk for suicide and educating patients, health
professionals, and community stakeholders about suicide risk and
prevention.119 Intervention and prevention activities target veterans
who show 1) Imminent Risk, 2) Short-Term Risk, and 3) Long-Term
Risk.
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Selective prevention focuses on veterans with known risk factors for
suicide. Individuals with only unmodifiable risk factors may be
monitored more closely than other veterans. The modifiable risk
factors most commonly targeted are PTSD, depression, and other
mental health disorders associated with the risk of suicide.
Interventions designed to improve the care and outcomes of mental
health disorders apply not only to OEF/OIF veterans but also veterans
of all eras including the oldest age veterans who are in the
demographic subgroup of the general population whose rate of suicide
is the highest.
Interventions to reduce the symptoms and outcomes of mental
disorders include access to evidence-based psychiatric treatments as
well as evidence-based services delivery models. For example, the
VHA supports several primary care models of mental health care,
including co-location of mental health professionals into primary care
clinics and collaborative care models including the use of depression
care managers in primary care. Indicated prevention interventions
focus on individuals who have expressed suicidal thoughts and
behaviors.108,114 The interventions therefore specifically target suicide
and not just proximal risk factors. At the system level, interventions
include training clinicians in high suicide risk management and
supporting suicide crisis lines for veterans. At the patient level,
interventions include intensive monitoring and safety plans for such
high-risk patients and evidenced-based pharmacotherapy and
psychotherapy treatments for suicidal risk.114
Caring For The Caregiver
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Working with suicidal patients is demanding and encompasses unique
challenges for the clinician. The clinician is working with someone who
is in crisis, and the moral, personal, professional, and legal
responsibilities and consequences can be overwhelming. Research
consistently finds that suicidal statements and behaviors are among
the most stressful client interactions for clinicians. Many clinicians are
very distressed when a patient commits suicide, they consider leaving
the profession, and they have intense feelings of embarrassment,
guilt, self-doubt, and shock. Health clinicians have described losing a
patient as the most profoundly disturbing event of their professional
careers, with some clinicians experiencing severe distress lasting a
significant time beyond the initial loss.124-130
Health clinicians must be aware of their reactions to suicidal patients
during the treatment process, taking appropriate steps to increase
self-care. Professional experience that includes exposure to trauma,
such as a clinician experiencing a patient’s suicide, can cause
secondary traumatic stress or vicarious traumatization.130 People
suffering from secondary traumatic stress develop signs and such as
arousal, avoidance, and intrusion that parallel post-traumatic stress
disorder; people suffering from vicarious traumatization develop
trauma symptoms and intense disruptions in self-belief and belief in
others – what is commonly called a crisis of faith.130
Peer Supervision/Consultation
Peer supervision/consultation has been described as one of the most
effective strategies for therapists working with suicidal or high-risk
patients. Supervision provides an opportunity for the clinician to
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explore and discuss feelings and fears. Treatment of a chronically
suicidal patient presents many challenges for clinicians. These include:
1) anger at being “manipulated” by the patient (who may be seeking
extra support), 2) fear that the patient will die, and 3) fear of being
held responsible for the patient’s actions via a malpractice suit.
Supervision provides an opportunity for the clinician to explore and
discuss these common feelings and fears. Supervision/consultation can
also assist the clinician in separating the meaning of the suicide to him
or her from its meaning to their patient. Supervisors, or clinical
consultants, can often assist in allowing clinicians to separate the
meaning of the suicide to him or her from its meaning to their patient.
Supervisors can also help recognizing the anxiety that comes from
holding the patient’s pain, and can offer needed empathy, perspective,
and support.
One way to support clinicians is by use of regular team consultation.
For example, one of the components of dialectical behavior therapy
with clients who are suicidal is consultation meetings.131 While less
formal in nature it is also helpful to engage in activities such as peer
debriefing, or in buddy systems in which novice therapists are paired
with more experienced clinicians. Appropriate supervision/consultation,
reduces emotional risk to the clinician, and increases awareness of
internal feeling states. These can be useful as a barometer of the state
of the client, can aid diagnostic formulation, can help clarify how
others may respond to the individual, and may facilitate therapeutic
intervention.
Signs of Burnout
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Burnout first started to be identified as problematic among clinician
caregivers in the early 1980s. Burnout is manifested by a lack of
energy and a feeling that one’s emotional resources are lacking. It can
negatively affect the clinician on both a personal and professional
level, and burnout can be hastened by working with suicidal clients.
Signs of burnout can be physiological (i.e., fatigue, irritability,
headaches, weight shifts, GI disturbances), behavioral (i.e., loss of
enthusiasm, calling off from work, accomplishing little despite long
hours, indecisiveness, irritation at co-workers), psychological (i.e.,
depression, negativity, pessimism, low self-esteem, increased medical
errors, self-blame, anxiety, guilt) or spiritual (i.e., loss of faith, loss of
meaning, loss of purpose, despair, changes in religious beliefs) or
clinical (cynicism, boredom, hostility, blaming clients, daydreaming in
sessions). Clinicians suffering from burnout may use an unhealthy
means to find relief, such as quitting a job or occupational field,
suffering from problematic substance use or attempting suicide
themselves.129
Yaseen, et al. looked at clinician responses to suicidal patients. The
researchers assessed clinician response by using the Therapist
Response/Countertransference Questionnaire.130 Clinicians reported on
patients who had completed suicide, made high-lethality attempts,
low-lethality attempts, or died unexpectedly from non-suicidal deaths.
The researchers found that clinicians treating imminently suicidal
patients had less positive feelings towards these patients than for nonsuicidal patients, but had higher hopes for their treatment, while
finding themselves notably more overwhelmed, distressed by, and to
some degree avoidant of them.
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Compassion Fatigue
Closely related to the idea of vicarious traumatization is that of
compassion fatigue. This is another phenomenon that can be a
consequence of working with suicidal individuals. Compassion fatigue
refers to the stress resulting from helping or wanting to help a
traumatized or suffering person, and it is the natural consequent
behaviors and emotions resulting from knowing about a traumatizing
event experienced or suffered by a person. Psychotherapists who work
with distressed patients may disregard their own needs, and there can
be a significant psychic cost to this, such as confusion, feelings of
helplessness, isolation, fear, and suffering. In some cases, an
individual who has compassion fatigue will have signs and symptoms
that fit the diagnostic criteria for PTSD.
Working with suicidal patients can be emotionally and psychologically
difficult, and stress mediators can do much to help clinicians cope; a
short list of these is provided below.

Emotional self-care

Collegial support

Exercise

Work-life balance (time for hobbies, leisure, family and friends)

Meditation and mindfulness skills

Therapeutic self-awareness/regular self-examination

Limiting caseload/severity of cases

Resilience
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Resilience is particularly important. The phenomenon of resilience in
crisis care mental health clinicians involves adaptive coping and is
defined as the ability of an individual to respond positively to adversity
and persevere through difficult times. Resilience is both innate and
developed, and it also depends on an individual’s social support.
Individual characteristics such as ego strength, positive emotions,
optimism, and spirituality are part of resilience. Family, professional,
and social support systems influence and help strengthen resilience,
and resilience can be fostered and learned.131,132 The experience of
resilience may be developed by 1) Collegial relationships, 2) A strong
sense of self, 3) Faith and hope, 4) Insight, and 5) Self-care.
Taking these themes, and integrating insights from other studies of
traumatic stress, it is clear that there are many facets to the need for
self-care.
Personal and Professional Boundaries
Maintaining personal and professional boundaries when working with
suicidal patients is very important. Boundaries in the psychotherapy
relationship, according to Knapp and VandeCreek are “... rules of the
professional relationship that set it apart from other relationships ...
and “clarify which behaviors are appropriate and inappropriate in
psychotherapy.”133 The clinician–patient relationship in these situations
is intense and emotional and boundaries define the clinician–patient
relationship and help ensure patient safety and clinician effectiveness.
Maintaining boundaries requires the clinician to keep a balance
between empathy and the proper professional distance and this can be
quite challenging because of the nature of the relationship. But it is the
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clinician’s responsibility to be sure that he or she does not develop an
inappropriate personal connection with the patient or allow the
clinician–patient relationship to develop into a personal relationship or
have aspects of a personal relationship.133 The clinician must be
careful to avoid behavior on his or her part or from the patient that
does not advance the therapeutic goals, i.e., inappropriate disclosure
of personal information, time spent discussing issues that are not
professional, and inappropriate touching.133-136
Patient Suicide and Clinician Response
There may be times that despite the best efforts of the clinician a
patient will make the choice to end his or her life. The loss of a patient
by suicide is a traumatic event, and many clinicians who have lost a
patient to suicide describe the experience as the most profoundly
disturbing event of their professional careers.
The American Association of Suicidology Clinical Survivor Task Force
has developed on-line resources for clinicians who have experienced a
patient suicide, i.e., Clinicians as Survivors: After a Suicide Loss.144
Some of the guidelines in these resources are:
1. Procedural (Immediate)
a. Notify supervisor
b. Notify supervisors or contact peer consultant
c. Strongly consider contacting family
d. Consider attending funeral
2. Emotional (As soon as possible)
a. Attend to your need to mourn
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b. Seek support from your supervisor, colleagues, significant
others
c. Use cognitive strategies to dispute dysfunctional selfstatements and beliefs
3. Educational (With a supervisor or review group)
a. Write a case summary, including course of treatment
b. Review case formulation, identifying risk and protective
factors
c. Review intervention strategies
Ethical And Legal Issues When Caring For Suicidal Patients
The preceding sections have focused on the foundation for working
with suicidal patients. As a clinician, it is important to be aware of the
ethical and legal issues connected to a patient’s suicide. The detection,
prediction, and management of patient suicide present an array of
ethical and legal challenges.
Ethical Issues
In addition to the clinical challenges associated with managing a
patient’s suicidality, there are also some specific ethical challenges.
The general ethical standards that are involved are: 1) Autonomy and
Non-maleficence, 2) Informed Consent, 3) Confidentiality, and 4) Duty
to Protect and confidentiality.
Autonomy/Non-maleficence
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Autonomy or self-determination involves the idea that patients have a
right to decision-making on their own behalf. This poses an ethical
dilemma when faced with a patient who wants to kill him- or herself.
Many authors discuss the idea of rational suicide. Granting a suicidal
person the right to committing suicide, however, comes into conflict
with other ethical principles.
The National Association of Social Workers (NASW) ethical Code allows
social workers to limit self-determination when self-determination
poses a serious risk to the person.133 Additionally, non-maleficence is
the ethical principle addressing the therapist’s responsibility to do no
harm including the removal of present harm and the prevention of
future harm. Thus, clinicians are expected to take active steps to
prevent patient suicide.
Informed Consent:
The process of informed consent is an opportunity for the therapist
and patient to make sure they understand their shared venture. Knapp
and VandeCreek term ‘informed consent’ as empowered
collaboration,133 in that patients have the right to actively participate
in their care. In terms of providing informed consent, clinicians should
explain the process of a suicide assessment, their recommendations
regarding treatment, and the limits of confidentiality. Whenever
possible, the patient should be involved in developing a plan of
treatment, i.e., determining where they are hospitalized. Four
exceptions to the need for informed consent are 1) Emergencies
(immediate treatment is needed to prevent imminent harm),
2) Waiver (the patient waives the right to informed consent),
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3) Therapeutic privilege (the clinician determines that a complete
disclosure might have deleterious effects on the patient's wellbeing),
and 4) Incompetence (the patient is unable to give consent).
Duty to Protect/Confidentiality:
When patients are at immediate risk of suicide, the clinician’s primary
obligation is to protect the patient from harming him- or herself. One
of the most valuable tools for this is the strength of the therapeutic
relationship and the power of the therapist to diffuse the situation. In
situations where a therapist believes that a patient is in immediate
danger and he/she refuses treatment, the clinician may be required to
breach confidentiality. Any decision to breach confidentiality should be
made with careful consideration. The difficulty in making this decision
in cases of suicide risk is in the assessment of clear and imminent
danger.
Risk Management/Therapeutic Risk Management
The term risk management refers to a clinician’s efforts to identify the
risk factors for suicide that are present, and the clinician’s efforts to
manipulate these factors so as to prevent the patient from harming
him or herself. Therapeutic risk management was described by
Wortzel, et al. as: “... clinical risk management that is patientcentered, supportive of the treatment process, and maintains the
therapeutic alliance.”140 Key aspects of therapeutic risk management
are the clinical evaluation and the use of structured assessment tools,
estimation of the level of risk, and safety planning.137 The structured
evaluation tools are helpful because many patients are reluctant to
directly report suicidal ideation and behavior and may be more willing
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to do so using a self-reporting questionnaire.
Wortzel, et al. also recommended that the assessment consider the
severity of risk at the time of assessment and the future risk.137 Risk
for suicide has traditionally been considered as low, medium, or high
at the time of the assessment, given current aggravating factors and
the situation. However, this does not factor in chronic issues such as
psychiatric comorbidities that place the patient at a chronic risk for
suicide.
Some clinicians have little to no experience with suicidality, some
encounter suicidality on a weekly or monthly basis, and others, such
as crisis clinicians, have jobs with daily risk management needs. Often
(but not always) comfort levels with risk management are tied to the
frequency with which clinicians address these concerns in their work.
Whatever the comfort level, clinicians would be wise to increase their
knowledge of suicidality when an immediate crisis is not occurring.
Aspects of Risk Management
For patient interventions to be considered both ethical and thorough,
clinicians must maintain an acceptable standard of care. Standard of
care is defined as the degree of skill and care that would be used by a
typical clinician in a similar situation. Practices of dubious benefit can
invite a malpractice suit and are clinically unsound.
Another legal factor involves the idea of negligence. The act of suicide
is impossible to predict, and negligence is not synonymous with
inaccurate prediction. For negligence to occur, there must be: 1) A
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professional relationship, 2) Violation of a standard of care, 3) A
violation of a standard of care that results in damage or harm, and
4) There is a direct causal relationship between the clinician’s actions
and the suicidal act. The following are considered reasonable duties for
clinicians in terms of suicide prevention.

Clinicians must know how to make assessments of a patient’s risk
for suicide and must be able to defend their decisions.

When a decision is made that the patient is a danger to self,
clinicians must take whatever steps are necessary to prevent the
harm.

Actions to prevent harm must be the least intrusive to accomplish
that result.
Examples of such steps to prevent harm include facilitating the
patient’s psychiatric hospitalization, involving a family member or
friend in the treatment plan, consulting with the patient’s psychiatrist,
increasing the frequency or intensity of the patient’s treatment, or
attempting to increase the degree of social support available to the
patient. The preventive measures that a clinician employs when
working with a patient depends on the needs of the patient, the
surrounding circumstances, and any information that may be available
to him or her regarding the patient. Some overall guidelines for
working with suicidal patients include those outlined below.138-140

Maintain Competence:
The clinician should possess the training, knowledge and skills to
treat and assess suicidality. Understand the literature related to
suicide including risk factors, epidemiology, and management of
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the suicidal patient.

Conduct an initial suicide assessment with every patient:
The clinician should take a complete patient history that includes
indicators of suicide risk based known risk factors for suicide.
Throughout treatment when risk is elevated the clinician should ask
specific questions about suicidal feelings, thoughts, level of
depression and hopelessness.

Set goals and identify strategies.

Repeat suicide assessments as needed:
Any person who is identified as being at possible suicide risk
should be formally assessed for suicide risk. This includes any
person that reports suicidal thoughts during depression screening,
one who scores very high on depression, who is seeking help
(self-referral) and reporting suicidal thoughts or for whom the
clinician has concerns about suicide based on his or her clinical
judgment.

Keep accurate and up-to-date records:
In cases of suicidality, accurate record keeping should include a
risk-benefit note.

Refer the patient to a psychiatric clinician for evaluation and
diagnosis and treatment of any comorbid medical and psychiatric
condition.
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
Obtain releases to consult with therapists who have worked with
the patient secure the patient's medical and mental health records.
Relying on a patient’s personal report of suicide is insufficient when
there is a prior treatment history. When patients refuse to give a
clinician permission to get past treatment records, it may be an
indicator of a high-risk situation. With patient permission, it is also
helpful to contact family members who can help to determine the
gravity of past suicide attempts.

Develop an adequate treatment plan that encompasses the
suicidality.

Take preventive measures (as discussed above), such as
hospitalization, consultation with family or friends.

Seek consultations from professional colleagues who have expertise
in treating suicidal patients.
Suicide Risk Assessment and Safety
To review, suicide risk assessment is a process in which the health
clinician gathers clinical information to determine the patient’s risk for
suicide. The assessment and determination of risk includes gathering
information related to the person’s intent to engage in suicide-related
behavior, evaluating factors that elevate or reduce the risk of acting
on the intent, and integrating all available information to determine
the level of risk and appropriate care. Indicators of risk include
ideation, intent, plan and access to means.
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Other Helpful Interventions
Other things that are helpful include family involvement for support
and increased safety, the provision of hope, particularly to new-onset
patients, assessment of and restriction of the availability of lethal
agents, and assessment of the indications for psychiatric
hospitalization.
Safety Plans/Contracts and Risk Management
There has been much debate in the literature regarding the use of
safety plans as either a clinical intervention or as a risk management
strategy. Safety plans are a plan that the patient is supposed to follow
when feeling suicidal. These plans contain specific steps that a patient
can do when he/she is feeling unsafe, a list of reasons that suicide or
self/harm is not a good option, and a list of emergency contacts.
Safety plans can be viewed within the clinical context as part of an
overall strategy for helping to increase patient safety, or as an
agreement between the clinician and the patient. A safety plan is a list
of strategies that a patient can use to decrease suicidal ideation and
involves collaboration between the clinician and patient. The use of a
safety plan as a clinical strategy is supported by many of the major
therapeutic and evidence-based approaches to treatment, including
cognitive-behavioral approaches. It is also an integral part of
treatment planning.142-145
Safety planning should be done collaboratively with the patient; this
helps improve the therapeutic relationship, individualizes the plan, and
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makes the process more useful for the patient. The specifics of each
plan will of course differ, but a suicide safety plan should include the
following six elements.
1. Recognizing warning signs, which may include situations,
thoughts, emotions, behaviors and physical sensations (personal
red flags).
2. Using internal coping strategies. Some of these should be things
that the individual is likely to do and do not involve the need to
contact another person (i.e., listening to music, journaling,
exercise).
3. Utilizing social contacts that can serve as a distraction from
suicidal thoughts and who may offer support.
4. Contacting family members or friends who may offer help to
resolve a crisis.
5. Contacting professionals and agencies.
6. Reducing the potential for use of lethal means.
Sample Safety Plan
The following are strategies that can be employed by a patient when
he/she is feeling unsafe, and should be kept in a secured area that is
easily visible:
•
Identifying situations, thoughts or warning signs that feel unsafe:
For example, fighting with the boyfriend, feeling angry and
overwhelmed.
•
Some things that are soothing/comforting that can be done:
For example, writing in a journal, being with a pet, taking a walk
in the park.
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•
People/places that help to feel connected:
For example, talking to a spiritual advisor or attending a spiritual
gathering.
•
Family member or friends to talk with (keeping a list of names
and phones numbers accessible).
•
Phone number of professionals and other services:
For example, mental health clinician, or National Suicide
Prevention Line.
•
Other safety actions that can be done:
For example, distractions, contacting a friend to take a walk.
•
Identifying ways to make one’s environment safe:
For example, listing items likely to be used for self-injury, and
detail how these can be removed or secured.
Support For Family And Friends Of A Suicide Victim
Exposure to suicide is very common. Recent research indicates that
almost half of the population of the U.S. has a lifetime familiarity with
suicide.143 The American Academy of Suicidology estimates that there
are six survivors for every completed suicide and this estimate is
probably conservative. A suicide survivor will be defined here as
anyone who is significantly negatively impacted by the suicide of
someone in their social network.144
The term grief describes the emotional, cognitive, functional and
behavioral responses to the death. There are some general aspects
that are known about grief, but the expression of the grief, the
grieving process, is different for every person and every loss. The
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intensity and duration of grief is also highly variable, not only in the
same individual over time or after different losses, but also in different
people dealing with ostensibly similar losses.
Case Study: Bridgette is a 40-year-old woman presenting for
treatment six months after the death of her son by suicide. She
reports continued and intense grief, feelings of isolation, marital
distance and lack of support from family. She also experiences
intense nightmares of being with son in hospital as he was
removed from life support. Bridgette feels she may never get
over the loss, and that if it were not for her daughter she may
“join my son.”
Some of the things that affect the grieving process include the
individual’s preexisting personality, attachment style, genetic makeup
and unique vulnerabilities, age and health, spirituality and cultural
identity, supports and resources, the number of losses, the nature of
the relationship (i.e., interdependent vs. distant, loving vs.
ambivalent), the relation (parent vs. child vs. spouse vs. sibling vs.
friend, etc.), type of loss (sudden and unanticipated vs. gradual and
anticipated, or natural causes vs. suicide, accident or homicide).143-147
Reactions to the loss of a loved one from suicide vary from person to
person and those closest to the death appear to be the most adversely
affected. Individuals who lose a loved one to suicide often go through
a grieving process that can sometimes be more difficult than those
people who experience other types of loss.
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Grief is a universal and adaptive reaction to the loss of a loved one.
Grief can be subcategorized as acute grief, which is the initial painful
response, integrated grief, which is the ongoing, attenuated adaptation
to the death of a loved one, and complicated grief, which is sometimes
labeled as prolonged, unresolved, or traumatic grief.145-147 Complicated
grief remains persistent and intense and does not transition into
integrated grief.159
Acute Grief
Mourners focus their attention, emotions, thoughts, and behavior upon
the deceased person and what has been lost. However, the painful
feelings and memories are commonly intermingled with periods of
respite and positive feelings, thoughts, and reminiscing.3,145 These
positive experiences during bereavement reflect resilience and foretell
better outcomes.
Acute grief symptoms vary across individuals and differ in the same
person after different losses. Symptoms also vary over time and are
influenced by social, religious, and cultural norms. The features,
intensity, and duration of grief are also influenced by age, health,
religious and ethnic identity, coping style, attachment style, available
social support and material resources, situation and circumstances of
the death, and the experience of prior losses.3,4,145
The symptoms of acute grief are typically related to either separation
from the deceased or to stress and trauma:145

Symptoms of separation distress

Yearning for and seeking proximity to the deceased

Loneliness
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
Crying, sadness, and other painful emotions (i.e., anger, guilt, and
anxiety) that occur upon confrontation with reminders of the loss

Somatic symptoms including distressing physical sensations and
disrupted sleep or appetite

Insistent thoughts and memories of the lost person, sometimes
including hallucinations

Feeling drawn to things associated with the deceased

Social withdrawal and disinterest in other people and activities not
associated with the deceased

Confusion about one’s identity and feeling lost or uncertain without
the deceased

Symptoms of trauma/stress reaction

Disbelief and shock

Numbness

Impaired attention, concentration, or memory
Studies of older adults greater than 55 years with acute grief found
that the most common symptoms were yearning, distressing
memories, emptiness, and feeling drawn to things associated with the
deceased. Despite wanting and needing other people, the bereaved
often find it difficult to feel connected to them and may thus withdraw
from others. Bereavement may leave people uncertain about changes
in their identity.
During acute grief, people sometimes transiently wish they had died
with their loved one or instead of that person. These fleeting thoughts
may be relatively common among bereaved individuals, but should be
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taken seriously, and warrant assessment for suicidal thoughts, plans,
intent, and acts.
Thoughts and images of the deceased occur frequently, and may be
vivid to the point that they are hallucinatory. Visual, auditory, or
tactile hallucinations represent a more general and intense sensation
of the presence of the deceased. Patients may be frightened by these
experiences and can be reassured that hallucinations are a means of
seeking proximity to the deceased and are not abnormal.
Bereaved people may consult clinicians because they are surprised and
alarmed by the intensity of their acute grief. It can be helpful to
provide information about grief to promote a better understanding of
the experience, and to provide patients an opportunity to talk about
their loved one. Management of grief is discussed separately.
Evolution of Acute Grief
The evolution of acute grief does not proceed according to a
predictable series of stages; rather, symptoms vary as bereaved
people adapt to the loss and acute grief is transformed and integrated.
The course of acute grief varies depending upon the circumstances and
consequences of the death, as well as social and cultural
expectations.145
Some individuals cope better with losses than others. Coping may
depend in part upon how individuals make sense of and interpret what
is happening to them, as well as the strategies that are used to
regulate intense emotions. In some people there is relatively little
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distress or disruption in functioning. These are likely people who have
lost someone to whom they were not so close or someone whose
death they had anticipated. Many people ultimately find that
bereavement leads to psychological growth.18
Acute grief is usually time-limited. For most people, considerable
progress in adapting to the loss occurs within six months and
restoration of ongoing life is well underway within 6 to 12 months; in
some cases, adjustment occurs more quickly (i.e., within weeks of the
loss). As a person adapts to the loss, grief becomes more subdued and
thoughts and memories of the deceased recede to the background and
are no longer insistent. Grief becomes integrated as the finality and
consequences of the death are understood. One way of thinking about
adaptation to loss is that the sense of connection to the deceased
gradually moves from preoccupying the mind to residing comfortably
in the heart.145
However, the response to the loss of a loved one does not end. The
deceased person is not forgotten and is still missed, and the intensity
of grief may flare during anniversaries of the death, holidays, or
periods of heightened stress.
In some instances, acute grief does not abate because certain kinds of
thinking and behavior derail and impede the process of adapting to the
loss. One such thought is second-guessing oneself or someone else in
relation to the death, thinking “if only” someone had done something
different, the loved one would still be alive or would have lived longer.
In addition, excessive avoidance or frequent prolonged proximity
seeking can also complicate grief.
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Grief complications can lead to the distressing and disabling syndrome
of complicated grief. Other types of psychopathology may arise as
well, such as major depression, anxiety disorders, and PTSD, even
when grief is not intense or prolonged.
Delayed or absent grief has not been found in systematic, communitybased studies of bereaved individuals.145 However, when the death
occurs in a circumstance that threatens the survival of the bereaved
person, it is hypothesized that grief may be postponed until the
survival issue is resolved.
In the acute grieving process, emotions are often intense. Common
emotions include defensiveness (uncertainty about how others will
react), depression and anxiety, and despair. Shock is a common
immediate reaction, especially to a death by suicide, as are feelings of
numbness, denial, and disorientation.145 Denial may be adaptive as it
allows survivors to manage the realities of loss, such as planning a
funeral or settling an estate, and it may be some time following the
death when the reality of loss settles in. At this point in the grieving
process, survivors of suicide loss may experience more acute
symptoms of depression, including disturbed sleep, loss of appetite,
and difficulty concentrating, intense sadness, and lack of energy.
There may be fears about not being able to live with a loss. Physical
symptoms, such as headaches, stomach upset, and compromised
immune system are common. In a death from suicide, there may also
be PTSD-type responses, such as intrusive images, depersonalization,
and a state of feeling overwhelmed.145 Anger towards the deceased,
another family member, a therapist, or oneself is also common. Guilt
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around actions taken or not taken may also occur. At first, these acute
feelings of sadness may seem like they will never end.
Following the initial stages of the acute grieving process, feelings are
sometimes experienced in waves or bursts of emotion. Those
experiencing these types of reactions see them as sometimes
frightening or shameful. Over time, the waves of feeling become less
frequent and intense, or are provoked by thoughts of the deceased.
There may be other reactions, such as relief that a loved one’s physical
or emotional suffering has ended, or there may be positive
associations towards the deceased. It is helpful to normalize these
feelings for family members. During the acute stage of grief, when the
loss is due to a suicide, several studies have confirmed that survivors
have an increased risk for suicide.145
Integrated Grief
For most people who have lost a loved one under circumstances other
than suicide, acute grief transitions to what is called integrated grief,
which occurs over several months. For those that have lost a loved
one to suicide, this period may be extended. In this stage of grieving,
the survivor begins to assimilate the reality and meaning of the death.
The survivor begins to once again engage in pleasurable and satisfying
relationships and activities. While the survivor still misses their loved
one, the loss becomes integrated into autobiographical memory and
the thoughts and memories of the deceased are no longer
preoccupying or disabling. Unlike acute grief phase, integrated grief
does not persistently preoccupy the mind or disrupt other activities.
There may be periods when the acute grief reoccurs, such as around
significant life events such as holidays, birthdays, anniversaries, etc.
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Something that is often helpful following the acute grieving process is
for the survivor to find meaning and connection in the loss. This may
include wearing clothing that belonged to the deceased, establishing a
memorial for their loved one, or lighting candles to keep the memory
alive. Some of the rituals in various religions, such as saying mass for
Catholics, may support this process. Bereaved individuals may take
some comfort in learning that the relationship does not need to be
totally severed, but that it is perfectly acceptable and even normal for
the relationship to endure.
While death from suicide may result in a more complicated picture,
there is no empirical evidence to suggest that all survivors require
specific therapeutic interventions. Most people who have lost loved
ones to suicide achieve an acceptable level of adjustment. Some do
require additional support from clergy or a support group. A small
percentage of individuals are not able to come to such a resolution and
go on to develop a complicated grief reaction.
Complicated Grief
Some studies have suggested that bereavement after suicide is
qualitatively and/or quantitatively different from mourning after other
types of deaths and may lead to a phenomenon known as complicated
grief.159 With suicide loss, grief may be prolonged or indefinite.
Complicated grief is diagnosed when a patient has:159

Ruminative preoccupation with troubling aspects of the
circumstances or consequences of the death.

Excessive avoidance of reminders of the loss.
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
Excessive difficulty regulating emotions.

Complicated grief symptoms persisting for at least six months
after the death and interfering with functioning.
Signs and symptoms of complicated grief are often like those of
uncomplicated grief, but there are some unique features of this
phenomenon. Intense and prolonged yearning for the deceased person
and feeling very upset by memories of that person are quite common
in complicated grief. Complicated grief lasts much longer than
uncomplicated grief, and it often occurs in people who have a mood
disorder, often feel excessively guilty and experience much self-blame,
impaired functioning and loss of interest in life (relatively common),
and approximately more than half of all people going through
complicated grief have suicidal behavior and/or suicidal ideation.159
Risk factors for complicated grief include:159

Older age (i.e., greater than 61 years)

Female sex

Low socioeconomic status

Non-Caucasian race

Prior psychiatric history (i.e., anxiety and depressive disorders)

Death of a spouse, child, or young person

Unexpected or violent death of a loved one
Other Issues of Grief and Suicide
The shame and stigma associated with death by suicide may also lead
to relational disruption. Fear of social ostracism and self-isolation are
common among survivors. Some survivors may choose to keep the
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suicide a secret, which further increases this isolation. There is
evidence that suicide survivors experience more stigmatization from
their social networks than survivors of most other types of death.
Thus, it is helpful for clinicians to distinguish between experiences of
stigmatization from others, and self-stigmatization, and avoidance of
friends and family out of a sense of shame and guilt.
Additionally, survivors of suicide may re-experience symptoms of
traumatic stress reactions. There may be a sense of horror about the
manner of death, and the intrusive reliving and avoidance behaviors
that are typical of posttraumatic stress disorder. Survivors may also
ruminate about the physical or emotional suffering of the deceased. In
some cases, it has been the survivor that has discovered the body or
suicide note or has needed to address the realities of clearing out the
space in which their loved one has died. Depending on the
circumstances of the death, and the symptom picture, interventions
commonly associated with posttraumatic stress disorder would be
appropriate.
The natural coping efforts used by suicide survivors, and specific
problems and needs survivors experience following the death of a
significant other by suicide have been studied. Results indicated that
survivors experienced high levels of psychological distress since the
suicide, including elevated symptoms of depression, guilt, anxiety, and
trauma. Participants experienced substantial difficulties in the social
arena (i.e., talking with others about the suicide). Most the sample
viewed professional help as beneficial; although many informal sources
of support were also valued (i.e., one-to-one contact with other
survivors). Depression and a lack of information about where to find
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help served as barriers to help-seeking behaviors for participants.
Participants who reported higher levels of functional impairment were
more likely to report higher levels of psychological distress, social
isolation, and barriers to seeking help.
Earlier studies of grieving time for survivors of a loved one’s suicide
suggested that the time at which grief after a suicide loss begins to
integrate is 3 to 5 years. Thus, it may be important to not use the
amount of time as a framework for norms, but to use symptom picture
and severity. For most people, acute grief begins to resolve within six
months from the time of the loss.
Family Impact
As mentioned previously, suicide loss has an impact on the entire
family system. Some of the prominent themes for survivors include:

Information Management:
There is often the question of who and what to tell others. The
family may choose to keep the suicide a secret or to make up a
story about death by another manner.

Disruption of family routines, rituals, and role functions:
 Changes in role functioning (i.e., surviving children may
take on a parental role).
 Changes in emotional availability of survivors and lack of a
comforting presence for one another.
 Changes in distance and power in relationships.
 Communication shut-down (between husband and wife,
parents and children).
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 Perceived fragility of members (keeping secrets from other
family members for fear that they “cannot handle” the
suicide).
 Anger/conflict management.

Coping Asynchrony:
Family members may exhibit differences in grieving styles, which
may lead to conflict with one another. This is an important are of
education.

Blame/Scapegoating:
This may contribute to the development of cut-offs and
estrangement from family members and friends, who survivors
fear may not be accepting of the suicide. Family members may
also struggle to construct a shared narrative.

Developmental anxiety about repetition:
There may be hypervigilance about surviving children, which
may contribute to overprotectiveness, and lack of ageappropriate autonomy. Families may also experience problems
with developmental separations, including college, and young
adulthood, etc.

The result of these problems may be a loss of family cohesion.
Interventions for Suicide Loss
In situations where there is a normal grieving process (acute grief
followed by integrated grief), specific psychological interventions are
not needed. If there are symptoms of posttraumatic stress, major
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depression/suicidal ideation (as opposed to intense sadness) then
therapy can be beneficial.
Generally, interventions for suicide loss are supportive or
psychoeducational. It may be helpful to provide information about
things including causes of suicide and its impact on the family system
and to normalize emotions such as sadness or anger. Therapy can also
allow survivors of suicide loss to express thoughts or feelings, share
memories of the deceased (it is often helpful to create a box of
mementos and photos or a journal of memories), or to develop rituals
to mark the person’s life, such as creating a lasting memorial or by an
act such as lighting a candle at the same time each week.
The goal of the therapeutic intervention is to provide a safe and
sheltered context for doing grief-work and learning coping skills. It can
also help the survivor learn how to pick up the pieces and go on living
in as meaningful a way as possible. Guidelines for clinicians during
therapy include:

Recognize and be aware of their attitudes, including prejudices,
about suicide (some questions to ask: beliefs about why people
take their lives; and to explore the question of how suicide can
be prevented).

Be present with survivors’ pain rather than trying to “fix” it;
listen to them.

Pace treatment to allow survivors to break down experiences
into smaller doses.
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
Allow the ability for survivors to integrate the loss into their
narratives and to honor the deceased’s life not focus on their
death.

Set realistic expectations about the grieving process, including
the uniqueness of each situation. Be empathic, compassionate
and nonjudgmental.

Help the survivor to address guilt and self-blame; communicate
that suicide losses are beyond anyone’s control.

Promote focus on survivor self-care and use of positive ways to
cope (sleep, exercise, stress-reduction); if the survivor is selfmedicating, point this out in a non-judgmental way.

Encourage the survivor to continue to participate in things they
enjoy, such as sports, social events or music.
Contact with other survivors, such as through participation in peer or
professionally led support groups, also appears to be helpful. Support
groups may provide a safe and nonjudgmental environment to
compare and normalize experiences, reduce the sense of social
isolation and stigma, and to receive support. It may be beneficial for
survivors to seek out suicide-specific survivor (such as Survivors of
Suicide or Samaritans) groups rather than a more general support
group.
Children and Loss
Children experience loss by suicide differently from adults. While there
should be differences in how adults choose to explain suicide to
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children, considering the child’s age, development and maturity, and
the situation, there are some general guidelines that may be helpful.

Be truthful, encourage questions, and offer loving reassurance.

Make sure that children know they are not responsible for the
suicide, and that nothing they said or did contributed.

Be prepared to talk about the suicide for many days and weeks,
and again later in the child’s life.

Consider having the child attend a children’s bereavement
support group.
While there are differences in the reasons that people chose to take
their own lives, many who die from suicide do so because of mental
illness. Looking at suicide as tragic outcome of a serious illness, rather
than as a moral weakness, a character flaw, irresponsibility, or a
hostile act is a schema for explaining suicide to children in a caring
and compassionate way.
Some overall guidelines include:

Be honest and use direct, non-judgment language. For example,
“Mommy died by suicide. Suicide means she killed herself.”

Talk to the child in a quiet place where there is a low chance of
being interrupted. If possible, include a family member of other
person whose presence they find comforting. Very young
children do not understand the permanence of death but
primarily need comfort, physical affection and the reassurance
that there is someone there to care for them. Let the child lead
the conversation.
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
Answer questions honestly and avoid euphemisms such as
‘passed away’ or ‘went to a better place’, which can confuse
children. If adults cannot answer a question it is better to say ‘I
don’t know’ than to make up an answer. Emphasize that suicide
is complicated and there may be some answers that adults do
not know.
Adults should not try to hide their sadness, but to reassure children
that sadness in themselves and others is a normal reaction to grief.
Summary
Working with a patient in suicidal crisis can be difficult and evoke
strong feelings in the clinician. Clinicians need to be aware of their own
feelings about patient suicide. Additionally, clinicians need to be
knowledgeable about the legal aspects of suicide prevention and of
their resources in the event a patient completes suicide. Available
professional support for the clinician following a patient suicide is often
needed, as the loss of a patient to suicide can be a very difficult
experience.
Veterans have been reported to take their own lives at more than
double the rate of civilians. Often veterans will not identify themselves
as having served in the military and may avoid bringing up those past
experiences. Appropriate evaluation of suicide risk in the veteran
population will often depend on clinicians’ screening tools and
incorporation of specific screening questions related to the branch of
military service, course of duty and whether military combat was part
of veteran duty.
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Patients reporting suicidal ideation should be provided with resources
to develop and follow through with a safety plan. Having a referral
contact person or crisis phone number visible can help to avoid an
adverse outcome. The clinician needs to emphasize recent treatment
advances for depression and other mental illnesses. Providing a
suicidal patient with resources to distract from a hopeless outlook and
to contact a mental health professional knowledgeable about suicidal
risk factors and the role of screening as a preventive strategy can be
lifesaving. It is important to be aware of the ethical and legal issues
connected to a patient’s suicide. The detection, prediction, and
management of patient suicide present an array of ethical and legal
challenges.
Mental health professionals also have a role in supporting family
members of patients that completed suicide to survive their loss and
recover. Clinicians will need to explain levels of grief and recovery,
encourage, and help to normalize the shock, sadness, guilt, and anger
family may feel about the suicide victim. Additionally, clinicians may
need to challenge common misconceptions that someone else is to
blame for the death of a loved one. Clinicians encountering suicidal
thoughts and behaviors in patients may tend to focus more on patient
suffering and risk than their own rate of stress and emotional burnout.
Members of the health team will need to attend to their own feelings of
loss and grief, locating available resources that help them to heal.
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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. Key to a veteran’s engagement and adherence to a
treatment program is
a.
b.
c.
d.
the
the
the
the
veteran’s education.
veteran’s understanding of mental illness.
veteran’s agreement to the treatment decision.
veteran knowing the options.
2. True or False: Screening for a medical condition has been
defined as the examination of a person with symptoms of a
condition to determine if the person actually has the
condition.
a. True
b. False
3. Screening for a mental disorder
a.
b.
c.
d.
replaces formal assessment of mental illness.
is used in lieu of diagnosis.
may be done by an untrained clinician.
serve as a decision support tool.
4. When a veteran is referred to a mental health professional
for evaluation,
a.
b.
c.
d.
an initial evaluation should be done within 14 days of referral.
data is maintained on the proportion who begin evaluation.
data is tracked to confirm the veteran completed evaluation.
All of the above
5. Veteran status is not always disclosed to a healthcare
provider because
a. it is not asked in traditional behavioral health screenings.
b. a patient’s military service is confidential.
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c. asking a patient about military service is not important.
d. veterans routinely deny their service.
6. The Veterans Administration with the Department of Defense
(VA/DoD) Clinical Practice Guidelines support assessment of
patients for psychiatric and medical conditions, which does
NOT include
a.
b.
c.
d.
Past and current psychiatric problems and treatment.
Past and current substance use problems and treatment.
Prior trauma exposure.
Exposure to an event through media such as television.
7. True or False: There IS evidence that identifying primary
psychiatric symptoms early and formulating an effective
treatment plan improves mental health outcomes.
a. True
b. False
8. A diagnosis of PTSD requires a duration of PTSD symptoms
for what period of time?
a.
b.
c.
d.
There is no minimum period
More than 1 month
It depends on an objective severity of the event
More than six months
9. The current policy for VA and DoD recommends screening for
major depressive disorder (MDD)
a.
b.
c.
d.
annually.
whenever a patient asks for a screening.
every two years.
whenever a patient is symptomatic of mild/severe depression.
10. True or False: The current policy for VA and DoD requires a
patient to use the Patient Health Questionnaire-9 (PHQ-9),
NOT the Patient Health Questionnaire-2 (PHQ-2).
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a. True
b. False
11. In some instances, acute grief does not abate because
certain kinds of thinking and behavior derail and impede
the process of adapting to the loss, such as
a.
b.
c.
d.
the deceased person is not forgotten and is still missed.
grief returning during anniversaries of the death.
anticipatory grief.
second-guessing what could have been done.
12. Suicide rates among veterans
a.
b.
c.
d.
are higher than in the general population.
decrease the more time that passes after active service.
is the third highest cause of death of veterans.
All of the above
13. Which of the following is one of the three direct warning
signs particularly indicative of suicide risk?
a.
b.
c.
d.
Putting affairs in order
Training with firearms
Chronic traumatic grief
Denial of veteran status
14. It is generally accepted that screening for depression,
PTSD and other mental health issues is ineffective unless
a. the veteran admits his or her veteran status.
b. the screening is done at least bi-annually.
c. there is adequate follow-up to confirm or refute the screening
result.
d. the veteran accepts the initial, positive screening result.
15. Should health clinicians routinely ask patients if they are
veterans?
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a. No, the American Academy of Nursing (AAN) discourages this
question based on privacy concerns.
b. No, since only a small percentage of veterans receive services
outside the Veterans Health Administration.
c. Yes, because veterans and service members may not selfidentify as such to their health professionals.
d. Answers a., and b., are correct
16. Several risk factors for suicide and suicidal self-directed
violence have been identified; most notably,
a.
b.
c.
d.
male gender.
middle age and female gender.
denial of veteran status.
All of the above
17. True or False: Everyone with PTSD has been through a
dangerous event.
a. True
b. False
18. Users of VHA services account for 1600-1900 suicides per
year. Among the deaths from suicide, approximately _____
had a diagnosis of a mental health condition recorded in
their medical records in the year prior to their deaths.
a.
b.
c.
d.
1/3
half
60%
3/4
19. The VA/DoD guideline recommends intoxicated patients at
acute risk for suicide be monitored ________________
and reassessed after they are sober.
a.
b.
c.
d.
by family
in an outpatient setting
through an AA program
in an acute care setting
20. A patient with current suicidal ideations but with good
impulse control and no intent or preparatory behavior is at
_________________ risk for suicide.
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a.
b.
c.
d.
low
high
intermediate
no
21. The process of ________________ is an opportunity for
the clinician and patient to make sure they understand
their shared venture.
a.
b.
c.
d.
22.
limited confidentiality
limited self-determination
informed consent
non-maleficence
One of the exceptions to informed consent is
a.
b.
c.
d.
incompetence.
limited self-determination.
confidentiality.
non-disclosure.
23. True or False: While a history of suicidal behavior is a clear
predictor of suicide risk, the most common risk factor for
suicide is the presence of psychiatric illness.
a. True
b. False
24. Bereavement after suicide may be qualitatively and/or
quantitatively different from mourning arising from other
types of deaths, and may lead to a phenomenon known as
a.
b.
c.
d.
transformed grief.
integrated grief.
acute grief.
complicated grief.
25. In this stage of grieving, known as ___________ grief, the
survivor begins to assimilate the reality and meaning of
the death.
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a.
b.
c.
d.
complicated
transitional
transformed
integrated
CORRECT ANSWERS:
1. Key to a veteran’s engagement and adherence to a
treatment program is
c. the veteran’s agreement to the treatment decision.
“During the evaluation, the veteran being evaluated should be
educated regarding PTSD and other relevant diagnoses,
should have treatment options explained, and should
participate and agree with treatment decisions. The latter is
key to later patient engagement and adherence to
treatment.”
2. True or False: Screening for a medical condition has been
defined as the examination of a person with symptoms of a
condition to determine if the person actually has the
condition.
b. False
“Screening has been defined as the examination of a
generally healthy population to identify people as likely or
unlikely to have a particular condition.”
3. Screening for a mental disorder
d. serve as a decision support tool.
“Screening is not meant to replace assessment or diagnosis,
but it can serve as a decision support tool.”
4. When a veteran is referred to a mental health professional
for evaluation,
a. an initial evaluation should be done within 14 days of
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referral.
“In the Veterans Health Administration (VHA), positive
screenings … result in referral of the veteran to a mental
health professional for evaluation. Patients referred are to
receive an initial evaluation within 24 hours and a full
evaluation within 14 days after referral.”
5. Veteran status is not always disclosed to a healthcare
provider because
a. it is not asked in traditional behavioral health screenings.
“Assessing veteran status is not included in traditional
behavioral health screenings. Since patients may not
volunteer this information, asking patients if they have served
in the military has important implications for the available
benefits and care.”
6. The Veterans Administration with the Department of Defense
(VA/DoD) Clinical Practice Guidelines support assessment of
patients for psychiatric and medical conditions, which does
NOT include
d. Exposure to an event through media such as television.
“Screening for PTSD is usually not the sole focus of a clinical
assessment but is combined with screening and assessment
of other conditions. The Veterans Administration with the
Department of Defense (VA/DoD) Clinical Practice Guidelines
support assessment of patients for psychiatric and medical
conditions, which includes “past and current psychiatric and
substance use problems and treatment, prior trauma
exposure, pre-injury psychological stressors, and existing
social support.” The number of deployments that a person
has had should also be considered.”
7. True or False: There IS evidence that identifying primary
psychiatric symptoms early and formulating an effective
treatment plan improves mental health outcomes.
a. True
“Research has shown that identifying primary psychiatric
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symptoms early helps to formulate an effective treatment
plan and leads to improved mental health outcomes.”
8. A diagnosis of PTSD requires a duration of PTSD symptoms
for what period of time?
b. More than 1 month
“Other Criteria for PTSD Diagnosis: Duration of at least one
month.”
9. The current policy for VA and DoD recommends screening for
major depressive disorder (MDD)
a. annually.
“The current policy for VA and DoD recommends annual
screening for MDD.”
10. True or False: The current policy for VA and DoD requires a
patient to use the Patient Health Questionnaire-9 (PHQ-9),
NOT the Patient Health Questionnaire-2 (PHQ-2).
b. False
“Both the Patient Health Questionnaire-2 (PHQ-2) and the
Patient Health Questionnaire-9 (PHQ-9) are reliable and valid
measures of detecting depression and identifying the level of
depression severity. Moreover, ease of use makes both the
PHQ-2 and PHQ-9 useful and efficacious clinical tools for the
primary care setting.”
11. In some instances, acute grief does not abate because
certain kinds of thinking and behavior derail and impede
the process of adapting to the loss, such as
d. second-guessing what could have been done.
“In some instances, acute grief does not abate because
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certain kinds of thinking and behavior derail and impede the
process of adapting to the loss. One such thought is secondguessing oneself or someone else in relation to the death,
thinking ‘if only’ someone had done something different, the
loved one would still be alive or would have lived longer.”
12. Suicide rates among veterans
a. are higher than in the general population.
“Suicide rates among veterans are higher than in the general
population, and the suicide rates in the United States military
dramatically increased after the wars in Iraq and Afghanistan.
In 2010, suicide became the second highest cause of death in
the military (death by combat was first) and this increased
risk of suicide has been found to continue many years after
active service has ended.”
13. Which of the following is one of the three direct warning
signs particularly indicative of suicide risk?
a. Putting affairs in order
“Three direct warning signs are particularly indicative of
suicide risk. These are when the patient is communicating
suicidal thought verbally or in writing, is seeking access to
lethal means such as firearms or medications, and is
demonstrating preparatory behaviors such as putting his or
her affairs in order. Presence of one or more of these warning
signs is a strong indication that further assessment is
needed.”
14. It is generally accepted that screening for PTSD,
depression, and other mental health problems is ineffective
unless
c. there is adequate follow-up to confirm or refute the
screening result.
“It is generally accepted that screening for PTSD, depression,
and other mental health problems is ineffective unless it is
integrated into a total management program with adequate
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follow-up to confirm or refute a positive screening result and
adequate capability to provide appropriate treatment.”
15. Should health clinicians routinely ask patients if they are
veterans?
c. Yes, because veterans and service members may not selfidentify as such to their health professionals.
“Veterans and service members may not self-identify as such
to their health professionals. Assessing veteran status should
be integrated into the behavioral health screening process.
The American Medical Association (AMA) has urged health
clinicians to ask patients if they have served in the military
and to include that experience in their records. The American
Academy of Nursing (AAN) launched an awareness campaign
in 2013 to encourage health professionals to ask patients if
they are veterans or family members of veterans. Health
clinicians do not routinely ask this question. Only a small
percentage of veterans receive services through the Veterans
Health Administration. Many more veterans receive health
care through community health professionals.”
16. Several risk factors for suicide and suicidal self-directed
violence have been identified; most notably,
a. male gender.
“Several risk factors for suicide and suicidal self-directed
violence have been identified; most notably, older age, male
gender, physical and mental health disorders (including
depression and substance use disorders), familial and genetic
influences, impulsivity, poor psychosocial support, and access
to and knowledge of firearms.”
17. True or False: Everyone with PTSD has been through a
dangerous event.
b. False
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“Not everyone with PTSD has been through a dangerous
event. Some people get PTSD after a friend or family member
experiences danger or are harmed. The sudden, unexpected
death of a loved one can also cause PTSD.”
18. Users of VHA services account for 1600-1900 suicides per
year. Among the deaths from suicide, approximately _____
had a diagnosis of a mental health condition recorded in
their medical records in the year prior to their deaths.
b. half
“Users of VHA services account for 1600-1900 suicides per
year .... Among the deaths from suicide, approximately half
had a diagnosis of a mental health condition recorded in their
medical records in the year prior to their deaths, and
approximately three-fourths within the past five years. For
those with a mental health diagnosis within the past year, the
rate of suicide was noted to be 70 per 100,000.”
19. The VA/DoD guideline recommends intoxicated patients at
acute risk for suicide be monitored ________________
and reassessed after they are sober.
d. in an acute care setting
“In addition to routine, repeat assessments for substance use
in individuals at risk for suicide, the VA/DoD guideline
recommends intoxicated patients at acute risk for suicide be
monitored in an acute care setting and reassessed after they
are sober.”
20. A patient with current suicidal ideations but with good
impulse control and no intent or preparatory behavior is at
_________________ risk for suicide.
c. intermediate
“Once assessment is complete, clinicians should consider all
gathered information to formulate the patient's level of risk in
one of the following categories: ... High risk includes patients
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with a recent suicide attempt, serious suicidal thoughts or
plans and limited impulse control; the patient requires
constant observation and monitoring while arranging for
immediate transfer for psychiatric evaluation or
hospitalization. Intermediate risk: Intermediate risk
comprises patients with current suicidal ideations but with
good impulse control and no intent or preparatory behavior;
individuals identified to be at intermediate risk in primary care
settings should be evaluated by a behavioral health
professional. Low risk: Low risk includes patients with recent
suicidal ideations who have good impulse control and no
current suicidal thoughts, plans, or intent; patients identified
as low risk in primary care should be considered for referral to
a mental health clinician.”
21. The process of ________________ is an opportunity for
the therapist and patient to make sure they understand
their shared venture.
c. informed consent
“The process of informed consent is an opportunity for the
therapist and patient to make sure they understand their
shared venture. Knapp and VandeCreek term informed
consent empowered collaboration, in that patients have the
right to actively participate in their care.”
22. One of the exceptions to informed consent is
a. incompetence.
“Four exceptions to the need for informed consent are 1)
Emergencies: immediate treatment is needed to prevent
imminent harm, 2) Waiver: the patient waives the right to
informed consent, 3) Therapeutic privilege: the psychologist
determines that a complete disclosure might have deleterious
effects on the patient's wellbeing, and 4) Incompetence: the
patient is unable to give consent.”
23. True or False: While a history of suicidal behavior is a clear
predictor of suicide risk, the most common risk factor for
suicide is the presence of psychiatric illness.
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a. True
“While a history of suicidal behavior is a clear predictor of
suicide risk, the most common risk factor for suicide is the
presence of psychiatric illness.”
24. Bereavement after suicide may be qualitatively and/or
quantitatively different from mourning arising from other
types of deaths, and may lead to a phenomenon known as
d. complicated grief.
“Some studies have suggested that bereavement after suicide
is qualitatively and/or quantitatively different from mourning
after other types of deaths and may lead to a phenomenon
known as complicated grief.”
25. In this stage of grieving, known as ___________ grief, the
survivor begins to assimilate the reality and meaning of
the death.
d. integrated
“Integrated Grief: ... In this stage of grieving, the survivor
begins to assimilate the reality and meaning of the death.”
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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
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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,
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
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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/
families, and friends of people with severe
mental illnesses, such as schizophrenia,
major depression, bipolar disorder,
obsessive-compulsive disorder, and
anxiety disorders
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 selfscreening 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.
The information presented in this course is intended solely for the use of healthcare professionals taking
this course, for credit, from NurseCe4Less.com. The information is designed to assist healthcare
professionals, including nurses, in addressing issues associated with healthcare.
The information provided in this course is general in nature, and is not designed to address any specific
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of healthcare professionals.
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review the contents of this publication to ensure accuracy and compliance before using this publication.
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