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Suicide Prevention: Identify and Treat at Risk Patients (FL INITIAL Autonomous Practice - Differential Diagnosis)

6 Contact Hours
Only FL APRNs will receive credit for this course.
This course is only applicable for Florida nurse practitioners who need to meet the autonomous practice initial licensure requirement.
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN)
This course will be updated or discontinued on or before Saturday, March 25, 2023

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


AOTA Classification Code: CAT 1: Client Factors. CAT 2: Approaches to Intervention
Education Level: Intermediate
AOTA does not endorse specific course content, products, or clinical procedures. AOTA provider number 9575.


FPTA Approval: CE21-787962. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.
Outcomes

92% of participants will know how to assess, treat, and manage suicidal thought, plans and behaviors.

Objectives

After completing the course, the learner will be able to:

  1. Recall terms that describe suicidal thinking and behavior.
  2. Define both suicide risk factors and protective factors.
  3. Differentiate suicide risk screening and assessments.
  4. Describe the current prevalence of suicide rates compared with other major causes of death.
  5. Identify the major risk factors for suicide.
  6. Differentiate between high-risk and low-risk characteristics.
  7. Define parasuicidality.
  8. Distinguish lethal means from self-injurious behaviors.
  9. Outline how to complete a comprehensive suicide assessment.
  10. Identify psychiatric signs and symptoms that increase a person's suicide risk.
  11. Describe the appropriate treatment and management of suicidal behaviors.
  12. Summarize how to determine the treatment setting following a suicide attempt or aborted suicide attempt.
  13. Recognize when and how to document suicidal thoughts, plans, and behaviors in order to mitigate risk and prevent malpractice lawsuits.
  14. Illustrate the increased need for suicide prevention in the veteran population.
  15. Relate non-pharmacological interventions' role in the management of depression.
  16. Discuss the safety and efficacy of different antidepressant medications.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Melissa DeCapua (DNP, PMHNP-BC)

Introduction

In Latin for "self-murder," suicide is a psychiatric emergency that claims over 47,000 lives annually in the United States. It is a fatal act that represents a person's desire to die. Suicide is almost always the result of mental illness, usually depression, and is preventable when recognized early and treated effectively.

Suicide is ranked the 10th overall cause of death in the United States (Table 1). Suicide accounts for over 42,000 deaths annually, while homicide accounts for around 20,000 (CDC, 2017). Estimates suggest a 25:1 ratio of suicide attempts to completed suicides. Over the past century, these rates have remained constant, averaging 14 per 100,000 persons.

Table 1: Leading Causes of Death in the United States (APA, 2013)
Heart disease647.457
Cancer599,108
Accidents (unintentional injuries)169,936
Chronic lower respiratory diseases160,201
Stroke146,383
Alzheimer’s disease121,404
Diabetes83,564
Influenza and Pneumonia55,672
Nephritis, nephrotic syndrome, and nephrosis50,633
Intention self-hard harm (suicide)47,173

In the United States, suicide rates are lowest in New Jersey for both genders; Montana and Wyoming have the highest for men, and Alaska and Idaho have the highest for women (CDC, 2016). International suicide rates range from 25 per 100,000 in Lithuania, South Korea, and Russia to 10 per 100,000 in Portugal and Australia (WHO, 2020). The Golden Gate Bridge, located in San Francisco, California, is the most common suicide site in the world. Over 1,600 suicides have been completed there since it was built in 1937.

Suicide is the deliberate act of taking one's own life; however, various terms are used to classify the range of suicidal-type behaviors (Table 2) (Sadock et al., 2015). Suicide not only ends a patient's life but can also have a devastating impact on the patient's loved ones and result in litigation against the provider.

Table 2: Terms Describing Suicidal Thinking and Behavior (Sadock et al., 2015).
Aborted suicide attemptPotentially self-injurious behavior with explicit or implicit evidence that the person intended to die but stopped the attempt before physical damage could occur.
Deliberate self-harmWillful self-inflicting of painful, destructive, or injurious acts without the intent to die.
Lethality of suicidal behaviorObjective danger to one's life associated with a suicide method or action. Lethality is distinct from and may not always coincide with an individual's expectation of what is medically dangerous.
Suicidal ideationThought of serving as the agent of one’s own death. The seriousness of suicidal ideation may vary depending on the specificity of suicidal plans and the degree of suicidal intent.
Suicidal intentSubjective expectation and desire for a self-destructive act to end in death.
Suicide attemptSelf-injurious behavior with a nonfatal outcome accompanied by explicit or implicit evidence that the person intended to die.
SuicideSelf-inflicted death with explicit or implicit evidence that the person intended to die.

Suicide Assessment

create a specialized treatment plan. During a suicide assessment, clinicians should conduct a thorough psychiatric evaluation. This information should be obtained from the patient, family members, and friends.

In the context of a suicide assessment, the purpose of the psychiatric evaluation is to:

  • Identify specific psychiatric signs and symptoms
  • Assess past suicidal behavior
  • Review past treatment history and treatment relationships
  • Identify a family history of suicide and mental illness
  • Identify the current psychosocial situation and the nature of the crisis
  • Appreciate psychological strengths and vulnerabilities (Jacobs et al., 2010)

The five domains of suicide assessment are summarized in Table 3.

Table 3: Domains of Suicide Assessment (Jacobs et al., 2010).
Current Presentation of SuicidalitySuicidal or self-harming thoughts, plans, behaviors, and intent.
Specific methods considered for suicide, including their lethality and the patient’s expectation about lethality, as well as whether firearms are accessible.
Evidence of hopelessness, impulsiveness, anhedonia, panic attacks, or anxiety.
Reasons for living and plans for the future.
Alcohol or other substance use associated with the current presentation.
Thoughts, plans, or intentions of violence toward others.
Psychiatric IllnessCurrent signs and symptoms of psychiatric disorders with particular attention to depressive disorders.
Previous psychiatric diagnoses and treatments, including illness onset and course and psychiatric hospitalizations, as well as treatment for substance use disorders.
HistoryPrevious suicide attempts, aborted suicide attempts, or other self-harming behaviors.
Previous or current medical diagnoses and treatments, including surgeries or hospitalizations.
Family history of suicide or suicide attempts or a family history of mental illness, including substance abuse.
Psychosocial situationAcute psychosocial crises and chronic psychosocial stressors, which may include actual or perceived interpersonal losses, financial difficulties or changes in socioeconomic status, family discord, domestic violence, and past or current sexual or physical abuse or neglect.
Employment status, living situation (including whether or not there are infants or children in the home), and presence or absence of external supports.
Family constellation and quality of family relationships
Cultural or religious beliefs about death or suicide.
Individual strengths and weaknessesCoping skills
Personality traits
Past responses to stress
Capacity for reality testing
Ability to tolerate psychological pain and satisfy psychological needs

Structure Interview to Gather Information

An interview to gather information during a suicide assessment must be done privately. The clinician must approach the situation with empathy and compassion. Table 4 includes a list of questions clinicians can use when inquiring about different aspects of suicide. Clinicians should follow these steps:

  • Elicit the presence or absence of suicidal ideation
  • Elicit the presence or absence of a suicide plan
  • Assess the degree of suicidality, including intent and lethality (Jacobs et al., 2010)
Table 4: Questions during a suicide assessment (Jacobs et al., 2010).
Opening questionsOpening questions
Follow-up questionsIs death something you’ve thought about recently?
Have things ever reached the point that you’ve thought of harming yourself?
Thoughts of self-harm and suicideWhen did you first notice such thoughts?
What led up to the thoughts (e.g., interpersonal and psychosocial precipitants, including real or imagined losses; specific symptoms such as mood changes, anhedonia, hopelessness, anxiety, agitation, psychosis)?
How often have those thoughts occurred (including frequency, obsessional quality, controllability)?
How close have you come to acting on those thoughts?
How likely do you think it is that you will act on them in the future?
Have you ever started to harm (or kill) yourself but stopped before doing something (e.g., holding knife or gun to your body but stopping before acting, going to edge of bridge but not jumping)?
What do you envision happening if you actually killed yourself (e.g., escape, reunion with significant other, rebirth, reactions of others)?
Have you made a specific plan to harm or kill yourself? (If so, what does the plan include?)
Do you have guns or other weapons available to you?
Have you made any particular preparations (e.g., purchasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid discovery, rehearsing the plan)?
Have you spoken to anyone about your plans?
How does the future look to you?
Previous suicide attemptsCan you describe what happened (e.g., circumstances, precipitants, view of future, use of alcohol or other substances, method, intent, seriousness of injury)?
What thoughts were you having beforehand that led up to the attempt?
What did you think would happen (e.g., going to sleep versus injury versus dying, getting a reaction out of a particular person)?
Were other people present at the time?
Did you seek help afterward yourself, or did someone get help for you?
Had you planned to be discovered, or were you found accidentally?
How did you feel afterward (e.g., relief versus regret at being alive)?
Did you receive treatment afterward (e.g., medical versus psychiatric, emergency department versus inpatient versus outpatient)?
Has your view of things changed, or is anything different for you since the attempt?
Are there other times in the past when you’ve tried to harm (or kill) yourself?
Repeated suicidal thoughts and attemptsAbout how often have you tried to harm (or kill) yourself?
When was the most recent time?
Can you describe your thoughts at the time that you were thinking most seriously about suicide?
When was your most serious attempt at harming or killing yourself?
What led up to it, and what happened afterward?
PsychosisCan you describe the voices (e.g., single versus multiple, male versus female, internal versus external, recognizable versus non-recognizable)?
What do the voices say (e.g., positive remarks versus negative remarks versus threats)? (If the remarks are commands, determine if they are for harmless versus harmful acts; ask for examples)?
How do you cope with (or respond to) the voices?
Have you ever done what the voices ask you to do? (What led you to obey the voices? If you tried to resist them, what made it difficult?)
Have there been times when the voices told you to hurt or kill yourself? (How often? What happened?)
Are you worried about having a serious illness or that your body is rotting?
Are you concerned about your financial situation even when others tell you there’s nothing to worry about?
Are there things that you’ve been feeling guilty about or blaming yourself for?
Harm to othersAre there others who you think may be responsible for what you’re experiencing (e.g., persecutory ideas, passivity experiences)?
Are you having any thoughts of harming them?
Are there other people you would want to die with you?
Are there others who you think would be unable to go on without you?

Suicidal assessment scales have limited value. These self-reported scales can help facilitate conversation between patients and providers; however, the American Psychiatric Association states they have limited clinical utility (Jacobs et al., 2010). The existing suicide assessment scales have elicited high false positives, false negatives, and low predictive values. Rating scales are no substitute for clinical expertise.

Suicide Risk, Protective Factors and Warning Signs

Clinicians should understand high-risk and low-risk characteristics. High-risk characteristics include older than 45 years, male gender, alcohol dependence, violent behavior, previous suicidal behavior, and previous psychiatric hospitalization.

Table 5: Comparison of high-risk and low-risk characteristics (Sadock et al., 2015).
CharacteristicHigh-riskLow-risk
Age>45 years<45 years
SexMaleFemale
Marital StatusDivorced or widowedMarried
EmploymentUnemployedEmployed
Interpersonal relationshipsConflictualStable
Family backgroundChaoticStable
Physical HealthChronic illness, hypochondriac, excessive substance intakeGood health, feels healthy, low substance use
Mental HealthSevere depression, psychosis, severe personality disorder, substance abuse, hopelessnessMild depression, neurosis, normal personality, social drinker, optimism
Suicidal ideationFrequent, intense, prolongedInfrequent, low intensity, transient
Suicide attemptMultiple, planned, rescue unlikely, specific wish to die, self-blaming, available lethal methodFirst attempt, impulsive, rescue inevitable, wish for change rather than wish to die, external anger, low lethality method
Personal resourcesPoor achievement, poor insight, unstable affectGood achievement, insightful, controllable affect
Social resourcesPoor rapport, socially isolated, unresponsive familyGood rapport, socially integrated, concerned family

Clinicians should begin by assessing current signs and symptoms of psychiatric disorders (Jacobs et al., 2010). They should pay close attention to signs of a depressive disorder and note any high-risk characteristics (Table 5).

Gender: Men are four times more likely to commit suicide than women, regardless of age, race, religion, or marital status. On the other hand, women experience suicidal thoughts and attempt suicide three times as often as men. This disparity appears to be related to the different ways men and women attempt suicide.

Age: The rate of suicide increases as a person ages. Prior to puberty, suicide is extremely rare. For men, suicide rates are highest at age 45; for women, they are highest after age 55. Elderly persons attempt suicide less often than younger persons but are typically more successful. Unfortunately, the suicide rate is rising quickly in younger populations. Today, suicide is the third leading cause of death for those aged 15 to 24 years, followed by accidents and homicides.

Race and Religion: Caucasian men and women are three times more likely to commit suicide than African American men and women. Native American and Alaskan Native youth experience suicide rates much higher than the national average (CDC, 2016). Rates among immigrants are higher than those among citizens (WHO, 2020). Protestants and Jews have higher suicide rates in the United States than Catholics and Muslims. Overall, the level of orthodoxy and social integration is a more accurate predictor of suicide than religion alone (Sadock et al., 2015).

Marital Status: Married individuals with children are much less likely to commit suicide than single persons. Single, never-married individuals experience double the suicide rate compared with married persons (CDC, 2016). Divorce increases the risk of suicide; divorced men are three times more likely to commit suicide than divorced women. Homosexual men and women have higher rates than heterosexual persons, married or single. Some individuals commit "anniversary suicides" when their family member or loved one dies (Sadock et al., 2015).

Occupation: The risk of suicide increases as a person's socioeconomic status increases. Employment is a protective factor against suicide; however, certain occupations increase a person's risk. High-risk occupations include healthcare providers, artists, mechanics, lawyers, and insurance agents. Unemployed persons are more likely to commit suicide than their employed counterparts. Suicide rates increased during economic recessions and decreased during economic booms (Sadock et al., 2015).

Physical Health: Over 30 percent of people who commit suicide have seen a healthcare professional within the previous six months. Physical illness, in general, is a significant contributing factor in half of all suicides. Factors contributing to suicide include loss of mobility, disfigurement, and chronic pain. Especially when these impact personal relationships and occupational status. Persons on hemodialysis are also at an increased risk (Sadock et al., 2015).

Mental Illness: Nearly 95 percent of those who commit or attempt suicide have a diagnosed mental health disorder. Major depression and other depressive disorders account for 80 percent of suicides; those with delusional depression are at the highest risk (Sadock et al., 2015). Furthermore, schizophrenia accounts for 10 percent, and dementia or delirium accounts for the remaining five percent. Over one-quarter of those who commit suicide are dependent on alcohol at the time (Sadock et al., 2015).

Substance Abuse: Substance abuse may contribute to suicide. When suspecting substance use disorder, please consider:

  • Ask first about socially acceptable substances such as caffeine or tobacco products. This question helps to establish a level of comfort for the rest of the interview. Always ask "how many" and "how often," e.g.," You mentioned you drink the occasional latte. How many of those during a week?" "So you have three, 4 shot, Grande lattes, six days a week, is that correct?"
  • Next, inquire about alcohol use. Be sure to ask specifically about beer, wine, and spirits, as many cultures do not consider beer to be alcohol.
  • Next, inquire about over-the-counter substances, including diet aids, cough and cold preparations, and herbal supplements.
  • Ask about the misuse of prescription items such as sleep medications, pain preparations, medications for attention deficit disorder or weight loss.
  • Next, ask about marijuana, which is legal for use in some states or settings. Be sure to quantify how much and how often.
  • Next, ask about illicit drugs. Be consistently non-judgmental and focus on the information needed for accurate health assistance. Street drugs such as heroin, cocaine, hallucinogens, methamphetamine and inhalants should be asked about here.
  • Remember to ask how much, how often, the length of use, and the last time each substance was used. Route of administration is also important, and be sure to ask whether the person has shared substances, especially injected drugs and needles.
  • If prior substance use disorders are mentioned, ask about participation in Alcoholics Anonymous (AA), Narcotics Anonymous (NA), other twelve-step programs, addiction treatments, detoxifications or periods of abstinence from the substance. Of special interest is the length of the longest period without the substance without using other illicit substances or alcohol to help maintain it.
  • Ask the person what benefits they obtain from their substance of choice. This question will be very helpful information when treatment for their substance use disorder begins.
  • And finally, ask what negative consequences have arisen from their substance use. Should they need coaching, look for items in each of these three key areas;
    • Physical risks include sickness, accidents, fractures, burns, and car wrecks.
    • Psychiatric problems – focusing problems, anxiety, depression, suicidal thoughts, psychosis.
    • Relationship problems – work, social relationships, legal difficulties, financial worries.

Alcohol use disorder is a known contributor to suicide risk and depressive and bipolar disorders.

Impaired judgment and muddled perceptions associated with hallucinogens can lead to heightened injury from accidents or self-injuries, although suicide is reported to be rare among hallucinogen users.

Inhalation, also called bagging, places the open-source or saturated cloth into a plastic or paper bag over the nose, mouth, or head. The risk of asphyxia with bagging is high due to hydrocarbons displacing oxygen in the lung alveoli. Be alert that a high association with suicide accompanies individuals who bag using the over-the-head method.

Opioid withdrawal is known to cause brief but severe episodes of depression that can lead to suicide attempts and completed suicide. Accidental opioid overdose, particularly among those desperate to avoid withdrawal, is common and should not be mistaken for a suicide attempt.

Over 6% of emergency room visits for suicide attempts have cocaine as a factor.

More detail on the identification and treatment of substance abuse is available in the course: Substance Abuse.

Using Information to Understand the Risk of Suicide

The best predictor of a suicide attempt is a previous suicide attempt. Around 40 percent of those who commit suicide have attempted in the past. The chances of a second attempt are highest within three months of the first attempt.

Clinicians should consider previous psychiatric hospitalizations and prior substance use disorder treatment (Sadock et al., 2015). Specific psychiatric symptoms that increase a person's risk of suicide include aggression, violence toward others, impulsiveness, hopelessness, agitation, psychic anxiety, anhedonia, global insomnia, and panic attacks.

Clinicians should obtain a thorough history of the patient's previous suicide attempts, aborted suicide attempts, and self-harming behaviors (Sadock et al., 2015). Do not forget that a previous suicide attempt is one of the strongest risk factors for another attempt. Clinicians should contact the patient's current primary care or psychiatric provider (Jacobs et al., 2010).

Clinicians should also inquire about the patient's family history. Family dysfunction is linked to suicide and other self-harming behaviors (Sadock et al., 2015). Clinicians must assess for a family history of suicide or psychiatric disorders. Clinicians should also document a history of familial conflict or separation, parental legal trouble, family substance abuse, domestic violence, and physical or sexual abuse (Jacobs et al., 2010).

Next, the clinicians should assess the patient's psychosocial situation (Jacobs et al., 2010). What are their current stressors? Have they experienced any recent interpersonal losses, financial difficulties, or changes in socioeconomic status? The clinician should document acute crises, chronic stressors, employment status, living situation, family constellation, and cultural or religious beliefs about suicide (Jacobs et al., 2010).

Finally, clinicians must appreciate the patient's psychological strengths and weaknesses. These may include coping skills, personality traits, thinking style, and development needs. Patients are at an increased risk of exhibiting polarized thinking, closed-mindedness, perfectionism, and excessively high self-expectations (Jacobs et al., 2010).

Appropriate Actions and Referrals for Various Levels of Risk

Admission to an inpatient psychiatric hospital is usually indicated after a suicide attempt or an aborted suicide attempt (Jacobs et al., 2010). Admission may be necessary if the patient expresses suicidal ideation, has previous attempts and has a diagnosed psychiatric disorder. Outpatient treatment is most beneficial for those with chronic suicidal ideation or a stable, supportive living situation (Jacobs et al., 2010).

Table 6: Guidelines for Determining Treatment Setting (Jacobs et al., 2010)
Inpatient treatment recommendedAfter a suicide attempt or aborted suicide attempt if:
  • The patient is psychotic
  • Attempt was violent, near-lethal, or premeditated
  • Precautions were taken to avoid rescue
  • Persistent plan or intent
  • The patient regrets surviving
  • The patient is male, older than 45 years, with new-onset suicidal thinking
  • The patient has limited family and social support
  • The patient lacks a stable living condition
  • Current impulsive behavior and severe agitation
  • The patient is refusing help
  • In the presence of suicidal ideation with a specific plan with high lethality.
Inpatient treatment might be necessaryIn the presence of suicidal ideation with:
  • Psychosis
  • Major psychiatric disorder
  • Past attempts
  • Lack of response to or inability to cooperate with partial hospital or outpatient treatment
  • Need for supervised setting for medication trial or ECT
  • Need for skilled observation, clinical tests, or diagnostic assessments that require a structured setting
  • Limited family and/or social support, including lack of stable living situation
  • Lack of access to timely outpatient follow-up
Outpatient treatment recommendedAfter a suicide attempt or in the presence of suicidal ideation/plan when:
  • Suicidality is a reaction to precipitating events (e.g., exam failure, relationship difficulties), particularly if the patient’s view of the situation has changed since coming to the emergency department
  • Plan/method and intent have low lethality
  • Patient has stable and supportive living situation
  • Patient is able to cooperate with recommendations for follow-up
  • Patient has chronic suicidal ideation without prior medically serious attempts and has a safe and supportive living situation

After a person has attempted suicide, they often require inpatient psychiatric treatment. Sometimes patients will agree to this treatment, while others will not. The Involuntary Treatment Act governing the psychiatric detainment against the patient's will is state specific. Follow the law in your state.

Documentation of Suicide Risk

Risk management is an important aspect of clinical practice, particularly related to assessing and treating patients at risk for attempting or committing suicide. To mitigate risk, the provider should maintain a positive, collaborative relationship with the patient and remain attentive to what information is documented in the medical record (Jacobs et al., 2010).

Thorough and appropriate documentation is essential to prevent malpractice lawsuits. Documentation should always occur:

  • At the first psychiatric assessment or inpatient hospitalization
  • With every occurrence of suicidal behavior or ideation
  • Whenever there is a noteworthy clinical change (Jacobs et al., 2010)

This documentation should include:

  • Risk assessments
  • Decision-making processes
  • Changes in treatment
  • Communications with other clinicians
  • Records of prescribed medication
  • Records of previous treatment related to past suicide attempts
  • Whether the patient has access to firearms (Jacobs et al., 2010)

Treatment and Management of Suicide Risk

In their publication Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors, the American Psychiatric Association defines six key components of the management of suicidal behavior:

  • Therapeutic Alliance
  • Patient Safety
  • Determine Treatment Setting
  • Treatment Plan
  • Care Coordination
  • Patient & Family Education (Jacobs et al., 2010).

First, the healthcare provider must develop a strong therapeutic alliance with the patient (Jacobs et al., 2010). The clinicians should begin by building trust and establishing mutual respect. Patients will feel comfortable discussing and addressing their suicidal ideation and behaviors within a trusting relationship. The ultimate goal of the patient-provider relationship is to reduce the risk of suicide (Jacobs et al., 2010).

Next, the clinician must attend to the patient's safety (Jacobs et al., 2010).

After developing a therapeutic alliance and attending to the patient's safety, the clinician must select the most appropriate treatment setting. The patient should always be treated in the least restrictive yet safest, most effective setting (Sadock et al., 2015). Table 6 provides the guidelines for determining when a patient needs inpatient psychiatric treatment (Jacobs et al., 2010).

Counseling

Psychiatric specialists and primary care providers must coordinate their care to offer the best treatment to patients with suicidal behaviors. These patients are often complex, requiring an interdisciplinary team of healthcare professionals such as social workers, case managers, and psychiatric nurses.

Patients will be encouraged to undergo education and supportive psychotherapy during the early stages of recovering from a suicide attempt. Depressive disorders, the most common underlying condition in patients who attempt suicide, should be managed. Counseling may be effective in treating depression or substance abuse.

Talk therapy can be used to treat depression either alone or in combination with medications. In a large meta-analysis, psychotherapy was more effective than a placebo, and the total number of sessions was not associated with the degree of clinical benefit (Williams & Nieuwsman, 2020). Psychotherapy and medications are generally comparable for mild to moderate major depression (Williams & Nieuwsman, 2020).

Psychotherapy helps to address the causative factors and the maintaining factors in depression. It is most effective in moderate-to-severe depression after a medication has stabilized the disease. The two most common therapies are cognitive behavioral therapy (CBT) and interpersonal therapy (IPT).

Cognitive-behavioral therapy helps change thought patterns and behaviors to improve mood. It is believed that how one thinks and behaves contributes to depression (Sharf, 2012).

Talk therapy is effective in certain groups of people. Talk therapy is recommended for those with mild to moderate depression. In severe depression, it is recommended to stabilize the patient on medications before implementing talk therapy. A combination of talk therapy and medications is ideal for adolescents with depression (March et al., 2004).

For those individuals with mild depression, the use of self-guided self-help therapy may be considered. This therapy may involve using a structured workbook or guidance by a clinician. If this option is attempted, the patient should inform the staff if there is no response, worsening, or suicidal ideation. Research suggests a small but significant benefit to this type of treatment (Cuijpers et al., 2011).

The use of relaxation techniques such as relaxation imagery, progressive muscle relaxation and autogenic training is better than no treatment but less effective than psychotherapy (Jorm et al., 2011).

Medical Interventions

In the early phases of treatment, specialists will monitor the patient closely and prescribe specific treatments for symptoms such as anxiety, insomnia, and hopelessness.

Some medications can cause depression leading to suicidal risk (Sadock et al., 2015). Common medications to consider as causes of depression include:

  • Beta-blockers
  • Calcium channel blockers
  • Corticosteroids
  • H2 blockers
  • Sedatives
  • Chemotherapy agents

The use of these medications should be evaluated.

The most serious complication of depression is suicide. Along with substance abuse, depression is the most common mental disease afflicts those who commit suicide (Sadock et al., 2015). Depression is associated with higher rates of substance abuse. It is unclear if depression causes substance abuse or if substance abuse causes depression. There is likely a complex interaction between the two conditions.

Depression often co-exists with other mental health conditions. Healthcare professionals need to be on the lookout for other conditions. Identifying other conditions is important because it can significantly impact treatment options. For example, certain antidepressant medications are indicated for both anxiety and depression. Other antidepressant medications, while treating depression, will worsen anxiety.

One of the most common co-existent conditions is anxiety disorder (Sadock et al., 2015). Anxiety disorders may include generalized anxiety disorders, social phobia, obsessive-compulsive disorder, panic disorder, and post-traumatic stress disorder. Other mental health conditions that may co-exist with depression include substance and alcohol abuse, personality disorders, bipolar disease, eating disorders, adjustment disorder and schizophrenia.

In addition to mental illness, depression often co-exists with many medical diseases (Stahl, 2014). Depression may result from medical diseases, or depression may exacerbate the medical disease. Common medical illnesses in combination with depression include heart disease, cancer, stroke, Parkinson's disease, dementia and diabetes.

A variety of treatments are available to manage depression. Common treatments include lifestyle changes, psychotherapy, medications, electroconvulsive therapy and light therapy.

More detail on the identification and treatment of depression is available in the course: Depression.

Medications

Psychopharmacology studies and uses medications that treat psychiatric disorders (Stahl, 2014). Psychopharmacology aims to help regain proper balance in the brain's chemistry and restore optimal functioning (Sadock et al., 2015). The use of medications for the mind is, in most instances, directed towards controlling symptoms. Psychiatric medications are not like antibiotics. Medications alone seldom result in a permanent "cure" of mental or emotional troubles. This medication means that most psychiatric type medications will need to be taken or be available over an extended period while other treatments or therapy seek a resolution to the problem causing the symptoms.

Medications for depression are not as effective as medications for many other conditions. A recent analysis showed that 38% of those treated with antidepressants had no positive response in 6-12 weeks (Gartlehner et al., 2007).

Follow-up on the effectiveness of antidepressant use is critical because the FDA suggests that all agents with antidepressant properties may increase the risk of suicide – especially in patients under 25.

Many different medication choices are available for the management of depression. Medications used to manage depression work mainly by altering the chemicals in the brain, particularly serotonin, norepinephrine and dopamine. Medications take time before they work (Gabbard, 2014). The effect may be noticed as early as one to two weeks, but it typically requires four to six weeks before a significant effect is noticed.

Antidepressant Medication: Several classes of antidepressant medication exist, grouped by the neurotransmitter they primarily affect. Antidepressant groupings include:

  • Monoamine Oxidase Inhibitors
  • Norepinephrine Dopamine Reuptake Inhibitor
  • Selective Serotonin Reuptake Inhibitors
  • Serotonin Modulators
  • Serotonin Norepinephrine Reuptake Inhibitor
  • Tricyclic Agents

Monoamine Oxidase Inhibitors: Monoamine oxidase is an enzyme that breaks down neurochemicals such as serotonin, dopamine, and norepinephrine (Higgins & George, 2013). Medication that inhibits the degradation of these neurotransmitters promotes higher levels of mood by increasing the quantity of available neuroactive chemicals.

MAOIs are effective in many anxiety and mood disorders, especially depression (Stahl, 2014). However, due to the risk of hypertensive crisis, practitioners must be very selective in whom they prescribe MAOIs. The client must understand potential risks and follow a strict, low-tyramine diet.

MAOIs are useful in treating "atypical" depression (e.g., depression with hyperphagia, hypersomnia, leaden paralysis, or rejection sensitivity). Clinicians should also consider the MAOIs for use in clients exhibiting treatment-resistant depression (Stahl, 2014).

Table 7: Monoamine Oxidase Inhibitors (Hirsch et al., 2013)
Name (Generic)Brand NameElimination Half-life
(hours)
Dietary Restrictions
PhenelzineNardil®1.5-4Yes
TranylcypromineParnate®1.5-4Yes
Selegiline
(transdermal patch)
Emsam®1.2No – however, caution advised if exceeding recommended dosages

MAOIs are effective yet not a first-line drug due to a range of severe food-drug and drug-drug interactions accompanying them (Sadock et al., 2015).

Table 8: Monoamine Oxidase Inhibitor Interactions (Sadock et al., 2015)
Food Interactions (Tyramine containing foods)Drug Interactions
  • Aged cheese
  • Aged, smoked, or pickled meats
  • Yeast extracts
  • Wine (red more than white)
  • Beer
  • Avocado
  • Sauerkraut
  • Caffeine
  • Chocolate
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Meperidine
  • Dextrmethorphan
  • Sertraline
  • Sumatriptan
  • Linezolid
  • All serotonergic agents
Interaction symptoms are similar and represent the effects of excessive catecholamine neurotransmitters in the body: Hypertension, Tachycardia, Tremors, Hyperthermia, and Seizures.

Norepinephrine Dopamine Reuptake Inhibitors: Bupropion is an antidepressant distinctly different from the others. Chemically its structure resembles amphetamines and can increase available levels of the "brain reward" neurotransmitter dopamine. A spotty past has led to some hesitancy among prescribers.

Table 9: Norepinephrine Dopamine Reuptake Inhibitors (Katon et al., 2010)
Name (Generic)Brand NameStarting dose, mg/dayUsual dose, mg/day
BupropionWellbutrin®75-150300-450
Bupropion SRWellbutrin® SR100300-400
Bupropion XLWellbutrin® XL150300-450

Selective Serotonin Reuptake Inhibitors and Serotonin Modulators: Serotonin abnormalities are linked to many emotional and behavioral disorders, including mood disorders, obsessive-compulsive disorder, and aggressive behaviors (Sadock et al., 2015). Selective serotonin reuptake inhibitors (SSRIs) can effectively increase the amount of serotonin available within the brain (Stahl, 2014). Increased levels of serotonin occur quickly after initiation of medication therapy. Initial medication response may be seen in about two weeks; however full effect may not be observed for up to eight weeks from initiation of treatment (Stahl, 2014).

Overall efficacy of the SSRIs in relieving depression appears similar. The choice of agent should be determined by matching medication characteristics with individual needs. Serotonin modulators (e.g., nefazodone, trazodone) are similar to SSRIs, even though they operate by a slightly different mechanism. Special caution is indicated when liver damage is present due to how the body metabolizes these agents.

Table 10: Selective Serotonin Reuptake Inhibitors (Katon et al., 2010)
Name (Generic)Brand NameStarting dose, mg/dayUsual dose, mg/day
CitalopramCelexa®10-2020-60
EscitalopramLexapro®1010-20
FluoxetineProzac®10-2020-60
FluvoxamineLuvox®5050-300
ParoxetinePaxil®10-2020-60
Paroxetine CRPaxil® CR12.5-2525-75
SertralineZoloft®5050-200
Serotonin Modulators (Boyar, 2010)
NefazodoneSerzone®, Nefadar®50300-600
TrazodoneDesyrel®5075-300
Table 11: Serotonin Syndrome (Boyar, 2010)
Serotonergic activity in the central nervous system
  • The majority of cases of serotonin syndrome present within 6 to 24 hours of a change or initiation of a drug
  • Serotonin syndrome is a clinical diagnosis based on observation as no laboratory test is available to confirm the diagnosis
  • Typical vital sign abnormalities include;
    • Tachycardia and hypertension
    • Severe cases may develop hyperthermia and rapid, dramatic swings in pulse and blood pressure
  • Physical examination findings include;
    • Hyperthermia, agitation, ocular clonus (rapid repetitive contractions and relaxations in a muscle), tremor, akathisia (uncontrollable limb and body movements), deep tendon hyperreflexia, inducible or spontaneous clonus, muscle rigidity, dilated pupils, dry mucus membranes, increased bowel sounds, flushed skin, and diaphoresis
  • Treatment of serotonin syndrome includes;
    • Discontinuation of all serotonergic agents
    • Supportive care aimed at normalization of vital signs
    • Sedation, usually with benzodiazepines
    • Possible administration of serotonin antagonists (e.g., Cyproheptadine, a histamine-1 receptor antagonist)

Fluoxetine (Prozac®) is dosed at 20 mg in the morning and can be increased to 80 mg daily. Each titration must occur after a few weeks on the medication. It is not indicated for those less than eight years old. Fluoxetine has a long half-life and is less likely to lead to withdrawal symptoms if abruptly discontinued. A weekly formulation is available that is dosed 90 mg once a week (Stahl, 2014).

Fluoxetine can increase warfarin, phenytoin, carbamazepine, TCAs and benzodiazepines. It may lower the therapeutic effect of codeine. It may cause serotonin syndrome when combined with other SSRIs and other antidepressants. It is pregnancy category C. Pregnancy category C means that in animal studies, adverse effects on the fetus were found; however, there are no adequate human studies, and the potential benefits of the drug may outweigh the potential risks (Stahl, 2014).

Sertraline (Zoloft®) is started at 25-50 mg orally daily, and the dose can be increased gradually to a maximum of 200 mg daily. It is not indicated for those less than six-years-old. Zoloft® is a common first-line drug for depression and is associated with few side effects. Common side effects include dizziness, fatigue, headache, insomnia, somnolence, diarrhea, nausea, tremor and diaphoresis. It may interact with warfarin, cimetidine, digoxin and diazepam. It is indicated for major depressive disorder, premenstrual dysphoric disorder, panic disorder, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD) and social anxiety disorder (Stahl, 2014).

Paroxetine (Paxil®) has a short half-life and may lead to discontinuation syndrome when the medication is stopped, or doses are missed. It has the strongest anticholinergic effects of any of the SSRIs. For major depression, the standard form is dosed 10 mg per day to a maximum of 50 mg orally per day, and the extended-release form (Paxil® CR) is dosed at 12.5 mg once to a maximum of 62.5 mg orally every day.

Paroxetine is indicated for major depressive disorder, panic disorder, OCD, social anxiety disorder, generalized anxiety disorder, PTSD, and premenstrual dysphoric disorder. Side effects include somnolence, insomnia, dizziness, headache, nausea, xerostomia, constipation, diarrhea, weakness, tremor and diaphoresis. Sexual dysfunction is most problematic with paroxetine among the SSRIs. Fluvoxamine (Luvox®) is approved for obsessive-compulsive disorders but is frequently used off-label in treating depression and anxiety (Stahl, 2014). The starting dose for adults is usually 50 mg once a day and has multiple drug interactions, including benzodiazepines (Stahl, 2014).

Citalopram (Celexa®) is indicated for depression and is dosed at 20 mg once a day, and the dose can be increased to 40 mg once a day after one week. It interacts with macrolide antibiotics, cimetidine, azole antifungal, omeprazole and carbamazepine. Side effects include sleep disturbance, xerostomia, nausea and diaphoresis (Stahl, 2014).

Escitalopram (Lexapro®) is dosed at 10 mg daily and can be increased to 20 mg after one week. It has few interactions but may interact with other SSRIs, cimetidine and alcohol. It is pregnancy category C. The FDA warns that both citalopram (more than 40 mg/day) and escitalopram (more than 20 mg/day) can potentially prolong the QT interval and may be fatal. They should be used cautiously in those with underlying heart disease and those prone to becoming hypokalemic (Stahl, 2014).

Serotonin Norepinephrine Reuptake Inhibitors: Combining the "high alert" system arousal effects of increased norepinephrine with the positive mood benefits of serotonin may be a good combination for some clients struggling with depression. The serotonin-norepinephrine reuptake inhibitors (SNRIs) also tend to have a weak uptake effect. The safety and tolerability of the SNRIs are similar to the SSRIs, although monitoring is warranted for an uncommon sustained rise in blood pressure (Stahl, 2014).

Table 12: Serotonin Norepinephrine Reuptake Inhibitors (Katon et al., 2010)
Name (Generic)Brand NameStarting dose, mg/dayUsual dose, mg/day
DesvenlafaxinePristiq®5050 (no titration)
DuloxetineCymbalta®3060-120
VenlafaxineEffexor®37.575-300
Venlafaxine XREffexor® XR37.575-300
Noradrenergic and Specific Serotonergic Antidepressant (Katon et al., 2010)
MirtazapineRemeron®1515-45

Venlafaxine (Effexor®) comes in an immediate-release form and an extended-release form. The extended-release form is dosed with 37.5 to 75 mg daily and can be titrated up to 225 mg daily. The immediate-release form is started at 75 mg, divided two to three times a day and titrated up to a maximum of 375 mg daily. It may interact with other antidepressants, cimetidine, diuretics and alcohol. It should not be used in those with severe uncontrolled hypertension. It is pregnancy category C. At doses less than 150 mg daily, it mainly affects serotonin levels, but at higher doses, it affects dopamine and norepinephrine levels. Discontinuation syndrome is high with this medication (Stahl, 2014).

Desvenlafaxine (Pristiq®) is a new drug in this class and is dosed 50 mg daily for adults. It may be titrated up to 400 mg once daily, but positive effects are not proven with higher doses. Common side effects include nausea, headache, dizziness, dry mouth, insomnia, fatigue and bowel disturbance. It may interact with other SSRIs or blood thinners. It is pregnancy category C (Stahl, 2014).

Milnacipran (Savella®) is dosed 12.5 mg once a day on the first day and titrated upwards to 200 mg a day divided every 12 hours. It should be used cautiously in those with moderate to severe renal and hepatic impairment. Those who take it may suffer from nausea, headache, dizziness, sleep disturbance and constipation (Stahl, 2014).

Levomilnacipran (Fetzima®) is started at 20 mg once a day and increased to 40 mg once a day. The maximum dose is 120 mg a day. Doses needed to be reduced in those with moderate and severe renal insufficiency. Common side effects include nausea but may also be associated with sexual dysfunction, constipation, urinary hesitancy, and elevated heart rate (Stahl, 2014).

Duloxetine (Cymbalta®) is dosed at 20 mg twice a day to start and may be increased to 30 mg twice daily or 60 mg once a day in the adult. The maximum dose is 120 mg a day. It may interact with ciprofloxacin, SSRIs, TCAs, antiarrhythmic agents and anticoagulants. Common adverse effects include nausea, headache, dry mouth, dizziness, sleep disturbance and fatigue (Stahl, 2014).

Duloxetine has multiple indications. It is approved for the treatment of depression in addition to diabetic peripheral neuropathy, fibromyalgia and generalized anxiety disorder. This drug is often used by those with depression in addition to one of these co-morbid conditions (Stahl, 2014).

Mirtazapine (Remeron®) is an antidepressant without a home. It is neither an SSRI nor is it an SNRI. Its effects are similar yet subtly different from either grouping, and because of those differences, it should be considered an option in clients with treatment-resistant depression who are not responsive to SNRI or SSRI medications (Stahl, 2014).

Mirtazapine is dosed at 15 mg at bedtime and may be increased every 1-2 weeks up to 45 mg daily in adults. It is given at bedtime because sedation is a major side effect. Another common side effect is weight gain. Other side effects include dry mouth, constipation and dizziness (Stahl, 2014).

Tricyclic Antidepressants: Cyclic antidepressants were discovered in the 1950s. The first cyclic antidepressants were named "tri" because their chemical structure resembled three interlocked rings drawn out in the scientific notation. Several other cyclic formulations have been discovered since the three-ringers; however, the tradition carries the name tricyclic forward for the general grouping despite its current descriptive inaccuracy (Hirsch & Birnaum, 2010).

Cyclic antidepressants are less common than the current first-line SSRI and SNRI agents. This use, in part, is due to a wider neurotransmitter effect, with more brain chemicals being shifted and a resultant broadening of potential side effect profiles (Hirsch & Birnaum, 2010).

Table 13: Tricyclic Antidepressants (Katon et al, 2010)
Name (Generic)Brand NameStarting dose, mg/dayUsual dose, mg/day
AmitriptylineElavil®25-50100-300
AmoxapineAsendin®50100-400
ClomipramineAnafranil®25100-250
DesipramineNorpramin®25-50100-300
DoxepinAdapin®, Sinequan®25-50100-300
ImipramineTofranil®25-50100-300
MaprotilineLudiomil®50100-225
NortriptylinePamelor®2550-200
ProtriptylineVivactil®1015-60
TrimipramineSurmontil®25-50100-300

Common side effects with TCAs include urinary retention, drowsiness, blurred vision, dry mouth, constipation, orthostatic hypotension, lower seizure threshold and sexual side effects. One major concern with TCAs is that they are more lethal in overdose when compared to newer antidepressants.

Cyclic antidepressants have been associated with occasional cardiac problems. Before prescribing any of the cyclic agents, it is highly recommended that a baseline electrocardiogram (ECG) and cardiac history be conducted. The ECG may not be warranted in younger clients (less than 40) with a negative cardiac history (Hirsch & Birnaum, 2010).

Treatment is typically started at a low dose and slowly titrated upwards to the therapeutic range. Some response is typically seen within one to two weeks (Uher et al., 2021). Individuals who respond early to treatment with antidepressants are more likely to go into remission (Ciudad et al., 2012). Up to three months of treatment is generally recommended to determine if the treatment was effective (Papakostas et al., 2009). The treatment regime should be reevaluated for those with minimal effect after 4-6 weeks (McIntyre, 2010).

Medications must be continued for at least 6-12 months to have lasting effects. If treatment is discontinued early, there is a high risk of relapse. Most antidepressants need to be weaned gradually. Abrupt discontinuation of antidepressants can result in serious side effects known as the discontinuation syndrome. Medications should be discontinued over about two months for those on treatment for 6-12 months and up to 6 months for those on long-term treatment. Gradually tapering the medication is more critical if the patient is on a high dose.

Substance Abuse Care

Acute treatment, follow-up, and ongoing maintenance therapies are all essential in treating substance abuse. Acute medical interventions focus on the individual's specific medical needs at the time of diagnosis. However, the consensus of the medical and mental health community is that acute treatment alone is rarely enough. Every client with a substance use disorder diagnosis will benefit from consistent follow-up treatment and lasting support to maintain a substance abuse-free life.

Several treatment modalities exist for follow-up treatment of substance problems. Individual factors such as time, expense, personality and available support must all be factored into the decision-making process. The therapeutic regimen known as Brief Intervention has gathered a growing following amongst practitioners due to its well-documented efficacy among the substance-dependent, especially in the subset of problem alcohol behaviors.

Brief intervention is a strategy that utilizes short-duration sessions, which can begin at the time of admission. Brief intervention can be woven into treatment planning and used at the bedside throughout medical recovery while forming an integrated strategy throughout follow-up office visits or referrals. The techniques involved often take around five minutes or less, which makes it a prized therapeutic method useful to even the busiest health professional. For example, the ability to hold a meaningful session during a routine office visit makes for a happy client and clinician.

Brief intervention sessions focus on finding and emphasizing the specific motivation that will work for that particular client. These short yet structured sessions continue over a regular schedule until the client is motivated to take positive actions to change behaviors that support their substance use problem. While brief intervention has shown success, it must be followed up with a structured support system that focuses on maintaining the person vulnerable to substance use issues.

One of the prized brief intervention tools when dealing with clients is motivational interviewing. Motivational Interviewing (MI) is based on an empathetic, respectful view of the client's life struggles, with simple techniques for promoting behavioral change. Originally, MI was developed for dealing with problem drinkers yet has proven effective across the board for substance use issues. MI focuses on enhancing the client's self-motivation for change, addressing ambivalence to change, and emphasizing personal responsibility and the ability to make meaningful choices.

Table 14: Principles of Motivational Interviewing (SAMSHA, 2020)
  • Empathy, reflective listening
  • Respect and acceptance
  • Non-judgmental, collaborative relationship
  • Supportive, knowledgeable consulting
  • Positive focus
  • Listening, not telling
  • Change is up to the client
  • Support
  • Helping the client recognize discrepancies between goals and behavior
  • Avoiding confrontation or argumentation
  • Adjusting to client resistance, e.g., “roll with resistance”
  • Supporting the client’s self-efficacy and optimism
Key Skills of Motivational Interviewing
  • Open-ended questions
  • Reflective listening
  • Affirmations
  • Summarizing
  • Eliciting self-motivational statements

Strategy for Safety Planning and Monitoring Use of the Safety Plan

Suicidal thinking and behavior are considered a psychiatric emergency, requiring expert evidence-based assessment and treatment. Importantly, suicide can be prevented. Take immediate action to place the patient in a protective environment.

The clinician may need to intervene directly to prevent the patient from harming himself or herself. For example, the clinician may need to search the patient's belongings for weapons, lighters, matches, medications, or other toxic substances. The healthcare provider may also determine that the patient needs constant observation by another clinician or closed-circuit television (Jacobs et al., 2010).

Careful monitoring of intoxicated individuals is needed as episodes of generally brief yet severe depression may be associated with severe sedative, hypnotic, or anxiolytic intoxication. Suicide or attempted suicide may occur during such intoxication and may be purposeful or accidental self-injury.

Table 6: Guidelines for Determining Treatment Setting helps providers identify a treatment setting. The specific treatment setting will lead to specific protocols based on the suicide risk. Seclusion is the safety plan used for imminent risk of self-harm. The nurse must be aware of and compliant with the standards and regulations of regulatory agencies.

A trained staff member monitors patients in seclusion for self-destructive behaviors on a one-to-one or face-to-face status. This monitoring can be done via video and audio equipment and by a staff member trained in this area. The staff member must document the patient's condition, any attempts at less restrictive intervention with results, a behavioral and medical evaluation, the response to the seclusion and the reason to continue seclusion.

Regulations and standards for seclusion include:

  1. An order for the seclusion must be obtained from a provider within one hour.
  2. The RN communicates with the family or legal caregiver about the need for seclusion and the procedure that will be followed.
  3. The RN explains to the patient the need for seclusion and attempts to solicit cooperation.
  4. The RN arranges for assistance from qualified staff to help with the seclusion, as well as for the care of the patient.
  5. The RN ensures continuous observation and treats the patient with dignity and respect.
  6. The RN attends to the psychological and physical needs of the patient at regular intervals.
  7. The RN documents the use of the seclusion and all assessments.
  8. The RN maintains competence and education on the use of seclusion.

More information on seclusion is available in the course: Restraint Use, Evidence-Based Practice.

Engagement of Supportive Third Parties

When the patient agrees, education should be provided to his or her involved family members. Family members must understand that psychiatric disorders are real and difficult illnesses requiring special treatment. Friends and family should also learn about the role of psychological and social stressors that can precipitate or worsen suicidal behaviors.

Reducing Access to Lethal Means

Preventing access to firearms can decrease firearm-related suicides by 32% among minors and 6.5% among adults (Shenassa et al., 2003). A recent study published in 2013 reached the same conclusions: restricting access to firearms reduces suicides and ultimately saves lives (Lewiecki & Miller, 2013). Handguns are the most common firearm used to commit suicide in the United States. Due to this impulsive nature of suicide, restricting access to firearms, particularly handguns, helps prevent suicides.

Continuity of Care through Care Transitions such as Discharge and Referral

Clinicians must develop a treatment plan (Jacobs et al., 2010). The treatment plan begins by ensuring the patient's safety and selecting the appropriate treatment setting. After acute treatment, the patient should be referred to a psychiatric specialist such as a psychiatrist or a psychiatric nurse practitioner. These specialized clinicians will continue the patient's care and ensure timely diagnosis and management of any underlying mental health conditions.

Suicidal ideation requires the management of a psychiatrist or psychiatric nurse practitioner. Primary care providers and psychiatric specialists should work together to ensure adequate treatment of the patient, especially those that are medically complex.

Veteran Population

Population-Specific Data:

There are an estimated 23.4 million living veterans of United States military service. Active servicemen and women are afflicted with high rates of suicidal thinking and behaviors. According to the National Alliance on Mental Illness (NAMI), veterans represent 20 percent of suicides nationally (NAMI, 2015).

Historically, suicide death rates in the US Army have been below the civilian rate; however, the suicide rate in the US Army began climbing in the early 2000s, and by 2008, it exceeded the demographically-matched civilian rate (20.2 military suicide deaths per 100,000 vs.19.2 civilians). US military suicide rates currently range around 18.7 per 100,000 (NAMI, 2015).

Risk, Protective Factors, and Intervention Strategies:

The veteran population is at an increased risk for suicide because they possess many risk factors:

  • Combat exposure
  • Combat wounds
  • Post-traumatic stress disorder
  • Major depressive disorder
  • Traumatic brain injury
  • Poor social support
  • Feelings of not belonging
  • Training and access to lethal means such as firearms (Selby et al., 2010)

Most military suicides occur among young men shortly after they are discharged; however, military women commit suicide three times more often than non-veteran women of the same age (McFarland et al., 2010).

Suicide risk among veterans has created an enhanced intervention system for the Veteran's Administration (VA). Suicide Prevention Education is provided to military personnel and their families at discharge. Suicide risk assessment has been incorporated into all primary care visits. Over the last decade, additional funding and focus on psychiatric services have resulted in increased resources. The VA has acute psychiatric units, extended inpatient psychiatric and substance abuse services, halfway houses, and outpatient psychiatric services.

Veterans Chat enables Veterans, their families, and friends to go online where they can anonymously chat with a trained VA counselor. If the chats are determined to be a crisis, the counselor can immediately transfer the chatter to the Veterans Crisis Line, where further counseling and referral services are provided, and crisis intervention steps can be taken. This same service is available to Service members through Military Crisis Line chat.

Locate A Local Suicide Prevention Coordinator: Each VA Medical Center has a suicide prevention coordinator to ensure veterans receive needed counseling and services. Calls to the Veterans Crisis Line are referred to suicide prevention coordinators.

Learn more about VA and other organizations' suicide prevention resources and other Veterans' issues:

Risk of Imminent Harm Through Self-Injurious Behaviors or Lethal Means

Parasuicide describes persons who injure themselves but do not intend to die. These patients self-mutilate by cutting their skin with a razor blade, knife, broken glass, or mirror. They injure their wrists, arms, thighs, legs, face, breasts, or abdomen (Sadock et al., 2015). These individuals typically have a personality disorder and display introverted, neurotic, and hostile characteristics.

About four percent of psychiatric patients engage in parasuicidal behavior, which is more than 50 times that of the general population (Sadock et al., 2015). The female-to-male ratio is 3:1 (Sadock et al., 2015). While the public may characterize self-injurious behaviors as "attention-seeking" and "avoiding responsibility," for most patients, this is not the case. Instead, these individuals harm themselves to relieve anxiety or tension and create a sense of self-control.

Sometimes, self-injurious behaviors can accidentally become near lethal. Research demonstrates that those who self-harm often underestimate the objective lethality of their attempt if they ever wish to commit suicide (Jacobs et al., 2010). Therefore, clinicians must always assess parasuicidal behavior's frequency, severity, and intent. Each act must be evaluated in the context of the patient's current life situation (Jacobs et al., 2010).

Lethal Means; Objects, Substances and Actions Commonly Used in Suicide Attempts: Men more commonly use firearms, hanging, or jumping from high places, whereas women use poison or medication overdose (Sadock et al., 2015). In states with more stringent gun control laws, suicide by firearms has decreased. Across the world, the most common method of suicide is hanging (WHO, 2020).

A 2003 study published in the Journal of Epidemiological Community Health examined the lethality of firearms relative to other suicide methods (Shenassa et al., 2003). This study found that suicide attempts by firearms are 2.6 times more lethal than the second most lethal method--suffocation. The percent lethality rate of firearms is the highest (97%), followed by suffocation (90%), jumping from high places (74%), poisoning (7%), and cutting (7%) (Shenassa et al., 2003).

Impulsivity and Lethality of Means: Suicide is commonly an impulsive act by a vulnerable individual. The impulsivity of suicide provides opportunities to reduce the risk of suicide by restricting access to lethal means. Nearly 40% of suicide attempt survivors report contemplating suicide for less than five minutes before they attempt (Lewiecki & Miller, 2013).

Communication Strategies for Talking with Patients and Their Support People About Lethal Means and Screening for and Restricting Access to Lethal Means Effectively to Prevent Suicide is discussed in this course section Structured Interview to Gather Information: Table 4: Questions During a Suicide Assessment, section Thoughts of Self-harm and Suicide, provides specific questions that can be used.

Healthcare providers must ask patients about suicidal thoughts, plans, and behaviors; however, cultural and religious beliefs about death and suicide may prevent a patient from speaking openly about his or her thoughts. In this case, clinicians must seek collateral sources such as spouses, friends, family members, clergy, or other healthcare providers (Jacobs et al., 2010).

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