≥ 92% of participants will know how to screen, assess, and refer patients with suicidal thoughts, plans, and behaviors.
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.
≥ 92% of participants will know how to screen, assess, and refer patients with suicidal thoughts, plans, and behaviors.
After completing this course, the participant will be able to meet the following objectives:
Latin for "self-murder," suicide is a psychiatric emergency that claims over 47,000 lives every year in the United States (U.S.) (CDC, 2022; Sadock et al., 2017). There is a 25 to 1 ratio between attempted suicide and completed suicide (Sadock et al., 2017). It is a fatal act that represents an individual's desire to die. Suicide is almost always the result of mental illness, usually depression, and is preventable when recognized early and treated effectively. This course identifies suicide risk, evidence-based treatments, and ethical and legal standards of care for patients and nurses who are suicidal.
Suicide is ranked as the 12th overall cause of death in the U.S. and accounts for over 47,000 deaths per year (CDC, 2022). These rates increased by 30% between 2000 and 2020 due to the COVID-19 pandemic (National Center for Health Statistics, 2021). Estimates suggest a 25:1 ratio of suicide attempts to completed suicides. Over the past century, these rates have remained constant, averaging 14.0 per 100,000 individuals (CDC, 2022).
In the U.S., suicide rates are lowest in New Jersey for both genders. Montana and Wyoming have the highest suicide rates for men, and Alaska and Idaho have the highest for women (CDC, 2022). International suicide rates range from 72.4 per 100,000 in Lesotho, 40.3 per 100,000 in Guyana, 29.4 per 100,000 in Eswatini, and 25.1 per 100,000 in Russia (Suicide Rate by Country, 2022). 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 rates for occupations providing services to the public show that nurses are ranked sixth highest for risk of suicide (Davidson et al., 2021). Findings in the first national longitudinal study of U.S. nurse suicide suggest that nurses are at an increased risk for suicide than the general population due to a lack of workplace wellness and occupational pressures, including chronic toxic stress, secondary traumatic stress, compassion fatigue, depression, ethical issues, depression and anxiety (Davidson et al., 2020). Suicidal risk factors for nurses include high-pressure nursing environments and frequent exposure to human suffering and death (Davidson et al., 2018), as well as avoiding the use of psychiatric care due to stigma and access to medications as a means of suicide (Culpepper & Schreiber, 2021). Cumulative stress and burnout result in this higher-than-average suicide risk.
|Aborted Suicide Attempt||Potentially self-injurious behavior with explicit or implicit evidence that the individual intended to die but stopped the attempt before physical damage could occur.|
|Deliberate Self-Harm||Willful self-inflicting of painful, destructive, or harmful acts without the intent to die.|
|Lethality of Suicidal Behavior||Objective danger to one's life associated with a suicide method or action. Lethality may not always coincide with an individual's expectation of what is medically dangerous.|
|Suicidal Ideation||Thought of servicing as the agent of one's death. The seriousness of suicidal ideation may vary depending on the specificity of suicidal plans and the degree of suicidal intent.|
|Suicidal Intent||Subjective expectation and desire for a self-destructive act to end in death.|
|Suicide Attempt||Self-injurious behavior with a non-fatal outcome accompanied by explicit or implicit evidence that the individual intended to die.|
|Suicide||Self-inflicted death with explicit or implicit evidence that the individual intended to die.|
Healthcare professionals should understand both protective and risk factors for suicide. Protective factors buffer individuals from both suicidal ideation and suicidal behaviors. On the other hand, risk factors encompass individual, relationship, community, and societal factors that increase an individual's likelihood of attempting suicide.
The Centers for Disease Control (CDC) notes that protective factors have not been studied extensively, but it is still crucial for healthcare professionals to understand them (CDC, 2021). Protective factors include:
Risk factors for suicide can be divided into two categories: high-risk and low-risk characteristics. High-risk characteristics include individuals older than 45 years of age, male gender, alcohol dependence, violent behavior, previous suicidal behavior, and previous psychiatric hospitalization (Sadock et al., 2017). Low-risk characteristics include individuals younger than 45 years of age, female gender, married, employed, and lack of previous mental health disorder or suicide attempt (Sadock et al., 2017).
Men are four times more likely to commit suicide than women, regardless of age, race, religion, or marital status (Sadock et al., 2017). On the other hand, women experience suicidal thoughts and attempt suicide three times more often than men. The reason for this disparity appears to be related to the different ways men and women attempt suicide.
The rate of suicide increases as people age (Sadock et al., 2017). Before puberty, suicide is extremely rare. For men, suicide rates are highest at age 45, and women suicide rates are highest after age 55. Older adults attempt suicide less often than younger individuals, but they 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" (Sadock et al., 2017).
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, 2022). Rates among immigrants are higher than those among citizens (WHO, 2021). In the U.S., Protestants and Jews have higher suicide rates than both Catholics and Muslims. Overall, the level of orthodoxy and integration with society is a more accurate predictor of suicide than religion alone (Sadock et al., 2017).
Married individuals with children are much less likely to commit suicide than single individuals. Single, never-married individuals experience double the suicide rate compared with married persons (CDC, 2022). 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 of suicide than heterosexual individuals, whether married or single. Some individuals commit "anniversary suicides" on the day their family member or loved one died (Sadock et al., 2017).
The risk of suicide increases both as an individual's socioeconomic status increases and their status decreases. In general, employment serves as a protective factor against suicide. However, certain occupations increase an individual's risk. High-risk occupations include healthcare professionals (e.g., physicians and nurses), artists, mechanics, lawyers, and insurance agents. Unemployed individuals are more likely to commit suicide than their employed counterparts. Suicide rates increase during economic recessions and decrease during economic booms (Sadock et al., 2017).
Nurses in the U.S. are at higher risk of suicide than both the general public and physicians (Davis et al., 2021). Davis et al. identified sex-specific suicide data that showed suicide rates among nurses far exceeded those of the general population, and female nurses were at two times the risk of suicide compared to women in the general population. These study findings are particularly alarming as data was collected prior to the COVID-19 pandemic, which exacerbated two well-known risk factors: work-related stressors and mental health problems (Guille, 2021). The lack of resources, risk of infection, and the mental burden of inadequate physical and emotional support increased the risk for suicide among medical staff (Vizheh et al., 2020) by creating chronic toxic stress secondary to trauma experienced while working.
Over 30% of individuals 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 that specifically contribute to suicide include loss of mobility, disfigurement, and chronic pain, especially when these impact personal relationships and occupational status. Individuals on hemodialysis are at an increased risk as well (Sadock et al., 2017).
Nearly 95% of those who commit or attempt suicide have a diagnosed mental health disorder. Major depression and other mood disorders account for 80% of suicides. Individuals with bipolar disorder are at the highest risk for suicide, "accounting for one-quarter of all completed suicides" (American Psychiatric Association, 2017). Furthermore, schizophrenia accounts for 10% of attempted or completed suicide, and dementia or delirium accounts for the remaining five percent.
Healthcare professionals must assess the risk for suicide based on a clinical examination. Still, there are warning signs that can be identified early as signs of immediate risk for suicide. These include (National Institute of Mental Health, 2021):
"Suicide Risk Assessment Standards focus on four core principles: Suicidal Desire, Suicidal Capability, Suicidal Intent, and Buffers along with subcomponents for each" (Suicide Prevention Lifeline: Best Practices, 2021). Suicide risk is evaluated through two means: screens and assessments. Suicide screening refers to the use of a standardized instrument or protocol to identify those at risk for suicide (Suicide Prevention Resource Center, 2014). These screens can be completed as part of a comprehensive suicide assessment or separately. Suicide screens may be conducted orally (the screener asking questions), on paper, or a computer (Suicide Prevention Resource Center, 2014).
Suicide assessment describes a comprehensive evaluation usually completed by a healthcare professional to determine suicide risk and the course of treatment (Suicide Prevention Resource Center, 2014). Sometimes assessments include screens, but they may also include an open-ended interview and broader conversations with the individual's friends, family, or other healthcare professionals to help reduce the stigmatization of mental health care. Assessments encompass detailed evaluations of an individual's thoughts, behaviors, risk factors, protective factors, and medical and psychiatric history (Suicide Prevention Resource Center, 2014).
Although screening scales can help facilitate conversation between patients and healthcare professionals, expert panels have determined that they have limited value. The following panels have independently reviewed the value of screening for suicide risk (Suicide Prevention Resource Center, 2014):
In their publication, Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide, the V.A./DoD wrote, "Suicide risk assessment remains an imperfect science, and much of what constitutes best practice is a product of expert opinion, with a limited evidence base" (V.A./DoD, 2019). Also, the U.S. Preventative Service Task Force (2014) concluded that routine suicide screens often elicit a high rate of false-positive, rendering them ineffective when used independently from a comprehensive assessment conducted by a professional.
During their workgroup on suicidal behaviors, the American Psychiatric Association (2010) determined that "although suicide assessment scales have been developed for research purposes, they lack the predictive validity necessary for routine clinical practice. Therefore, suicide assessment scales may be used as aids for suicide assessment but should not be used as predictive instruments or substitutes for a thorough clinical evaluation".
Even though screening for suicide using questionnaires has low predictive value, they can be useful when used in addition to a comprehensive suicide assessment. When choosing a suicide screen, consider the following (Suicide Prevention Resource Center, 2014):
In their publication, Assessment of Suicidal Behaviors and Risk among Children and Adolescents, the National Institute of Mental Health (2021) recommends four suicide screening instruments:
The Beck Scale for Suicidal Ideation (BSI) is a 21-question self-report questionnaire best used to detect and measure the severity of suicidal thoughts. The authors of this screen emphasize that if a child or adolescent endorses any item on the BSI, then a suicide assessment should immediately be initiated. The BSI is more thorough than other screens asking questions about the desire to live, suicidal ideation, duration and frequency of suicidal thoughts, and suicidal plan (Goldston, 2000).
The Harkavy Asnis Suicide Scale (HASS) is a 21-item questionnaire used to gather information about a child's current and past suicidal behavior. This screen collects demographic information, previous suicidal acts, frequency of suicide-related behaviors over the last two weeks, and recent substance misuse. The HASS is used most commonly in high school students and includes questions like, "Have you ever thought about killing yourself but did not try" (Goldston, 2000)?
The Suicide Ideation Questionnaire (SIQ) is used to determine the severity of suicidal ideation. A 30-item and 15-item version exist, both designed for younger adolescents. The SIQ asks individuals to rate the severity of their suicidal ideation on a 7-point Likert scale. This screen is based on a hierarchy of seriousness of suicidality ranging from thoughts of death to attempting suicide. This screen does not assess previous or recent suicide attempts and should almost always be supplemented by a comprehensive suicide assessment (Goldston, 2000).
The Suicidal Behaviors Questionnaire for Children (SBQ-C) is a 14-question screen designed to assess suicidal thoughts and behaviors in children and adolescents. It is a self-report tool designed to be easily understood by children and adolescents. Very little psychometric data is available for this questionnaire (Goldston, 2000).
There are various suicide risk screens available for adults. However, it is essential to remember that screens do not replace a comprehensive suicide assessment conducted by a healthcare professional. Commonly used suicide screens for adults include:
Aaron Beck developed the Scale for Suicide Ideation (SSI) in 1979 to evaluate the intensity of suicidal thoughts (Beck & Kovacs et al., 1979). It includes 19 questions; each scored 0.1 or 2 based on severity. It places individuals into three categories: active suicidal desire, preparation, and passive suicidal desire. This scale was later revised and named the Modified Scale for Suicide Ideation (MSSI). This screen used a scale of 0 to 3, increasing the ability to discriminate between those thinking about suicide and those who are likely to attempt it.
The Columbia-Suicide Severity Rating Scale (C-SSRS) is used primarily in primary care settings, and it is available in over 100 different languages. The C-SSRS does not require mental health training to administer effectively. It provides criteria for the next appropriate steps (e.g., referral to a psychiatric provider) based on the score (Posner et al., 2008).
The Nurses' Global Assessment of Suicide Risk includes 15 items that help assess an individual's risk of attempting suicide. It allows healthcare professionals to evaluate high and low-risk characteristics quickly. Each item on the screen is supported by research. However, the screen itself has not been empirically tested (Cutcliffe, 2004).
The University of California San Diego School of Medicine developed a mental health program, the Healer Education Assessment and Referral (HEAR) Program, initially for physicians and medical students (Davidson et al., 2018). Since its inception, the HEAR Program has been piloted to assess suicide risk in nurses by utilizing the Patient Health Questionnaire-9 depression screening tool and validated questions on suicide risk. During the pilot program, 97% of the nurses surveyed were found to be at moderate to high risk, leading nurses to access mental health services. The HEAR Program is endorsed by the American Medical Association as best practice in suicide prevention (Brooks, 2017; Davidson et al., 2018).
One of the most crucial stepwise strategies to help decrease the incidence of suicide, namely in the nursing population, is identification and intervention. With the negative stigma that still accompanies the need for mental health intervention, some nurses still attempt to prevent the action of seeking diagnosis and/or treatment. It is essential that workplaces that employ nurses offer and advertise a confidential, standardized pathway for nurses to utilize in order to capture those who are at risk and require intervention. Some workplaces have worked to satisfy this need by offering an Employee Assistance Program (EAP) that directly connects nurses to mental health professionals in their area. In many cases, the first several sessions might even be available to nurses for free, depending on the employer's benefit coverage plans. Check with your respective employer for options that are available to you.
Jack is a 47-year-old Caucasian male who works on a COVID-19 unit. He has a history of major depressive disorder without psychosis beginning in his early 20s that has been controlled with various antidepressants. Jack has a history of one suicide attempt in his 30s after the death of his mother. He and his wife separated two months ago. He currently resides in a hotel and is out of contact with his friends and family. Earlier in the evening, his wife called the police after receiving a text message from Jack where he said he wanted to kill himself after a patient he had been caring for over the last two weeks died from COVID-19. The police brought Jack to the emergency room, stating that they found him in his hotel room with a gun and a bottle of vodka. Jack appears disheveled, depressed, and withdrawn. He tells you his life is not worth living. He feels he is not making a difference at work, and his home life is in "shambles." He states he wants to end his life. He does express some desire to seek treatment but fears his situation is hopeless.
How should the healthcare professional respond? In this scenario, Jack has expressed to his wife and the healthcare professional that he wants to kill himself. He also has a highly lethal means, a gun, and appears to have limited social support. Recent traumatic life experiences and a history of suicide attempt increases his risk. Collectively, his risk and history indicate a need for inpatient hospitalization.
Within the mental health system, there are varying levels of care. These levels range from not at all restrictive (e.g., outpatient care) to very restrictive (e.g., acute inpatient care) (WHO, 2021). The more restrictive services are reserved for the most acute cases, whereas the less restrictive services are for less acute cases.
Individuals require different levels of care at various times during their treatment, depending on the severity of their symptoms or degree of occupational or social impairment (WHO, 2021). Levels of care in the mental health system include Inpatient, Residential, Partial Hospital, Intensive Outpatient, and Outpatient treatment.
Inpatient treatment is the highest, most acute nursing and medical services level. It is provided in a structured environment 24 hours a day. Patients have full and immediate access to healthcare professionals and undergo extensive and comprehensive psychiatric treatment. Inpatient treatment may be sought voluntarily by patients or deemed medically necessary by a healthcare professional. Inpatient treatment lasts anywhere from two to fourteen days, depending on the severity of the symptoms and the patient's response to treatment.
Residential treatment is one level down from inpatient and is considered sub-acute. These patients have access to 24-hour skilled nursing care, and they often live onsite throughout their recovery. They usually undergo treatment that combines medication with group and individual psychotherapy (Sadock et al., 2017).
Partial hospitalization refers to an intensive, non-residential setting where patients receive care during the day but return to their homes at night. They undergo structured medical and nursing care with services similar to inpatient psychiatric hospitals. Usually, the patient receives medication treatment in these settings and participates in group psychotherapy (Sadock et al., 2017).
Intensive outpatient treatment offers patients regular contact with mental health professionals, often multiple days per week. Patients in intensive outpatient programs receive care more often than those in general outpatient services but less often than those in partial hospital programs (Sadock et al., 2017). On the other hand, outpatient care is the least restrictive form of mental health care. Patients regularly meet with their mental health provider in an office setting to undergo psychotherapy sessions and medication management (Sadock et al., 2017).
After completing a suicide assessment, a qualified mental health clinician can determine the most appropriate level of care. Table 2 offers guidelines for determining the best treatment setting for a particular patient.
|Inpatient Treatment Recommended||After a suicide attempt or aborted suicide attempt if:|
|Inpatient Treatment Might Be Necessary||In the presence of suicidal ideation with:|
|Outpatient Treatment Recommended||After a suicide attempt or in the presence of suicidal ideation/plan, when:|
Following a suicide attempt, inpatient psychiatric treatment is recommended. Following an aborted suicide attempt, inpatient psychiatric treatment is most likely recommended, especially if the patient expresses regret at surviving or a persistent intent to end their life. If the patient has minimal family or social support, is psychotic, or is declining any type of mental health care, they most likely require inpatient treatment (Jacobs et al., 2010).
Furthermore, inpatient psychiatric hospitalization may also be necessary for the presence of suicidal ideations (Jacobs et al., 2010;Sadock et al., 2017). If a patient expresses suicidal thoughts, has a history of previous suicide attempts, the presence of a psychiatric disorder, and limited social support, they may require inpatient treatment. If the patient describes a specific plan with high lethality, they almost always need hospitalization (Sadock et al., 2017).
Partial hospitalization is appropriate for patients who do not require inpatient treatment but require more intensive services than available in outpatient settings (Sadock et al., 2017). Because partial hospitalization is highly structured with both nursing and medical services, it is advocated for those experiencing suicidal ideation without a specific plan and with some social support. Importantly, when choosing partial over inpatient hospitalization, consider whether the patient has the capacity for reliable attendance. Partial hospitalization is also used as a step-down from inpatient treatment to help patients transition to outpatient treatment (Jacobs et al., 2010; Sadock et al., 2017).
Outpatient mental health services are appropriate if patients experience transient or mild suicidal ideation without a specific plan or intent to attempt suicide (Sadock et al., 2017). These patients should also have a stable and supportive living situation and be willing to cooperate with follow-up recommendations.
After a patient has attempted suicide, they often require inpatient psychiatric treatment. Sometimes patients will agree to this treatment, while others will not. Involuntary commitment laws vary from state to state. Apply your state's laws.
Continuity of care refers to the link between providers from one setting to another. Care transition, the period following hospitalization to a lower level of care, is a high-risk time for patients (SAMHSA, 2022). Doupnik et al. (2020) completed a meta-analysis to review the research on suicide prevention interventions with subsequent suicide attempts and how follow-up care impacted outcomes. They published their findings in a paper titled Association of Suicide Prevention Interventions with Subsequent Suicide Attempts, Linkage to Follow-up Care, and Depression Symptoms for Acute Care Settings: A Systemic Review and Met-analysis.
The meta-analysis showed that "brief suicide prevention interventions were associated with reduced subsequent suicide attempts, and increased linkage to follow-up but were not associated with reduced depressive symptoms" (Doupnik et al., 2020). The results solidified the theory that continuity of care through brief interventions leads to more consistent follow-up encounters, thus reducing subsequent suicide attempts. Risks can be mitigated through a number of interventions, including coordination between inpatient and outpatient services, safety planning prior to inpatient discharge, immediate involvement of family, friends, and social support, maintaining continuity of care best practices, and follow-up with the patient within 24-hours after discharge (SAMHSA, 2022).
The Suicide Prevention Resource Center and the Joint Commission both recommend safety planning as a standard of care for individuals identified as at-risk for suicide-related behaviors. Safety planning is a brief intervention to help an individual survive suicidal crises by having the individual develop a set of steps to reduce the likelihood of engaging in suicidal behavior. It includes cognitive-behavioral interventions for suicide prevention and is usually used in collaboration with a referral for mental health treatment (Moscardini et al., 2020).
Safety plans typically include ways that the individual can identify that he/she is at increased risk for suicide (e.g., suicidal thoughts, looking for ways to commit suicide, changes in mood and behaviors, etc.). The safety plan will help the individual identify coping strategies to employ when these urges arise and the people or resources the individual can access during the crisis. It also helps the individual identify one or two things worth living for as means to arrest movement towards committing suicide.
Providing the individual with resources to access help is paramount to successful discharge planning. Crisis contact information such as the phone number for the local crisis center and the National Suicide Prevention website is considered best practice. Ensuring the patient has a follow-up appointment with an outpatient provider and reviewing the appointment with the patient helps ensure follow-through.
There are ethical challenges for healthcare professionals caring for suicidal patients and their families. These include:
Attitudes towards nurses who attempt suicide are reportedly negative and reflect a lower perception of professional competence (Giacchero et al., 2017). Maintaining the patient's privacy, maintaining confidentiality, and providing professional support specific for nurses who are suicidal have not yet been fully explored in the research but are paramount to the successful treatment of men and women in this occupation.
Following the Health Insurance Portability and Accountability Act (HIPPA), legislation protects a patient's privacy, and under the law, healthcare professionals must limit who can access records. All providers must respect patient privacy and maintain confidentiality under this law. Nurses are particularly vulnerable as access to care outside of their employer might contribute to the high rate of suicide within this demographic. Without access to care and appropriate interventions, the rates of suicide in the nursing profession will continue to remain high. It is not only an ethical issue to maintain confidentiality and privacy but also a legal issue.
About half of the cases in which a suicide occurs during inpatient treatment results in a lawsuit. Liability originates from questions surrounding a patient's "rate of deterioration, clinical signs of increasing risk and staff's awareness and response to these signs" (Sadock et al., 2017). Suicide is no longer considered a crime in the U.S. However, "some states have attempted suicide listed as a crime on their criminal statutes. Assisted suicide (when someone helps another to commit suicide) is a crime in all U.S. states with physician-assisted suicide being an exception to this rule" (Legal Information Institute, 2021).
Jack is a 47-year-old Caucasian male who works on a COVID-19 unit and was brought by the police to the hospital where he works after his wife called reporting Jack had suicidal ideations with a plan to shoot himself with a gun he had in the hotel. The emergency room staff quickly escorted Jack to a private room away from other staff and patients to ensure the confidentiality of his visit. His PHQ-9 score was 27 (severe depression). The emergency room physician assessed that Jack needed a higher level of care due to his suicidal ideations with plan and intent and his lethality and access to guns. The physician assigned a nurse to stay with him in the private room, providing one-on-one supervision until inpatient placement could be found. Strict HIPPA regulations were followed throughout his ER visit. An inpatient bed was located, and Jack was transported to a hospital thirty miles away for involuntary admission.
Suicide is almost always the result of mental illness, usually depression, and is preventable when recognized early and treated effectively. Recognizing who is at risk for suicide and reducing stigmas and barriers to care is critical in the fight to prevent suicide.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.