Suicide Prevention Training for Washington Healthcare Professionals - 6 Hours

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 that clinicians can use when inquiring about different aspects of suicide. Clinicians should follow these steps: (Jacobs et al., 2010)

• 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

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.

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.

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 make a note of any high-risk characteristics (Table 5).

Gender: Men are four times more likely to die by suicide compared with women, regardless of age, race, religion, or marital status (Boland et al., 2021). On the other hand, women experience suicidal thoughts and attempt suicide three times as often as men. The reason for 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. Before 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 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 (Boland et al., 2021).

Race and Religion: Caucasian men and women are three times more likely to die by suicide than African-American men and women. Native American and Alaskan Native youth experience suicide rates much higher than the national average (Suicide Prevention Resource Center, n.d.). Rates among immigrants are higher than those among citizens (WHO, 2021). In the United States, Protestants and Jews have higher suicide rates than both Catholics and Muslims. Overall, orthodoxy and integration with society are more accurate predictors of suicide than religion alone (Boland et al., 2021).

Marital Status: Married individuals with children are much less likely to die by suicide than single persons. 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 die by suicide than divorced women. Homosexual men and women have higher rates than heterosexual persons, whether married or single. Some individuals commit “anniversary suicides” on the day their family member or loved one dies (Boland et al., 2021).

Occupation: The risk of suicide increases as a person's socioeconomic status increases. In general, employment serves as 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 die by suicide than their employed counterparts. Suicide rates increased during economic recessions and decreased during economic booms (Boland et al., 2021).

Physical Health: Over 30 percent of people who die by 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 at an increased risk as well (Boland et al., 2021).

Mental Illness: Nearly 95 percent of those who die 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 (Boland et al., 2021). Furthermore, schizophrenia accounts for 10 percent, and dementia or delirium accounts for the remaining five percent. Over one-quarter of those who die by suicide are dependent on alcohol at the time (Boland et al., 2021).

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 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 the course of a week?” “So you have three, four-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 sure to 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 pattern, 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.
• Ask the person what benefits they obtain from their substance of choice. This 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 or illnesses – sickness, accidents, fractures, burns, 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 as well as 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 that is then placed 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 CEUfast course Substance Abuse.

The best predictor of a suicide attempt is a previous suicide attempt. Around 40 percent of those who die by 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 along with prior treatment for substance use disorders (Boland et al., 2021). 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 (Boland et al., 2021). Do not forget, a previous suicide attempt is one of the strongest risk factors for another attempt. When possible, clinicians should contact the patient’s current primary care or psychiatric provider (Boland et al., 2021).

Clinicians should also inquire about the patient’s family history. Family dysfunction is linked to suicide and other self-harming behaviors (Boland et al., 2021). 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 (Boland et al., 2021).

Next, the clinicians should assess the patient’s current psychosocial situation (Boland et al., 2021). 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 (Boland et al., 2021).

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 (Boland et al., 2021).

Admission to an inpatient psychiatric hospital is usually indicated after a suicide attempt or an aborted suicide attempt (Boland et al., 2021). Access 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 who have a stable, supportive living situation (Boland et al., 2021).

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 governs the psychiatric detainment against the patient's will in the state of Washington. This law can be found under Title 71.05 of the Revised Code of Washington (Washington State Legislature, 2015).

In Washington State, anyone who possesses first-hand knowledge of the patient can refer them for involuntary psychiatric treatment. A county-designated mental health professional, such as a psychiatric nurse practitioner or a psychiatrist, must see the patient and complete a thorough evaluation. The criteria for commitment include: (Washington State Legislature, 2015)

• The person has a diagnosable mental disorder. A mental disorder is defined as any organic, mental, or emotional impairment that substantially affects an individual's cognitive or volitional behavior.
• The person presents as a danger to self, others, or property, or the person is gravely disabled such that they cannot provide for their basic needs or health.

If the country-designated mental health professional determines that a person meets these criteria, they can authorize a 72-hour involuntary detention. The person will be sent to a psychiatric hospital. The patient maintains their individual rights at a psychiatric hospital and is not presumed incompetent, meaning their information remains strictly confidential. The patient will receive the appropriate treatment.

After 72 hours, the patient can request legal counsel and a court evaluator if he or she remains unwilling to accept treatment on a voluntary basis. The court evaluator is usually a psychologist who will perform an independent assessment of whether the patient meets the criteria for involuntary commitment. The patient's legal counsel will meet with the patient to represent their wishes during a formal hearing called the Probable Cause Hearing.

During the Probable Cause Hearing, a judge will determine if there is enough evidence to warrant further involuntary treatment. This hearing can result in one of four decisions (Washington State Legislature, 2015)

• The involuntary treatment petition can be dropped, and the patient can be released.
• The judge can dismiss the case, and the patient can be released.
• The judge can maintain the involuntary commitment, and the patient can be kept at a psychiatric facility for 14 more days.
• The patient can change their mind and agree to treatment voluntarily.

If the judge maintains the involuntary commitment, the patient will return to the psychiatric facility for at most 14 more days. If a county-designated mental health professional determines the patient needs to remain at the facility even longer, they can file a 90-day petition, and the process starts over. If the judge rules in favor of a 90-day commitment, the patient is transferred to the Western State Hospital (adults) or Fairfax Hospital (children) (Washington State Legislature, 2015).

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.

During the early stages of recovering from a suicide attempt, patients will be encouraged to undergo education and supportive psychotherapy. Depressive disorders, the most common underlying condition in patients who attempt suicide, should be managed. Counseling may be effective in the treatment of depression and/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 determined to be more effective than a placebo, and the total number of sessions was not associated with the degree of clinical benefit (William & Nieuwsma, 2020). For mild to moderate major depression, psychotherapy and medications are generally comparable (William & Nieuwsma, 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. Cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) are the two most common therapies.

Cognitive-behavioral therapy helps change thought patterns and behaviors to improve mood. It is believed that the way one thinks and behaves contributes to their depression.

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.

For those individuals with mild depression, the use of self-guided, self-help therapy may be considered. This may involve using a structured workbook or guidance by a clinician. If this option is attempted, the patient should let the staff know if there is no response, worsening, or suicidal ideation.

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.

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 (Boland et al., 2021), leading to suicidal risk. 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 severe complication of depression is suicide. Along with substance abuse, depression is the most common mental disease that afflicts those who die by suicide (Boland et al., 2021). 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 essential because it can significantly impact treatment options. For example, certain antidepressant medications are indicated for both anxiety and depression. Other antidepressant medications, while treating the depression, will make the anxiety worse.

One of the most common co-existent conditions is anxiety disorder (Boland et al., 2021). 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 disorders, and schizophrenia.

In addition to mental illness, depression often co-exist with many medical diseases. Depression may result from medical conditions, or depression may exacerbate the medical disorder. Common medical illnesses that are seen 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 CEUfast course “Depression.”

Psychopharmacology is the study and use of medications that treat psychiatric disorders (American Society of Clinical Psychopharmacology, n.d.). The goal of psychopharmacology is to help regain proper balance in the brain's chemistry and restore optimal functioning (Boland et al., 2021). The use of medications for the mind is, therefore, directed towards controlling symptoms in most instances. Psychiatric medications are not like antibiotics. Medications alone seldom result in a permanent “cure” of mental or emotional troubles. This means that most psychiatric-type medications will need to be taken or be available over an extended period while other treatments or therapies seek a resolution to the problem causing the symptoms.

Medications for depression are not as effective as medications for many other conditions.

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 the age of 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 a period before they work. The effect may be noticed as early as one to two weeks, but it typically requires four to six weeks before a significant impact is seen.

Antidepressant Medication: Several classes of antidepressant medication exist, grouped together 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 (Boland et al., 2021). Medication that inhibits the degradation of these neurotransmitters promotes higher mood levels by increasing the quantity of available neuroactive chemicals.

MAOIs have been found to be effective in a broad range of anxiety and mood disorders, especially depression. 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 very strict, low-tyramine diet.

MAOIs are helpful 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.

MAOIs are effective yet currently not a first-line drug due to a range of severe food-drug and drug-drug interactions that accompany them (Boland et al., 2021).

Norepinephrine Dopamine Reuptake Inhibitors: Bupropion is an antidepressant distinctly different from the others and specifically listed as an atypical agent for treating depression. Chemically, its structure resembles that of amphetamines and can increase available levels of the “brain reward” neurotransmitter dopamine. A spotty past has led to some hesitancy among prescribers.

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 (Boland et al., 2021).

Selective serotonin reuptake inhibitors (SSRIs) can effectively increase the 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, the full effect may not be observed for up to eight weeks from the initiation of treatment (Stahl, 2014).

Overall efficacy between 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, 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.

Fluoxetine (Prozac®) is dosed at 20 mg in the morning and can be increased up to 80 mg a day. 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 that is dosed at 90 mg once a week is available (Stahl, 2014).

Fluoxetine can increase the levels of 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 every day, and the dose can be increased gradually to a maximum of 200 mg per day. It is not indicated for those less than six years old. Zoloft® is a standard 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 with 20 mg per day to start to a maximum of 50 mg orally per day, and the extended-release form (Paxil CR®) is dosed at 25 mg once a day to a maximum of 62.5 mg orally every day (Rush, 2021).

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, tremors, and diaphoresis. Sexual dysfunction is most problematic with paroxetine among SSRIs (Williams & Nieuwsma, 2020; Stahl, 2014)

Fluvoxamine (Luvox®) is approved for obsessive-compulsive disorders but is frequently used off-label in treating depression and anxiety. 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 once a day 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 30 mg/day) have the potential to prolong the QT interval and may be fatal. They should be used cautiously in those with underlying heart disease and those who are prone to becoming hypokalemic (Rush, 2021; 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).

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 daily, 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 a day, it mainly affects serotonin levels, but it affects dopamine and norepinephrine levels at higher doses. Discontinuation syndrome is high with this medication (Stahl, 2014).

Desvenlafaxine (Pristiq®) is a new drug in this class and is dosed 25 to 50 mg once a day for adults. It may be titrated up to 400 mg once a day, 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 (Rush, 2021; Stahl, 2014).

On the first day, Milnacipran (Savella®) is dosed 12.5 mg once a day and is titrated upwards to a maximum of 200 mg a day divided every 12 hours. It should be used cautiously in those with moderate to severe renal impairment and severe 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 to 80 mg once a day. The maximum dose is 120 mg a day. Doses need 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 (Rush, 2021; Stahl, 2014).

Duloxetine (Cymbalta®) is dosed with 30 mg twice a day to start and may be increased to 30 mg twice a day or 60 mg once a day in adults. 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 (Rush, 2021; 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 who have 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 than either grouping. Because of those differences, it should be considered as an option for clients with treatment-resistant depression who are not responsive to SNRI or SSRI medications (Stahl, 2014).

Mirtazapine is dosed 15 mg at bedtime and may be increased every 1-2 weeks up to 45 mg a day in adults. It is given at bedtime because one of its major side effects is sedation. Another common side effect is weight gain. Other side effects include dry mouth, constipation, and dizziness (Rush, 2021; Stahl, 2014).

Tricyclic Antidepressants: Cyclic antidepressants were discovered in the 1950s. The first cyclic antidepressants were named “tri”-cyclic because their chemical structure somewhat resembled three interlocked rings when drawn out in scientific notation. Several other cyclic formulations have been discovered since the days of the three-ringers; however, the tradition carries the name tricyclic forward for the general grouping despite its current descriptive inaccuracy (Hirsch & Birnbaum, 2021)

Cyclic antidepressants find less common use than the current first-line SSRI and SNRI agents. This, 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 & Birnbaum, 2021).

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. A baseline electrocardiogram (ECG) and cardiac history should be conducted before prescribing any of the cyclic agents. In younger clients (less than 40) with a negative cardiac history, the ECG may not be warranted (Hirsch & Birnbaum, 2021)

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 (Hirsch & Birnbaum, 2021). Those individuals who respond early to treatment with antidepressants are more likely to go into remission. Up to three months of treatment is generally recommended to determine if the treatment was effective. In those who have minimal effect after 4-6 weeks, the treatment regime should be reevaluated (Hirsch & Birnbaum, 2021).

Medications need to be continued for at least 6-12 months for them 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 (Hirsch & Birnbaum, 2021).

Acute treatment, follow-up, and ongoing maintenance therapies are all essential in the treatment of substance abuse. Acute medical interventions focus on the individual's specific medical needs at the time of diagnosis. The consensus of the medical and mental health community, however, is that acute treatment alone is rarely enough. Virtually 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 be used at the bedside through the course of medical recovery while also forming an integrated strategy throughout follow-up office visits or referrals. The techniques often take around five minutes or less, making it a prized therapeutic method that is helpful 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 the maintenance of 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 a system based on an empathetic, respectful view of the client’s life struggles, with simple techniques used to prompt behavioral change. Originally, MI was developed for dealing with problem drinkers, yet it 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.

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 him 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.

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 be present 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 setting particular 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.

Patients who are in seclusion for self-destructive behaviors are to be monitored on a one-to-one or face-to-face status by a trained staff member. 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 for continuing 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 maintains continuous observation and ensures the patient is treated 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.

The CEUfast course Restraint Use, Evidence-Based Practice offers more information on seclusion.

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

Handguns are the most common firearm used to die by suicide in the United States. Due to this impulsive nature of suicide, restricting access to firearms, particularly handguns, helps prevent suicides.

Clinicians must develop a plan of treatment. 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 there is adequate treatment of the patient, especially those who are medically complex.