Chapter: Psychiatric Mental Health Nursing : Mood Disorders


Suicide is the intentional act of killing oneself. Suicidal thoughts are common in people with mood disorders, especially depression.


Suicide is the intentional act of killing oneself. Suicidal thoughts are common in people with mood disorders, especially depression. Each year, more than 30,000 suicides are reported in the United States; suicide attempts are esti-mated to be 8 to 10 times higher. In the United States, men commit approximately 72% of suicides, which is roughly three times the rate of women, although women are four times more likely than men to attempt suicide. The higher suicide rates for men are partly the result of the method chosen (e.g., shooting, hanging, jumping from a high place). Women are more likely to overdose on medication. Men, young women, whites, and separated and divorced people are at increased risk for suicide. Adults older than age 65 years compose 10% of the population but account for 25% of suicides. Suicide is the second leading cause of death (after accidents) among people 15 to 24 years of age, and the rate of suicide is increasing most rapidly in this age group (Andreasen & Black, 2006).


Clients with psychiatric disorders, especially depres-sion, bipolar disorder, schizophrenia, substance abuse, posttraumatic stress disorder, and borderline personality disorder, are at increased risk for suicide (Rihmer, 2007). Chronic medical illnesses associated with increased risk for suicide include cancer, HIV or AIDS, diabetes, cerebrovas-cular accidents, and head and spinal cord injury. Environ-mental factors that increase suicide risk include isolation, recent loss, lack of social support, unemployment, critical life events, and family history of depression or suicide. Behavioral factors that increase risk include impulsivity, erratic or unexplained changes from usual behavior, and unstable lifestyle (Smith et. al., 2008).


Suicidal ideation means thinking about killing oneself. Active suicidal ideation is when a person thinks about and seeks ways to commit suicide. Passive suicidal ideation is when a person thinks about wanting to die or wishes he or she were dead but has no plans to cause his or her death. People with active suicidal ideation are considered more potentially lethal.


Attempted suicide is a suicidal act that either failed or was incomplete. In an incomplete suicide attempt, the per-son did not finish the act because (1) someone recognized the suicide attempt as a cry for help and responded or (2) the person was discovered and rescued (Sudak, 2005).


Suicide involves ambivalence. Many fatal accidents may be impulsive suicides. It is impossible to know, for example, whether the person who drove into a telephone pole did this intentionally. Hence, keeping accurate sta-tistics on suicide is difficult. There are also many myths and misconceptions about suicide of which the nurse should be aware.



A history of previous suicide attempts increases risk for suicide. The first 2 years after an attempt represent the highest risk period, especially the first 3 months. Those with a relative who committed suicide are at increased risk for suicide: the closer the relationship, the greater the risk. One possible explanation is that the relative’s suicide offers a sense of “permission” or acceptance of suicide as a method of escaping a difficult situation. This familiarity and accep-tance also is believed to contribute to “copycat suicides” by teenagers, who are greatly influenced by their peers’ actions (Sudak, 2005).


Many people with depression who have suicidal ide-ation lack the energy to implement suicide plans. The natural energy that accompanies increased sunlight in spring is believed to explain why most suicides occur in April. Most suicides happen on Monday mornings, when most people return to work (another energy spurt). Research has shown that antidepressant treatment actually can give clients with depression the energy to act on sui-cidal ideation (Sudak, 2005).


Warnings of Suicidal Intent


Most people with suicidal ideation send either direct or indirect signals to others about their intent to harm them-selves. The nurse never ignores any hint of suicidal ide-ation regardless of how trivial or subtle it seems and the client’s intent or emotional status. Often, people contem-plating suicide have ambivalent and conflicting feelings about their desire to die; they frequently reach out to oth-ers for help. For example, a client might say,

“I keep thinking about taking my entire supply of medications to end it all” (direct) or “I just can’t take it anymore” (indirect).

Asking clients directly about thoughts of suicide is im-portant. Psychiatric admission assessment interview forms routinely include such questions. It is also standard practice to inquire about suicide or self-harm thoughts in any setting where people seek treatment for emotional problems.

Risky Behaviors


A few people who commit suicide give no warning signs. Some artfully hide their distress and suicide plans. Others act impulsively by taking advantage of a situation to carry out the desire to die. Some suicidal people in treatment describe placing themselves in risky or dangerous situations such as speeding in a blinding rainstorm or when intoxicated. This “Russian roulette” approach carries a high risk for harm to clients and innocent bystanders alike. It allows clients to feel brave by repeatedly confronting death and surviving.


Lethality Assessment


When a client admits to having a “death wish” or sui-cidal thoughts, the next step is to determine potential lethality. This assessment involves asking the following questions:


·    Does the client have a plan? If so, what is it? Is the plan specific?


·    Are the means available to carry out this plan? (For ex-ample, if the person plans to shoot himself, does he have access to a gun and ammunition?)


·    If the client carries out the plan, is it likely to be lethal? (For example, a plan to take 10 aspirin is not lethal, while a plan to take a 2-week supply of a tricyclic antidepressant is.)


·    Has the client made preparations for death, such as giv-ing away prized possessions, writing a suicide note, or talking to friends one last time?


·    Where and when does the client intend to carry out the plan?


·    Is the intended time a special date or anniversary that has meaning for the client?


Specific and positive answers to these questions all increase the client’s likelihood of committing suicide. It is impor-tant to consider whether or not the client believes her or his method is lethal even if it is not. Believing a method to be lethal poses a significant risk.


Outcome Identification


Suicide prevention usually involves treating the underly-ing disorder, such as mood disorder or psychosis, with psychoactive agents. The overall goals are first to keep the client safe and later to help him or her to develop new cop-ing skills that do not involve self-harm. Other outcomes may relate to activities of daily living, sleep and nourish-ment needs, and problems specific to the crisis such as stabilization of psychiatric illness/symptoms.


Examples of outcomes for a suicidal person include the following:


·    The client will be safe from harming self or others.


·    The client will engage in a therapeutic relationship.


·    The client will establish a no-suicide contract.


·    The client will create a list of positive attributes.


·    The client will generate, test, and evaluate realistic plans to address underlying issues.




Using an Authoritative Role


Intervention for suicide or suicidal ideation becomes the first priority of nursing care. The nurse assumes an authoritative role to help clients stay safe. In this crisis situation, clients see few or no alternatives to resolve their problems. The nurse lets clients know their safety is the primary concern and takes precedence over other needs or wishes. For example, a client may want to be alone in her room to think privately. This is not allowed while she is at increased risk for suicide.

Providing a Safe Environment


Inpatient hospital units have policies for general environ-mental safety. Some policies are more liberal than others, but all usually deny clients access to materials on cleaning carts, their own medications, sharp scissors, and pen-knives. For suicidal clients, staff members remove any item they can use to commit suicide, such as sharp objects, shoelaces, belts, lighters, matches, pencils, pens, and even clothing with drawstrings.


Again, institutional policies for suicide precautions vary, but usually staff members observe clients every 10 minutes if lethality is low. For clients with high poten-tial lethality, one-to-one supervision by a staff person is initiated. This means that clients are in direct sight of and no more than 2 to 3 feet away from a staff member for all activities, including going to the bathroom. Clients are under constant staff observation with no exceptions. This may be frustrating or upsetting to clients, so staff members usually need to explain the purpose of such supervision more than once.


No-suicide or no-self-harm contracts have been used with suicidal clients. In such contracts, clients agree to keep themselves safe and to notify staff at the first impulse to harm themselves (at home, clients agree to notify their caregivers; the contract must identify backup people in case caregivers are unavailable). These contracts, however, are not a guarantee of safety, and their use has been sharply criticized (McMyler & Pryjmachuk, 2008). At no time should a nurse assume that a client is safe based on a single statement by the client. Rather a complete assessment and a thorough discussion with the client are more reliable.


Creating a Support System List


Suicidal clients often lack social support systems such as relatives and friends or religious, occupational, and com-munity support groups. This lack may result from social withdrawal, behavior associated with a psychiatric or medi-cal disorder, or movement of the person to a new area because of school, work, or change in family structure or financial status. The nurse assesses support systems and the type of help each person or group can give a client. Mental health clinics, hotlines, psychiatric emergency evaluation services, student health services, church groups, and self-help groups are part of the community support system.


The nurse makes a list of specific names and agencies that clients can call for support; he or she obtains client consent to avoid breach of confidentiality. Many suicidal people do not have to be admitted to a hospital and can be treated successfully in the community with the help of these support people and agencies.


Family Response


Suicide is the ultimate rejection of family and friends. Implicit in the act of suicide is the message to others that their help was incompetent, irrelevant, or unwelcome. Some suicides are done to place blame on a certain person—even to the point of planning how that person will be the one to discover the body. Most suicides are efforts to escape untenable situations. Even if a person believes love for family members prompted his or her sui-cide—as in the case of someone who commits suicide to avoid lengthy legal battles or to save the family the finan-cial and emotional cost of a lingering death—relatives still grieve and may feel guilt, shame, and anger.


Significant others may feel guilty for not knowing how desperate the suicidal person was, angry because the per-son did not seek their help or trust them, ashamed that their loved one ended his or her life with a socially unac-ceptable act, and sad about being rejected. Suicide is news-worthy, and there may be whispered gossip and even news coverage. Life insurance companies may not pay survivors’ benefits to families of those who kill themselves. Also, the one death may spark “copycat suicides” among family members or others, who may believe they have been given permission to do the same. Families can disintegrate after a suicide.


Nurse’s Response


When dealing with a client who has suicidal ideation or attempts, the nurse’s attitude must indicate unconditional positive regard not for the act but for the person and his or her desperation. The ideas or attempts are serious signals of a desperate emotional state. The nurse must convey the belief that the person can be helped and can grow and change.


Trying to make clients feel guilty for thinking of or attempting suicide is not helpful; they already feel incom-petent, hopeless, and helpless. The nurse does not blame clients or act judgmentally when asking about the details of a planned suicide. Rather, the nurse uses a nonjudg-mental tone of voice and monitors his or her body lan-guage and facial expressions to make sure not to convey disgust or blame.


Nurses believe that one person can make a difference in another’s life. They must convey this belief when caring for suicidal people. Nevertheless, nurses also must realize that no matter how competent and caring interventions are, a few clients will still commit suicide. A client’s sui-cide can be devastating to the staff members who treated him or her, especially if they have gotten to know the per-son and his or her family well over time. Even with ther-apy, staff members may end up leaving the health care facility or the profession as a result.


Legal and Ethical Considerations


Assisted suicide is a topic of national legal and ethical debate, with much attention focusing on the court deci-sions related to the actions of Dr. Jack Kevorkian, a physi-cian who has participated in numerous assisted suicides. Oregon was the first state to adopt assisted suicide into law and has set up safeguards to prevent indiscriminate assisted suicide. Many people believe it should be legal in any state for health care professionals or family to assist those who are terminally ill and want to die. Others view suicide as against the laws of humanity and religion and believe that health care professionals should be prosecuted if they assist those trying to die. Groups, such as the Hemlock Society, and people, such as Dr. Kevorkian, are lobbying for changes in laws that would allow health care profes-sionals and family members to assist with suicide attempts for the terminally ill. Controversy and emotion continue to surround the issue.


Often, nurses must care for terminally or chronically ill people with a poor quality of life, such as those with the intractable pain of terminal cancer or severe disability or those kept alive by life-support systems. It is not the nurse’s role to decide how long these clients must suffer. It is the nurse’s role to provide supportive care for clients and fam-ily as they work through the difficult emotional decisions about if and when these clients should be allowed to die; people who have been declared legally dead can be discon-nected from life support. Each state has defined legal death and the ways to determine it.


Elder Considerations


Sakauye (2008) reports that depression is common among the elderly and is markedly increased when elders are medically ill. Elders tend to have psychotic features, par-ticularly delusions, more frequently than younger people with depression. Suicide among persons older than age 65 is doubled compared with suicide rates of persons younger than 65. Late-onset bipolar disorder is rare.


Elders are treated for depression with ECT more fre-quently than younger persons. Elder persons have increased intolerance of side effects of antidepressant medications and may not be able to tolerate doses high enough to effectively treat the depression. Also, ECT pro-duces a more rapid response than medications, which may be desirable if the depression is compromising the medical health of the elder person. Because suicide among the elderly is increased, the most rapid response to treatment becomes even more important (Sakauye, 2008).


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