Physical illness itself is a risk factor for suicide. Health-care providers are highly likely to see patients who are depressed and may be at risk of suicide. Most people who die by suicide leave signals of their intentions in some way.
According to the Substance Abuse and Mental Health Service Administration (SAMHSA), 77 percent of people who died by suicide had visited their primary care doctor within the last month and 45 percent had been to a doctor the month before they died. Rarely was the question of suicide addressed. The elderly population is especially likely to visit a primary care provider and make statements of physical pain, while displaying symptoms of depression. Caretakers of chronically or terminally ill patients should routinely be screened for depression as well as the patient. Rarely will patients immediately volunteer information that they are thinking of harming themselves. This is why screening is so important.
In an inpatient or other clinical setting, mental health resources may be available on-site. In other facilities, you may have to call a mental health clinic or emergency hotline for assistance. Every health-care facility, including private physician's offices, hospitals and school health clinics, should have a procedure for suicidal patients and know who to call. If you have suspicions of suicidal ideation in a patient, speak honestly and non-judgmentally about his or her suicidal thoughts. You always have an option to call 9-1-1 and tell the dispatcher you are concerned the person "is a danger to him or herself." Do not hesitate to make such a call if you suspect that someone is suicidal; it could save that person's life.
There are four key roles primary care physicians can play to assist in lowering the risk of suicide in their patients. The first is to screen for and aggressively treat or refer major depressive disorders and substance use and abuse. The second is to treat health problems that are key risk factors to suicide. The third is to provide education to all patients on the warning signs of suicide and provide patients with the National Suicide Prevention Lifeline 1.800.273.TALK (8255). The fourth is to teach patients the benefits of safe firearm and ammunition storage practices.
Illnesses commonly associated as risk factors to suicidal ideation include:
- Chronic pain.
- Severe anxiety disorders.
- Post traumatic stress disorder (PTSD).
- Acquired immune deficiency syndrome (AIDS); however, human immunodeficiency virus (HIV) is not necessarily associated with being a risk factor.
Strongest warning signs: If your patient displays or states anything listed below, take immediate action. A full risk assessment is warranted.
- Threatening to hurt or kill him/herself, or talking of wanting to hurt or kill him/herself.
- Looking for ways to kill him/herself by seeking access to firearms, available pills or other means.
- Talking or writing about death, dying or suicide, when these actions are out of the ordinary for the person.
Other warning signs include:
- Anxiety, agitation.
- Insomnia or sleep disturbance.
- Increased alcohol or drug use.
- Purposelessness (no reason for living).
- Withdrawing from friends, family and society.
- Rage, uncontrolled anger, seeking revenge.
- Acting reckless or engaging in risky activities, seemingly without thinking.
- Dramatic mood changes.
- Feeling trapped, like there's no way out.
People of different ages are at different levels of risk and display different types of warning signs. Depression often manifests in terms of substance abuse in adolescents. Diagnosing depression can be difficult in adolescents due to limited language skills. This makes screening even more vital when working with this age group. Adolescents are at an increased risk of suicidal behaviors. When treating adolescents, watch for the following risk factors for suicidal ideation:
- Conduct problems (anti-social, aggression, impulsivity)
- Volatile mood swings or sudden changes in their personality
- A sudden deterioration in their personal appearance
- Increased risk-taking behavior
- Eating disorders
- Gender or sexual orientation issues
- Family chaos
- History of physical or sexual abuse
- Romantic breakups
Medications can be helpful (especially antidepressants) and should be considered when developing a comprehensive treatment plan with patients who express suicidal intentions. Antidepressants are effective in reducing the symptoms of depression. There has been some evidence for an association between the class of antidepressants known as "selective serotonin reuptake inhibitors" (SSRI's) and the emergence of suicidal ideation, particularly in youth and young adults. Careful monitoring should accompany medication and can include frequent phone, or in person visits, as well as utilizing the patient's family as a support and monitoring system.
Because nurses spend so much time with patients, a trusting relationship often develops, which may encourage patients to reveal thoughts of suicide that they are reluctant to share with their family physician.
As a nurse, you play a powerful role in preventing suicide. But you should not have to handle emergencies alone. A policy prepared in advance of a crisis and defined roles for staff will assist in helping a suicidal patient. Being able to identify warning signs of suicidal ideation is an important step in preventing a suicide. Warning signs include:
- Talking about suicide or death.
- Giving direct verbal cues, such as "I wish I were dead" and "I'm going to end it all."
- Giving less direct verbal cues, such as "what's the point of living?" "Soon you won't have to worry about me," and "Who cares if I'm dead anyway?"
- Isolating him-or herself from friends and family.
- Expressing the belief that life is meaningless or hopeless.
- Giving away cherished possessions.
- Exhibiting a sudden and unexplained improvement in mood after being depressed or withdrawn.
- Neglecting his or her appearance and hygiene.
Elderly patients are at an increased risk of dying by suicide and are more likely to visit a physician when thinking about suicide. Patients with chronic diseases such as Parkinson's or Alzheimer's disease are at a greater risk of depression. When screening elderly patients for depression, always consider their level of cognitive functioning. Some warning signs specific to elderly patients include:
- Buying a gun.
- Giving away money or cherished personal possessions.
- Taking a sudden interest, or losing interest, in religion.
- Failing to care for themselves in terms of the routine activities of daily living.
- Withdrawing from relationships.
- Experiencing a failure to thrive, even after appropriate medical treatment.
- Scheduling a medical appointment for vague symptoms.
Adolescents are also a vulnerable population and are at a higher risk of suicide. Depression often manifests in terms of substance abuse in adolescents. Warning signs to watch for when working with adolescents include:
- Volatile mood swings or sudden changes in their personality.
- Indications that they are in unhealthy, destructive or abusive relationships, such as unexplained bruises, a swollen face or other injuries.
- A sudden deterioration in their personal appearance.
- A fixation with death or violence.
- Eating disorders, especially combined with dramatic shifts in weight (other than those associated with a diet under medical supervision).
- Gender identity issues.
For home care nurses
When working in a patient's home who may be suicidal, you may need to contact the local mental health crisis line, emergency department, or National Suicide Prevention Lifeline at 1.800.273.TALK (8255). You may need to work with the patient's family to ensure that he or she will be adequately supported until a mental health professional can provide an assessment.
It is estimated that on average as many as 400 physicians die by suicide every year, which is the equivalent of one medical class. This statistic puts suicide as the second leading cause of death of physicians.
Physician rates of suicide have not been decreasing, presumably because little attention has been paid to this issue. In the general population, males complete suicide four times more than females. However, female physicians have a rate equal to male physicians. This means suicide risks are equal among the sexes in physicians and when comparing female physicians to general population females, female physicians are at four times the risk of completing suicide. Some risk factors and barriers for physicians are:
- Bipolar disorder.
- Substance use and abuse.
- Fear of asking for help, and facing personal or occupational-related consequences.
- Legal or credentialing sanctions.
The most common means of suicide in physicians are overdoses and firearms. Contributing to the higher suicide rate among physicians is the higher completion to attempt ratio, which may result from greater knowledge of lethality of drugs and easy access to lethal means. Because of increased knowledge of lethal means, talking to a co-worker about known risk factors and concerns of suicide are particularly important in this population.
Information adapted from the American Foundation for Suicide Prevention.