ultimate guide to suicidal thoughts

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Outlines:
1) Introduction
2) Definition
3) Causes
4) Risk factors
5) Signs and symptoms
6) Warning signs of suicide
7) Treatment
8) prevention
9) Nursing management
10) references
Introduction:
Every year close to 800 000 people take their own life and there are many
more people who attempt suicide. Every suicide is a tragedy that affects
families, communities and entire countries and has long-lasting effects on the
people left behind. Suicide occurs throughout the lifespan and was the
second leading cause of death among 15-29 year-olds globally in 2016.
Suicide does not just occur in high-income countries, but is a global
phenomenon in all regions of the world. In fact, over 79% of global suicides
occurred in low- and middle-income countries in 2016.
Suicide is a serious public health problem; however, suicides are preventable
with timely, evidence-based and often low-cost interventions. For national
responses to be effective, a comprehensive multisectoral suicide prevention
strategy is needed.

Definition:
Suicide is when people direct violence at themselves with the intent to
end their lives, and they die because of their actions. It’s best to avoid the
use of terms like “committing suicide” or a “successful suicide” when
referring to a death by suicide as these terms often carry negative
connotations.
A suicide attempt is when people harm themselves with the intent to end
their lives, but they do not die because of their actions.
Causes:
Struggling to cope with certain difficulties in your life can cause
you to feel suicidal. These difficulties may include:
mental health problems
bullying or discrimination
different types of abuse, including domestic, sexual or physical
abuse
bereavement, including losing a loved one to suicide
the end of a relationship
long-term physical pain or illness
adjusting to a big change, such as retirement or redundancy
money problems
housing problems, including homelessness
isolation or loneliness
being in prison
feeling inadequate or a failure
addiction or substance abuse
postnatal depression
doubts about your sexual or gender identity
cultural pressure, such as forced marriage
other forms of trauma.

Conditions that researchers have linked to a higher risk of suicide
ideation include:
depression
schizophrenia
bipolar disorder
some personality traits, such as aggression
conditions that affect relationships
traumatic brain injury
conditions that involve chronic pain
alcohol or drug dependence
borderline personality disorder
post-traumatic stress disorder
Risk factors:
Suicide does not discriminate. People of all genders, ages, and ethnicities
can be at risk.
The main risk factors for suicide are:
A prior suicide attempt
Depression and other mental health disorders
Substance abuse disorder
Family history of a mental health or substance abuse disorder
Family history of suicide
Family violence, including physical or sexual abuse
Having guns or other firearms in the home
Being in prison or jail
Being exposed to others’ suicidal behavior, such as a family member,
peer, or media figure
Medical illness
Being between the ages of 15 and 24 years or over age 60

Even among people who have risk factors for suicide, most do not
attempt suicide. It remains difficult to predict who will act on suicidal
thoughts.
Signs and symptoms:
Severe sadness or moodiness.
Hopelessness.
Sleep problems.
Sudden calmness.
Increasing drug and alcohol usage.
Withdrawal.
Mood swings.
Changes in personality or appearance.
Dangerous or self-harmful behavior.
Recent trauma or life crisis.
Making preparations.
Threatening or talking about suicide.
Psychosis
Severe anxiety and agitation.
Depression
Panic attacks.

Warning signs of suicide:
The behaviors listed below may be signs that someone is thinking
about suicide.
Talking about wanting to die or wanting to kill themselves
Talking about feeling empty, hopeless, or having no reason to live
Planning or looking for a way to kill themselves, such as searching
online, stockpiling pills, or newly acquiring potentially lethal items
(e.g., firearms, ropes)
Talking about great guilt or shame
Talking about feeling trapped or feeling that there are no solutions
Feeling unbearable pain, both physical or emotional
Talking about being a burden to others
Using alcohol or drugs more often
Acting anxious or agitated
Withdrawing from family and friends
Changing eating and/or sleeping habits
Showing rage or talking about seeking revenge
Taking risks that could lead to death, such as reckless driving
Talking or thinking about death often
Displaying extreme mood swings, suddenly changing from very sad
to very calm or happy
Giving away important possessions
Saying goodbye to friends and family
Putting affairs in order, making a will

Treatment
Psychotherapy: Psychotherapy can often be beneficial for people who
are experiencing chronic suicidal ideation and behavior. However, when
individuals are at risk of suicide it is essential that they receive a higher
level of care, such as hospitalization or intense in-patient or out-patient
treatment. Weekly psychotherapy is simply insufficient to protect those
who are in crisis and adequately address their risk. Once an individual is
no longer in crisis, therapy to treat the underlying causes of suicidal
ideation or behavior is typically recommended.
The psychotherapy model considers hopelessness to be the strongest
contributing factor to suicidal ideation, and a large part of crisis
intervention and post crisis counseling aims to restore hope.
An individual who continues in therapy once the point of crisis has
passed will likely explore ways to resist urges to self-harm (if the person
engaged in self-harming behavior), address the factors that led to
suicidal thoughts, and create a plan that includes coping strategies and
methods to address suicidal thoughts in the event that they recur.
ECT: There appears to be some evidence demonstrating the reduction of
acute risk of suicidality with ECT.
Publications on the subjects of ECT and suicide stress the importance of
ECT as a valuable treatment in appropriately selected cases of suicidal
ideation or attempted suicide. There is no direct correlation between the
degree of suicidality and the usefulness of ECT. In the management of
cases with major affective disorder, particularly those showing delusions
and vegetative signs, ECT should be considered early in the treatment. The
presence of the potential for suicide provides an added incentive. However,

suicidal threats or attempts on the part of patients with severe personality
disorders are not likely to respond to ECT unless the picture is complicated
by major depressive illness. In the absence of such affective illness,
understanding and skilled psychotherapy are likely to be more effective.
Antidepressant medication and ECT should be administered within a
supportive, watchful, and compassionate setting.
Medications:
Pharmacologic intervention may be markedly helpful in managing
underlying mental disorders and the danger of repeated or more dangerous
self-directed violence. All medications (prescription drugs, over-the-
counter medications, and supplements) used by patients at risk for suicide
should be reviewed to ensure effective and safe treatment without adverse
drug interactions. When prescribing drugs to people who self-harm,
consider the toxicity of prescribed drugs in overdose and limit the quantity
dispensed or available, and/or identify another person to be responsible for
securing access to medications. The need for follow up and monitoring for
adverse events should be addressed.
The only two evidence-based medications that have been shown to lower
suicidal behaviors are lithium and clozapine. However, these medications
do not reach therapeutic levels immediately. Anxiolytics,
sedative/hypnotics, and short-acting antipsychotic medications may be used
to directly address agitation, irritability, psychic anxiety, insomnia, and
acute psychosis, until such time as a behavioral health assessment can be

made. The amount and type of medication must be carefully chosen and
titrated when the individual is deemed to be under the influence of alcohol,
illicit substances, or other medication in prescribed or overdose amounts.
Lithium
Lithium, which is an effective mood stabilizer, is approved for the treatment
of mania and the maintenance treatment of bipolar disorder. A number of
cohort studies have described the anti-suicide benefits of lithium for
individuals on long-term maintenance. Mood stabilizers are used primarily
to treat bipolar disorder, mood swings associated with other mental
disorders, and, in some cases, to augment the effect of other medications
used to treat depression.
A possible explanation for its anti-suicidal effects of lithium is that it
reduces the relapse of mood disorders. However, lithium is not as potent in
acute phase therapy as other antidepressants, which do not seem to have
similar anti-suicidal efficacy. Possible mechanisms include an effect on
aggression or impulsivity, both of which are associated with an increased
risk of suicide. People treated for an affective disorder have a 30 times
greater risk of suicide than the general population, and the evidence that
lithium reduces the risk of suicide and possibly deliberate self-harm in
people with bipolar disorder and recurrent unipolar depression indicates that
lithium should continue to have an important clinical role

Lithium Used to Treat Suicidal Ideation and Behavior
Lithium should be considered for patients diagnosed
with unipolar depressive disorder who have had a partial
response to an antidepressant and for those with recurrent episodes
who are at high risk for suicidal behavior, provided they do not
have a contraindication to lithium use and the potential benefits
outweigh the risks.
Lithium should be considered for patients diagnosed with bipolar
disorder who do not have contraindications to its use.
Lithium should be avoided or used in caution in patients with
impaired renal function, those taking concurrent medications that
increase or decrease lithium concentrations or those with other
risk factors for lithium toxicity.
When prescribing lithium to patients at risk for suicide, it is
important to pay attention to the risk of overdose by limiting the
amount of lithium dispensed and the form in which it is provided.
Antidepressants
Suicide is strongly associated with poor mental health, especially mood
disorders. Antidepressants are the most common treatment for mood
disorders, but effective use of these medications requires administration to
patients who have been properly diagnosed and then adequately followed up.
There is a consensus as to the importance of primary care doctors’ education
programs for improving the management of depression with antidepressants
in order to reduce the risk of suicide. Furthermore, a number of multi-
component suicide prevention programs emphasize the crucial importance of
primary care education programs to facilitate optimal antidepressant
prescribing.

Antidepressants Used to Treat Suicidal Ideation
and Behavior
Antidepressants may benefit suicidal behavior in patients with mood
disorders. Treatment for the underlying cause should be optimized
according to evidence-based guidelines for the respective disorder.
Young adults (18–24) started on an antidepressant for treatment of
depression or another psychiatric disorder should be monitored and
observed closely for emergence or worsening of suicidal thoughts or
behaviors during the initiation phase of treatment.
Patients of all age groups who are managed with antidepressants should
be monitored for emergence or worsening of suicidal thoughts or
behaviors after any change in dosage.
When prescribing antidepressants for patients at risk for suicide, pay
attention to the risk of overdose and limit the amount of medication
dispensed and refilled.
Clozapine
Clozapine is an atypical antipsychotic medication used primarily to treat
individuals with schizophrenia. However, it is the only medication with a
specific U.S. Food and Drug Administration (FDA) indication for reducing
the risk of recurrent suicidal behavior in patients with schizophrenia or
schizoaffective disorder who are at risk for ongoing suicidal behavior (NIH,
2017).
While clozapine is beneficial for some patients, there are risks associated
with this drug. Specifically, clozapine can decrease the number of
neutrophils, a type of white blood cell, that function in the body to fight off
infections. When neutrophils are significantly decreased, severe neutropenia
may result and the body may become prone to infections. For this reason,
patients taking clozapine need to have their absolute neutrophil count (ANC)
monitored on a regular basis (FDA, 2016).

Key Point about Clozapine
Clozapine should be considered for patients diagnosed with
schizophrenia at high risk for suicide, who do not have
contraindications to clozapine, and will be compliant with all required
monitoring.
Antipsychotics
Atypical antipsychotics may be used as treatment augmentation in the
management of major depressive disorder and treatment of bipolar
depressive disorders. Aripiprazole, quetiapine, and olanzapine in
combination with fluoxetine include depressive disorders in their label
indications. Their labels also include the same box warning as
antidepressants for an increased risk of suicidal thinking and behaviors.
There is no evidence to support this increased risk in adults, albeit atypical
antipsychotics have not been as extensively studied as antidepressants.
Key Points about Antipsychotics
There is no evidence that antipsychotics provide additional benefits in
reducing the risk of suicidal thinking or behavior in patients with co-
occurring psychiatric disorders. Treatment for the psychiatric disorder
should be optimized according to evidence-based guidelines for the
respective disorder.
Patients who are treated with antipsychotics should be monitored for
changes in behavior and emergence of suicidal thoughts during the
initiation phase of treatment or after any change in dosage.
When prescribing antipsychotics in patients at risk for suicide pay
attention to the risk of overdose and limit the amount of mediation
dispensed and refilled.

Antiepileptic Drugs
Patients started or who are managed with antiepileptics should
be monitored for changes in behavior and the emergence of suicidal
thoughts. There is no evidence that antiepileptics are effective in reducing
the risk of suicide in patients with a mental disorder
Antianxiety Agents
Anxiety is a significant and modifiable risk factor for suicide and the use
of anti-anxiety agents may have the potential to decrease this risk. Any
one of several rapidly acting, anti-anxiety agents (eg, clonazepam, a
benzodiazepine) are candidate pharmaceutics for use in emergency
psychopharmacology for anxiety reduction in patients who exhibit
suicidal behaviors. The use of any medications for this purpose must
consider the risk of death from suicide versus the risk of serious adverse
effects from psychopharmacology (to include disinhibition that could
lead to suicide) versus the utility of various psychosocial interventions
versus doing nothing.
Benzodiazepines can be effective in treating symptoms of anxiety,
insomnia, hypervigilance, and other anxiety symptoms. In general,
benzodiazepines are not recommended for long-term use in chronic
aggression because of the potential for dependence and tolerance,
resulting in an increase in impulsivity aggression. Benzodiazepines can
occasionally disinhibit aggressive and dangerous behaviors and enhance
impulsivity. Benzodiazepines taken in excessive amounts can cause
dangerous deep unconsciousness. In combination with other central
nervous system depressants, such as alcohol and opiates, the potential for
toxicity increases exponentially.

Prevention of suicide:
Suicides are preventable. There are a number of measures that can be
taken at population, sub-population and individual levels to prevent
suicide and suicide attempts. These include:
reducing access to the means of suicide (e.g. pesticides, firearms, certain
medications);
reporting by media in a responsible way;
school-based interventions;
introducing alcohol policies to reduce the harmful use of alcohol;
early identification, treatment and care of people with mental and
substance use disorders, chronic pain and acute emotional distress;
training of non-specialized health workers in the assessment and
management of suicidal behaviour;
follow-up care for people who attempted suicide and provision of
community support.
Suicide is a complex issue and therefore suicide prevention efforts
require coordination and collaboration among multiple sectors of
society, including the health sector and other sectors such as education,
labour, agriculture, business, justice, law, defense, politics, and the
media. These efforts must be comprehensive and integrated as no single
approach alone can make an impact on an issue as complex as suicide.

Nursing management:
Nursing assessment:
Ask the right questions
Many nurses struggle with how to begin a suicide risk assessment.
Start with these nine simple questions:
* How are you coping with what's been happening in your life?
* Do you ever feel like just giving up?
* Are you thinking about dying?
* Are you thinking about hurting yourself?
* Are you thinking about suicide?
* Have you thought about how you would do it?
* Do you know when you would do it?
* Do you have the means to do it?
* Have you ever attempted to harm yourself in the past?
Assess for nonverbal signs that may potentially indicate the patient is
considering self-harm, such as avoiding eye contact, tearfulness,
crying, or an abrupt change in behavior. Examples of abrupt changes in
behavior include:
1. Assess the ability to complete activities of daily living.
2. Assess the content of thought process as manifested through verbal
communication.
3. Assess affect and mood for appropriateness to situation.
4. Assess the degree of anxiety expressed by the patient regarding any
experiences, fears, or fantasies.

5. Assess the response of the patient to past and present pharmacological
interventions for psychiatric symptoms.
6. Assess problems in cognitive function as in memory, attention and
speech.
7. Assess for social changes as loss of drive or interest, inability to forming
relationships, mistrust and bad personal hygiene, dependency,
deterioration of social skills.
8. Assess the presence or absence of support system.
Nursing diagnosis:
1. Risk for suicide related to Alcohol and substance abuse and
psychiatric illness.
2. Ineffective Individual Coping related to Disturbance in pattern of tension
release and situtional crises.
3. Hopelessness related to Loss of significant support systems,Prolonged
isolation.
4. Anxiety related to situational crises.
5. Disturbed Thought Processes Overwhelming life circumstances and
Severe anxiety or depressed mood.
6. Impaired Social Interaction related to Altered thought processes and
Feelings of worthlessness.
7. Risk for self-directed violence Related to hopelessness, Loneliness,
psychosis.
8. Imbalanced Nutrition: Less Than Body Requirements related to
Insufficient dietary intake to meet metabolic needs for psychological,
physiological, or economic reasons.

References:
1. Suicide. (2019). Retrieved 19 May 2021, from https://www.who.int/news-
room/fact-sheets/detail/suicide
2. NIMH » Suicide in America: Frequently Asked Questions. (2021). Retrieved 19
May 2021, from https://www.nimh.nih.gov/health/publications/suicide-faq/
3. Causes of suicidal feelings. (2021). Retrieved 19 May 2021, from
https://www.mind.org.uk/information-support/types-of-mental-health-
problems/suicidal-feelings/causes-of-suicidal-feelings/
4. Signs, Symptoms & Effects of Suicidal Ideation | Valley Behavioral Health.
(2021). Retrieved 19 May 2021, from
https://www.valleybehavioral.com/suicidal-ideation/signs-symptoms-causes/
5. Medical Treatment of Suicide Risk | ATrain Education. (2021). Retrieved 19 May
2021, from https://www.atrainceu.com/content/6-medical-treatment-suicide-
risk
6. Help, G., Professionals, F., Listed, G., Help, G., Professionals, F., & Therapist, F. et
al. (2021). Suicide, Therapy for Suicide . Retrieved 19 May 2021, from
https://www.goodtherapy.org/learn-about-therapy/issues/suicide
7. Benzodiazepines: Uses, types, side effects, and risks. (2021). Retrieved 19 May
2021, from https://www.medicalnewstoday.com/articles/262809
8. 7 Anxiety and Panic Disorders Nursing Care Plans - Nurseslabs. (2016).
Retrieved 19 May 2021, from https://nurseslabs.com/anxiety-panic-disorders-
nursing-care-plans/

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