OBJECTIVES

 Describe the genetic, biologic, sociologic, and psychological factors believed to

precipitate suicidal behavior.
 Identify those clients or groups of individuals considered to be at risk for suicide.
 State at least two examples of verbal, behavioral, and situational suicidal clues.
 Differentiate three cultural beliefs about suicide.
 Distinguish among suicidal ideation, intent, threat, gesture, and attempt.
 Explain primary, secondary, and tertiary suicide prevention.
 Articulate the importance of self-assessment when providing care for suicidal clients.
 Define the term postvention.
 Describe the purpose of suicide precautions, no-suicide contracts, and seclusion and
restraints in the clinical setting.
 State the purpose of a psychological autopsy.
 Reflect on the impact of physician-assisted suicide on the nursing profession.

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 INTRODUCTION

Suicide is derived from the Latin word for self-murder. Latin suicidium, from Sui caedere,
"to kill oneself" is the act of a human being intentionally causing his or her own death It is a
fatal act that represents the person's wish to die. There is a range, however, between thinking
about suicide and acting it out. Some persons have ideas of suicide that they will never act
on; some plan for days, weeks, or even years before acting; and others take their lives
seemingly on impulse, without premeditation. W.H.O estimates that it is the thirteenth-
leading cause of death worldwide.

In 2002, there were 10,982 suicides in Tamil Nadu, 11,300 in Kerala, 10,934 in
Karnataka and 9,433 in Andhra Pradesh. Kerala, the country's first fully literate state, has the
highest number of DSH. Some 32 people commit DSH in Kerala every day. But According to
The Lancet, the respected British medical journal, the south India is the is the region account
for the world’s largest number of DSH by young people. Some 50,000 people in the four
states of Kerala, Karnataka, Tamil Nadu and Andhra Pradesh and the Union Territory of
Pondicherry kill themselves every year. This statistic becomes even more alarming when you
consider that the total number of DSH cases recorded in the whole of India in 2002 was
154,000. The suicide rate in Kerala was about 32 per 100,000 persons in 2002, thrice the rate
in India as a whole. Experts like him put forward various reasons for the dismal state of
mental health among people in the South.

KEY TERMS

Alexithymia Postvention
Altruistic suicide Primary prevention
Anomic suicide Psychological autopsy
Egoistic suicide Secondary prevention
Euthanasia Tertiary prevention
Parasuicide Trichotillomania

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SUICIDE
Definition:
Suicide is associated with thwarted or unfulfilled needs, feelings of hopelessness and
helplessness, ambivalent conflicts between survival and unbearable stress, a narrowing of
perceived options, and a need to escape.

SHNEIDMAN, 1996
Suicide may be the culmination of self-destructive urges that have resulted from the client's
internalizing his or her anger or a desperate act by which to escape a perceived intolerable
psychological state or life situation. The client may be asking for help by attempting suicide,
seeking attention, or attempting to manipulate someone with suicidal behavior.
SCHULTZ & VIDEBECK, 2002
Males are four times more likely to die from suicide than females. However, females are
more likely to attempt suicide than males (National Center for Health Statistics [NCHS],
2003; National Center for Injury Prevention and Control.

RISK FACTORS

Gender Differences:

Men commit suicide more than four times as often as women, a rate that is stable over all
ages. (70% male; female30%). Women, however, are four times more likely to attempt
suicide than men. Men's higher rate of completed suicide is related to the methods they use:
firearms, hanging, or jumping from high places. Globally, the most common method of
suicide is hanging.

Age:

Suicide rates increase with age and underscore the significance of the midlife crisis. Among
men, suicides peak after age 45; among women, the greatest number of completed suicides
occurs after age 55. Rates of 40 per 100,000 population occur in men age 65 and older. Older
persons attempt suicide less often than younger persons, but are more often successful. The
suicide rate, however, is rising most rapidly among young persons, particularly males 15 to
24 years of age, and the rate is still rising. The suicide rate for females in the same age group
is increasing more slowly than that for males. Among men 25 to 34 years of age, the suicide

3
rate increased almost 30 percent over the past decade. Suicide is the third leading cause of
death in those 15 to 24 years of age, after accidents and homicides, and attempted suicides in
this age group number between 1 million and 2 million annually. Most suicides now occur
among those aged 15 to 44. Suicide is rare before puberty.

MARITAL STATUS

Marriage lessens the risk of suicide significantly, especially if there are children in the home.
Single, never-married persons register an overall rate nearly double that of married persons.
Divorce increases suicide risk, with divorced men three times more likely to kill themselves
as divorced women. Widows and widowers also have high rates. Suicide occurs more
frequently than usual in persons who are socially isolated and have a family history of suicide
(attempted or real). Persons who commit so-called anniversary suicides take their lives on the
day a member of their family did.

OCCUPATION
Suicide is higher among the unemployed than among employed persons. The suicide rate
increases during economic recessions and depressions and decreases during times of high
unemployment and during wars.

PHYSICAL HEALTH

The relation of physical health and illness to suicide is significant. Previous medical care
appears to be a positively correlated risk indicator of suicide: About one third of all persons
who commit suicide have had medical attention within 6 months of death and a physical
illness is estimated to be an important contributing factor in about half of suicides.Factors
associated with illness and contributing to both suicides and suicide attempts are loss of
mobility, especially when physical activity is important to occupation or recreation;
disfigurement, particularly among women; and chronic, intractable pain. Patients on
hemodialysis are at high risk. In addition to the direct effects of illness, the secondary effects
for example, disruption of relationships and loss of occupational status are prognostic factors.
Certain drugs can produce depression, which may lead to suicide in some cases. Among these
drugs are reserpine (Serpasil), corticosteroids, antihypertensives, and some anticancer agents.

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MENTAL ILLNESS

Alcohol-related illnesses, such as cirrhosis, are associated with higher suicide rates.
Almost 95 percent of all persons who commit or attempt suicide have a diagnosed mental
disorder. Depressive disorders account for 80 percent of this figure, schizophrenia accounts
for 10 percent, and dementia or delirium for 5 percent. Among all persons with mental
disorders, 25 percent are also alcohol dependent and have dual diagnoses. Persons with
delusional depression are at highest risk of suicide. A history of impulsive behavior or violent
acts increases the risk of suicide as does previous psychiatric hospitalization for any reason.
Among adults who commit suicide, significant differences between young and old exist for
both psychiatric diagnoses and antecedent stressors. Diagnoses of substance abuse and
antisocial personality disorder occurred most often among suicides in persons less than 30
years of age, and diagnoses of mood disorders and cognitive disorders most often among
suicides in those age 30 and above. Stressors associated with suicide in those under 30 were
separation, rejection, unemployment, and legal troubles; illness stressors most often occurred
among suicide victims over 30.

The psychiatric diagnosis with greatest risk of suicide in both sexes is a mood disorder. For
both sexes, the suicide risk is highest in the first week of the psychiatric admission; after 3 to
5 weeks, inpatients have the same risk as the general population. Times of staff rotation,
particularly of the psychiatric residents, are periods associated with inpatient suicides. The
main risk groups are patients with depressive disorders, schizophrenia, and substance abuse,
and patients who make repeated visits to the emergency room. Patients, especially those with
panic disorder, who frequent emergency services, also have an increased suicide risk. Thus,
mental health professionals working in emergency services must be well trained in assessing
suicidal risk and making appropriate dispositions. They must also be aware of the need to
contact patients at risk who fail to keep follow-up appointments. , persons suffering from
certain mental illnesses are particularly susceptible to DSH ideation and DSH attempts. Their
DSH rate may be 10 or 20 times higher than for the average citizen.

CLIENTS WITH ALEXITHYMIA

Alexithymia is not a psychiatric diagnosis, but a construct introduced in 1972 by Peter

Sifneos. Derived from the Greek language, it literally means having no word for emotions.
This construct is useful for characterizing clients who seem not to understand the feelings

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they experience and who seem to lack the words to describe their feelings to others. It is a
real phenomenon and identifies a deficit of self. Individuals who experience this phenomenon
have been found to be at risk for self-mutilation and suicidal behavior (Muller, 2000b).

ALCOHOL DEPENDENCE

About 80 percent of all alcohol-dependent suicide victims are male, a percentage that largely
reflects the sex ratio for alcohol dependence. Alcohol-dependent suicide victims tend to be
white, middle-aged, unmarried, friendless, socially isolated, and currently drinking. Up to 40
percent have made a previous suicide attempt. Up to 40 percent of all suicides by persons
who are alcohol dependent occur within a year of the patient's last hospitalization; older
alcohol-dependent patients are at particular risk during the postdischarge period.
Studies show that many alcohol-dependent patients who eventually commit suicide are rated
depressed during hospitalization and that up to two thirds are assessed as having mood
disorder symptoms during the period in which they commit suicide. As many as 50 percent of
all alcohol-dependent suicide victims have experienced the loss of a close, affectionate
relationship during the previous year. Such interpersonal losses and other types of
undesirable life events are probably brought about by the alcohol dependence and contribute
to the development of the mood disorder symptoms, which are often present in the weeks and
months before the suicide.
The largest group of male alcohol-dependent patients is composed of those with an associated
antisocial personality disorder. Studies show that such patients are particularly likely to
attempt suicide; to abuse other substances; to exhibit impulsive, aggressive, and criminal
behaviors; and to be found among alcohol-dependent suicide victims.

OTHER SUBSTANCE DEPENDENCE

Studies in various countries have found an increased suicide risk among those who abuse
substances. The suicide rate for persons who are heroin dependent is about 20 times the
rate for the general population.

PERSONALITY DISORDERS

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A high proportion of those who commit suicide have various associated personality
difficulties or disorders. Having a personality disorder may be a determinant of suicidal
behavior in several ways: by predisposing to major mental disorders such as depressive
disorders or alcohol dependence; by leading to difficulties in relationships and social
adjustment; by precipitating undesirable life events; by impairing the ability to cope with a
mental or physical disorder;

ANXIETY DISORDER

Uncompleted suicide attempts are made by almost 20 percent of patients with a panic
disorder and social phobia. If depression is an associated feature, however, the risk of
completed suicide rises.

PREVIOUS SUICIDAL BEHAVIOR

A past suicide attempt is perhaps the best indicator that a patient is at increased risk of suicide.
Studies show that about 40 percent of depressed patients who commit suicide have made a previous
attempt. The risk of a second suicide attempt is highest within 3 months of the first attempt.

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8
 CLINICAL DETERMINANTS OF SUICIDE

EUTHANASIA AND PHYSICIAN-ASSISTED SUICIDE (PAS)

Euthanasia, defined as a health care provider's deliberate act to cause a client's death, and
physician-assisted suicide (PAS), defined as the imparting of information or means to enable
suicide to occur, have become controversial issues in the health care industry (Sadock &
Sadock, 2003). The increase in human longevity, development of modern medical
technology, and use of life-support systems have created an ethical dilemma for health care
providers who are often confronted with their responsibility to relieve pain and suffering as
well as their obligation to preserve life. Nurses who provide palliative care for dying clients
have difficulty distinguishing among allowing, hastening, or causing death when their only
goal is to help clients die with peace and dignity (Schwartz, 2002).
ETIOLOGY

SOCIOLOGICAL FACTORS

Durkheim's Theory:

Emile Durkheim, a French sociologist, identified society as an influencing factor on suicide

rates. He divided suicides into three categories based on the degree of an individual's

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socialization: egoistic, altruistic, and anomic. Egoistic suicide refers to suicide by
individuals who are not strongly integrated into any social group (eg, a divorced male, who
has no children and who lives alone, commits suicide). Altruistic suicide describes suicide
by persons who believe sacrificing their lives will benefit society. For example, a fireman
who knows his life is in danger and that he could die, sacrifices his life while attempting to
save the lives of others during the attack on the World Trade Center; a suicide bomber in
Palestine dies while fighting for independence from Israel. Anomic suicide refers to suicide
that occurs when an individual has difficulty relating to others, adapting to a world of
overwhelming stressors, or adjusting to expected normal social behavior (eg,loss of job,close
friend,a parent).also there is fatalistic suicide in which person feels that he is excessively
regulated.there is no personal freedome or hope for obtaining it(prisoner).
PSYCHOLOGICAL FACTORS

Sigmund Freud
offered the first important psychological insight into suicide. He described only one patient
who made a suicide attempt, but he saw many depressed patients. In his paper Mourning and
Melancholia, Freud stated his belief that suicide represents aggression turned inward
against an introjected, ambivalently cathected love object. Freud doubted that there would be
a suicide without an earlier repressed desire to kill someone else.
Menninger's Theory
Building on Freud's ideas, Karl Menninger, in Man against Himself, conceived of suicide as
inverted homicide because of a patient's anger toward another person. This retroflexed
murder is either turned inward or used as an excuse for punishment. He also described a self-
directed death instinct (Freud's concept of Thanatos) plus three components of hostility in
suicide: the wish to kill, the wish to be killed, and the wish to die.
Recent Theories
believe that much can be learned about the psychodynamics of suicidal patients from their fantasies
about what would happen and what the consequences would be if they commit suicide. Such
fantasies often include wishes for revenge, power, control, or punishment; atonement, sacrifice, or
restitution; escape or sleep; rescue, rebirth, reunion with the dead; or a new life. The suicidal
patients most likely to act out suicidal fantasies may have lost a love object or received a narcissistic
injury, may experience overwhelming affects like rage and guilt, or may identify with a suicide victim.
Group dynamics underlie mass suicides such as those at Masada, at Jonestown, and by the Heaven's
Gate cult.

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Depressed persons may attempt suicide just as they appear to be recovering from their
depression. A suicide attempt can cause a long-standing depression to disappear, especially if
it fulfills a patient's need for punishment. Of equal relevance, many suicidal patients use a
preoccupation with suicide as a way of fighting off intolerable depression and a sense of
hopelessness. A study by Aaron Beck showed that hopelessness was one of the most accurate
indicators of long-term suicidal risk.
Other Psychological Factors
Additional psychosocial factors or motives believed to precipitate suicidal behavior have
been identified and explained. Briefly summarized, these factors may include:

 A reunion wish or fantasy: A newspaper article described the death of an elderly man
whose wife had just died. He left a note to his children stating that he did not want to
live without his wife, and because of his belief in life after death, he planned to join
his wife.
 A way to end one's feelings of hopelessness and helplessness: Hope infers a sense of
the possible, giving promise for the future and an expectation of fulfilment. Persons
who experience hopelessness feel insecure, believing that there are no solutions to
problems. They experience a sense of the impossible. Helplessness is a feeling that
everything that can be done has been done; there is nothing left to sustain hope.
 A cry for help: Some people attempt suicide hoping to draw attention to themselves to
receive help. For example, a 49-year-old woman in financial distress attempts suicide
by taking a moderate overdose of sleeping pills, hoping that her boyfriend, who never
displayed an interest in her business, will come to her rescue financially as well as
emotionally.
 An attempt to save face or seek a release to a better life: Persons who were involved
in the stock market crash of 1929 precipitating the Great Depression jumped from
windows in suicide attempts caused by feelings of failure. These people had viewed
themselves as competent, successful, and respected before the crash. The suicides
were an effort to save face, relieving them of the responsibility of dealing with
business failures.

BIOLOGICAL FACTORS

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Diminished central serotonin plays a role in suicidal behaviour. A group at the Karolinska
Institute in Sweden first noted that low concentrations of the serotonin metabolite 5-
hydroxyindoleacetic acid (5-HIAA) in the lumbar cerebrospinal fluid (CSF) were associated
with suicidal behaviour. This finding has been replicated many times and in different
diagnostic groups. Post-mortem neurochemical studies have reported modest decreases in
serotonin itself or 5-HIAA in either the brainstem or the frontal cortex of suicide victims.
Post mortem receptor studies have reported significant changes in presynaptic and
postsynaptic serotonin binding sites in suicide victims. Together, these CSF, neurochemical,
and receptor studies support the hypothesis that reduced central serotonin is associated with
suicide. Recent studies also report some changes in the noradrenergic system of suicide
victims.
GENETIC FACTORS
Suicidal behaviour, as with other psychiatric disorders, tends to run in families. For example,
Margaux Hemingway's 1997 suicide was the fifth suicide among four generations of Ernest
Hemingway's family. In psychiatric patients, a family history of suicide increases the risk of
attempted suicide and that of completed suicide in most diagnostic groups. In medicine, the
strongest evidence for involvement of genetic factors comes from twin and adoption studies
and from molecular genetics. Such studies in suicide are reviewed below.
Para suicidal Behavior
Parasuicide is a term introduced to describe patients who injure themselves by self-mutilation
(e.g., cutting the skin), but who usually do not wish to die. Studies show that about 4 percent
of all patients in psychiatric hospitals have cut themselves; the female-to-male ratio is almost
3 to 1. The incidence of self-injury in psychiatric patients is estimated to be more than 50
times that in the general population. Psychiatrists note that so-called cutters have cut
themselves over several years. Self-injury is found in about 30 percent of all abusers of oral
substances and 10 percent of all intravenous users admitted to substance-treatment units.
These patients are usually in their 20s and may be single or married. Most cut delicately, not
coarsely, usually in private with a razor blade, knife, broken glass, or mirror. The wrists,
arms, thighs, and legs are most commonly cut; the face, breasts, and abdomen are cut
infrequently. Most persons who cut themselves claim to experience no pain and give reasons,
such as anger at themselves or others, relief of tension, and the wish to die. Most are
classified as having personality disorders and are significantly more introverted, neurotic, and
hostile than controls. Alcohol abuse and other substance abuse are common, and most cutters
have attempted suicide. Self-mutilation has been viewed as localized self-destruction, with

12
mishandling of aggressive impulses caused by a person's unconscious wish to punish himself
or herself or an introjected object.
VARIABLES ENHANCING RISK OF SUICIDE AMONG VULNERABLE GROUPS
Adolescence and late life Living alone
Bisexual or homosexual gender identity Low self-esteem
Criminal behaviour Male sex
Cultural sanctions for suicide Physical illness or impairment
Delusions Previous attempts that could have resulted
Disposition of personal property in death
Divorced, separated, or single marital Protestant or nonreligious status
status Recent childbirth
Early loss or separation from parents Recent loss
Family history of suicide Repression as a defence
Hallucinations Secondary gain
Homicide Severe family pathology
Hopelessness Severe psychiatric illness
Hypochondriasis Sexual abuse
Impulsivity Signals of intent to die
Increasing agitation Suicide epidemics
Increasing stress Unemployment
Insomnia White race
Lack of future plans
Lack of sleep
Lethality of previous attempt

MYTHS FACTS
People who talk about suicide never Suicidal people often send out subtle or not-so-subtle
commit suicide. messages that convey their inner thoughts of
hopelessness and self-destruction. Both subtle and
direct messages of suicide should be taken seriously
with appropriate assessments and interventions.

While the self-violence of suicide demonstrates anger

Suicidal people only want to hurt turned inward, the anger can be directed toward others
themselves, not others. in a planned or impulsive action.
PHYSICAL HARM: Psychotic people may be responding to
inner voices that command the individual to kill others
before killing the self. A depressed person who has
decided to commit suicide with a gun may impulsively
shoot the person who tries to grab the gun in an effort to
thwart the suicide.
EMOTIONAL HARM: Often family members, friends,
health care professionals, and even police involved in
trying to avert a suicide or those who did not realize
the person’s depression and plans to commit suicide
feel intense guilt and shame because of their failure to
help and are “stuck” in a never-ending cycle of
despair and grief. Some people, depressed after the
suicide of a loved one, will rationalize that suicide

13
 was a “good way out of the pain” and plan their own
suicide to escape pain. Some suicides are planned to
engender guilt and pain in survivors; for example, as
someone who wants to punish another for rejecting or
not returning love.

Suicidal people have mixed feelings (ambivalence)

about their wish to die, wish to kill others, or to be
There is no way to help someone killed. This ambivalence often prompts the cries for
who wants to kill himself or herself help evident in overt or covert cues. Intervention can
help the suicidal individual get help from situational
supports, choose to live, learn new ways to cope, and
move forward in life.

Suicidal people have already thought of the idea of

suicide and may have begun plans. Asking about
Do not mention the word suicide to suicide does not cause a non-suicidal person to
aperson you suspect to be become suicidal.
suicidal,because this could give him
or her the idea to commit suicide..
Suicidal gestures are a potentially lethal way to act
out. Threats should not be ignored or dismissed nor
Ignoring verbal threats of suicide or should a person be challenged to carry out suicidal
challenging a person to carry out his threats. All plans, threats, gestures or cues should be
or her suicide plans will reduce the taken seriously and immediate help given that focuses
individual’s use of these behaviors. on the problem about which the person is suicidal.
When asked about suicide, it is often a relief for the
client to know that his or her cries for help have been
heard and that help is on the way.

While it is true that most people who successfully

Once a suicide risk, always a suicide commit suicide have made attempts at least once
risk. before, the majority of people with suicidal ideation
can have positive resolution to the suicidal crisis.
With proper support, finding new ways to resolve the
problem helps these individuals become emotionally
secure and have no further need for suicide as a way
to resolve a problem.

INTENSITY OF RISK LOW MODERATE HIGH

Anxiety Mild Moderate High, or panic state
Depression Mild Moderate Severe
Isolation, withdrawal Some feelings of Some feelings of Hopeless, helpless,
isolation, no helplessness, withdrawn, and self
withdrawal hoplessness, and deprecating
withdrawal

14
 Daily functioning Fairly good in most Moderately good in Not good in any
activities some activities activities
Resources Several Some Few or none
Coping strategies, Generally constructive Some that are Predominantly
devices being used constructive destructive
Significant others Several who are Few or only one Only one or none
available available available
Psychiatric help in past None, or positive Yes, and moderately Negative view of help
attitude toward satisfied received
Lifestyle Stable Moderately stable Unstable
Alcohol or drug use Infrequently to excess Frequently to excess Continual abuse
Previous suicide None, or of low One or more, of Multiple attempts of
attempts lethality moderate lethality high lethality

Disorientation, None Some Marked

disorganization
Hostility Little or none Some Marked
Suicide plan Vague, fleeting Frequent thoughts, Frequent or constant
thoughts but no plan occasional ideas about thought with a specific
a plan plan

CHARACTERISTICS OF SUICIDE ATTEMPTERS WHICH ARE RELEVANT TO

TREATMENT NEED

 Repetition of attempts and risk of suicide, Psychiatric and personality disorders

 Life events and difficulties

 Poor problem-solving skills

 Impulsivity and aggression

 Hopelessness and low self-esteem

 Motivational problems and poor compliance with treatment

GENERAL OVERVIEW OF TREATMENTS

Questions about Suicidal Feelings and Behaviors*

Begin with questions that address the patient's feeling about living
Have you ever felt that life was not worth living?

15
Did you ever wish you could go to sleep and just not wake up?
Follow on with specific questions that ask about thoughts of death, self-harm, or suicide
Is death something you have thought about recently?
Have things ever reached the point that you have thought of harming yourself?
For individuals who have thoughts of self-harm or suicide
When did you first notice such thoughts?
What led up to the thoughts (e.g., interpersonal and psychosocial precipitants, including real
or imagined losses; specific symptoms such as mood changes, anhedonia, hopelessness,
anxiety, agitation, psychosis)?
How often have those thoughts occurred, including frequency, obsessional quality,
controllability?
How close have you come to acting on those thoughts?
How likely do you think it is that you will act on them in the future?
Have you ever started to harm (or kill) yourself but stopped before doing something (e.g.,
holding knife or gun to your body but stopping before acting, going to edge of bridge but not
jumping)?
What do you envision happening if you actually killed yourself (e.g., escape, reunion with
significant other, rebirth, reactions of others)?
Have you made a specific plan to harm or kill yourself? (If so, what does the plan include?)
Do you have guns or other weapons available to you?
Have you made any particular preparations (e.g., purchasing specific items, writing a note or
a will, making financial arrangements, taking steps to avoid discovery, rehearsing the plan)?
Have you spoken to anyone about your plans?
How does the future look to you?
What things would lead you to feel more (or less) hopeful about the future (e.g., treatment,
reconciliation of relationship, resolution of stressors)?
What things would make it more (or less) likely that you would try to kill yourself?
What things in your life would lead you to want to escape from life or be dead?
What things in your life make you want to go on living?
If you began to have thoughts of harming or killing yourself again, what would you do?
For individuals who have attempted suicide or engaged in self-damaging action(s),
parallel questions to those in the previous section can address the prior attempt(s).
Additional questions can be asked in general terms or can refer to the specific method
used and may include:

16
Can you describe what happened (e.g., circumstances, precipitants, view of future, use of
alcohol or other substances, method, intent, seriousness of injury)?
What thoughts were you having beforehand that led up to the attempt?
What did you think would happen (e.g., going to sleep versus injury versus dying, getting a
reaction out of a particular person)?
Were other people present at the time?
Did you seek help afterward yourself, or did someone get help for you?
Had you planned to be discovered, or were you found accidentally?
How did you feel afterward (e.g., relief versus regret at being alive)?
Did you receive treatment afterward (e.g., medical versus psychiatric, emergency department
versus inpatient versus outpatient)?
Has your view of things changed, or is anything different for you since the attempt?
Are there other times in the past when you have tried to harm (or kill) yourself?

For individuals with repeated suicidal thoughts or attempts

About how often have you tried to harm (or kill) yourself?
When was the most recent time?
Can you describe your thoughts at the time that you were thinking most seriously about
suicide?
When was your most serious attempt at harming or killing yourself?
What led up to it, and what happened afterward?

For individuals with psychosis, ask specifically about hallucinations and delusions

Can you describe the voices (e.g., single versus multiple, male versus female, internal versus
external, recognizable versus nonrecognizable)?
What do the voices say (e.g., positive remarks versus negative remarks versus threats)? (If the
remarks are commands, determine if they are for harmless versus harmful acts; ask for
examples.)
How do you cope with (or respond to) the voices?
Have you ever done what the voices ask you to do? (What led you to obey the voices? If you
tried to resist them, what made it difficult?)
Have there been times when the voices told you to hurt or kill yourself? (How often? What

17
happened?)
Are you worried about having a serious illness or that your body is rotting?
Are you concerned about your financial situation even when others tell you there's nothing to
worry about?
Are there things that you've been feeling guilty about or blaming yourself for?

Consider assessing the patient's potential to harm others in addition to him- or herself

Are there others who you think may be responsible for what you are experiencing (e.g.,
persecutory ideas, passivity experiences)?
Are you having any thoughts of harming them?
Are there other people you would want to die with you?
Are there others who you think would be unable to go on without you?

PSYCHOSOCIAL TREATMENTS:

Problem-solving therapy:

stepwise approach to dealing with the problems and working on the patient's cognitions or
beliefs when these interfere with the process

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Intensive care plus outreach:

outreach either for all patients, or for those that have not attended treatment sessions,
together with a relatively intense treatment programme.

Intensive psychotherapy:

One trial has been conducted in which an intensive form of psychological treatment known as
dialectical behaviour therapy was evaluated. Female patients with borderline personality
disorders who had a history of repeated self-harm were offered a year of individual and group
cognitive–behavioural therapy aimed at addressing the patients' problems of motivation and
strengthening their behavioural skills, particularly in relation to interpersonal difficulties.
Compared with routine care this approach seemed to result in a reduction in repetition of self-
harm as well as a number of other positive outcomes during the year of therapy. The
reduction in self-harming behaviour continued 6 months after therapy ended .

Other psychosocial approaches:

importance of continuity of care was emphasized in a study from Germany in which patients
who were followed up by the same therapist who assessed them in hospital after their
attempts were more likely to attend treatment sessions than patients who were offered
treatment with a different therapist than the one they saw in hospital. However, there was a
paradoxically higher repetition rate in the former group, but this seems to have been the result
of a failure of the randomization procedure to produce balanced groups in terms of risk
factors. The same investigators found that monthly therapy for a year did not produce any
difference in outcome compared with 3 months of weekly therapy, although the details of the
content of therapy were not provided. The most useful and relevant finding is that continuity
of care for suicide attempters increases compliance. Therefore, it is helpful if treatment for
many patients can be provided by clinicians who are working in general hospital services for
suicide attempters.

SECLUSION AND RESTRAINT

The hospitalized client may require confinement to a secure room to allow staff to observe
the client's behavior more readily. Objects that could prove to be dangerous to the client are
removed by searching the client's clothing, carry-in items, and body in a dignified and
professional manner. The body search includes checking any part of the body in which
harmful objects might be stored, such as body orifices and the hair.

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Street clothes are removed, and the client is placed in a seclusion gown. Clothing and bed
linens are removed from the room because these items have been used to attempt suicide by
hanging oneself.
The use of restraints, full or belt, is considered to be a last resort to immobilize agitated, self-
destructive clients. The door to the seclusion room is locked whenever the client is left alone,
and frequent, periodic checks are made according to established protocol.
MEDICATION MANAGEMENT

The use of psychotropic medication to manage behavior is, unfortunately, sometimes referred
to as chemical restraint. Individuals at risk for suicide, self-abusive behavior, or extreme
agitation may require medications parenterally to facilitate rapid absorption of medication,
stabilize mood and behavior, and prevent noncompliance (such as refusal to take oral
medication or the hoarding of it). Monitor the client's response to medication, including the
presence of any adverse effects .
CLIENT AND FAMILY EDUCATION
Commonly, health care providers tend to believe that suicidal clients or their family members
know all about the factors that place an individual at risk for suicidal behavior, especially if
the client has a history of previous psychiatric treatment. However, the client or family
member may be too polite, withdrawn, or embarrassed to initiate a conversation with the
psychiatric“mental health nurse or other health care providers. Although no immediate cure
exists, educating the client and family members about intervention and prevention strategies
can provide great relief

PHARMACOLOGICAL TREATMENTS

Antidepressants: serotonin reuptake inhibitor (SSRI) fluoxetine seemed to decrease self-

reported aggression in a short-term trial. Clearly this is an area where much further work is
required, although variable compliance with long-term medication may be a limiting factor.

Neuroleptics: trial in which the depot neuroleptic flupenthixol was administered monthly in
a dose of 20 mg for 6 months to repeaters of self-harm and compared with placebo in similar
patients appeared to show that the active drug was effective in reducing the recurrence of
self-harm.

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in patients who repeat self-harm frequently and are willing to receive a depot this approach
might be worth trying. It might also be worth using one of the atypical oral neuroleptics in
patients who are likely to comply with oral treatment.

Postvention: is a therapeutic program for bereaved survivors of a suicide. It allows family

members or other survivors to vent their feelings. Emphasis needs to be placed on one
unusual dynamic associated with suicide; that is, often the nonfamily members, such as co-
workers or significant others, may be more closely involved in the death than the spouse,
children, siblings, or parents of the victim. For this reason, it is extremely important for these
individuals to be recognized as survivors with legitimate needs of their own. In most cases,
the nonfamily survivors should be included in the network of the family (Staudacher, 1987).
Postvention involves three phases.
First phase, survivors are contacted immediately (within 24 hours) to assist them in coping
with their feelings of shock and grief.
Second phase, survivors are given the opportunity to develop new coping methods to help
prevent the development of maladaptive or destructive behaviours. The survivor learns to
cope with feelings of lowered self-esteem, depression, and the fear of developing a close
interpersonal relationship.
The third phase focuses on helping the survivor view the grief experience as a growth-
promoting experience. This last phase ends on the first anniversary of the suicide.
Children who are survivors require special attention because they are quite vulnerable to the
death of a parent, relative, peer, or close family friend. They may feel that they caused the
death by wishing Daddy dead or telling the person that I hate her. As a result of such feelings,
children may be unable to work through the grieving process, become preoccupied with the
subject of suicide, develop self-destructive behaviour, exhibit signs of depression, or have
difficulty working through the developmental tasks of childhood. The following are helpful
as preventive and postventive measures with children who are survivors:

 Allow to express feelings.

 Assist the child in developing a meaningful relationship with others.
 Encourage the development of positive coping skills.
 Teach the child assertiveness.
 Allow the child to develop ideas and values.

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  Expose the child to principles on human behaviour during the preventive or
postventive process.

MANAGEMENT IN CLINICAL PRACTICE

THE ASSESSMENT OF ATTEMPTED-SUICIDE PATIENTS

Factors to be covered

1. Life events preceded the attempt

2. Motives for the act
3. Problems faced by the patient
4. Psychiatric disorder
5. Personality traits and disorder
6. Alcohol and drug misuse
7. Family and personal history
8. Current circumstances
9. Social(extent of social relationship)
10. Domestic(living alone with others)
11. Occupation(whether employed)
12. Psychiatric history including previous attempts
ASSESSMENTS
Risk of further attempt
Risk of suicide
Coping resources and supports
What treatment is appropriate for patients needs
Motivation of patient to engage in treatment

FACTORS THAT SUGGEST HIGH SUICIDAL INTENT

 Act carried out in isolation

 Act timed so that intervention unlikely
 Precaution taken to avoid discovery
 Preparations made in anticipation of death(making will, organising
insurance)
 Communicating intent to others beforehand
 Extensive premeditation
 Leaving a note
 Not alerting potential helpers after the act
 Subsequent admission of suicidal intent

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 STRATEGIES FOR PREVENTION OF SUICIDE AND ATTEMPTED SUICIDE

1.population strategies:
Reducing availability of means of suicide
Educating of primary care nurses
Influencing media portrayal of suicide
Education of the public about mental illness and treatment
Educational approaches in schools
Befriending agencies and telephone hiplines
Addressing the economic factors associated with suicidal behaviour
2.High risk strategies:
Patients with psychiatric disorders
The elderly
Suicide attempters
High risk occupational groups
Prisoners
HIGH-RISK OCCUPATIONAL GROUPS
include farmers, veterinary surgeons, dental practitioners, medical practitioners,
pharmacists, and female nurses. It is interesting to note that all these groups have relatively
easy access to dangerous methods for suicide. Prevention of suicide in such occupational
groups is an important consideration, although each group makes a relatively small
contribution to the overall national suicide rate.

PRISONERS

There are relatively high suicide rates in prisoners, especially young males held on remand.(66)
While one aspect of prevention is through ensuring that prisons and police cells are safe in
terms of absence of structures from which inmates can hang themselves, there are a range of
other potentially useful and humane strategies. These include careful assessments of new
inmates using risk-assessment procedures, training of staff with regard to both assessment
skills and attitudes towards mental health problems and suicide prevention, in-reach
programmes by befriending organizations such as the Samaritans, and ready access to
psychiatric and psychological services. Clinicians involved in local suicide prevention
programmes should include prisons in their considerations.

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 NURSING MANAGEMENT

Terminology used to describe the range of suicidal thoughts and behavior,

(SUICIDE LEXICON)

 Suicidal ideation, or vague, fleeting thoughts about wanting to die

 Suicidal intent, or thoughts about a concrete plan to commit suicide
 Suicidal threat, or the expression of a person's desire to end his or her life
 Suicidal gesture, or intentional self-destructive behaviour that is clearly not life-
threatening but does resemble an attempted suicide
 Suicidal attempt, or self-destructive behaviour by which an individual responds to
ambivalent feelings about living (Badger, 1995)

SEVERETY INDEX FOR SUICIDAL RISK

1.No suicidal ideation, no risk of suicide

2.Mild thoughts of suicide: fleeting thoughts of suicide. Patient tells that he is not
going to suicide attempt. patient has support systems in her life and is able to identify a
purpose in life.eg:look after the children

3.Moderate thoughts of suicide: thinks about suicide as an option for solving

problems. Describes the feeling of wanting to go to sleep and never wake up. No explicit plan
to die. He states that he does not want to die. he has support people in his life, but the person
does not utilise them because he feels that he is a burden to others, religious belief are a
deterrent to suicidal threat.

4.Advanced thoughts of a suicide: patient makes a suicidal gesture, not necessarily

lethal.(a small overdose, cutting wrist).or has intrusive thoughts of suicide, and tells the nurse
that he is suicidal. patient is able to write his own contract for safety. patient seems more
interested in dying than continue to live. does not use support systems, starts to give things
away,doesnot buy needed items, and checks insurance policies. Patient rationalises religious
beliefs.

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5.Severe thoughts of suicide: patient wants to die and cannot identify any other
solution but suicide. Patient cuts off communication with others and isolates himself from
others. demonstrate an increase in energy after deciding on the details of suicide, including
the means of death and place and time death will occur. The patient may not disclose the plan
to nurse because she may intervene and prevent suicide attempt. Patient may not disclose any
commanding auditory hallucinations because voices are demanding not to disclose the
suicidal ideas. patient has begun to question relationship with god,if any and may state that
he is not worthy in gods eyes. the patient experiences intrusive thoughts of death and suicide
throughout most of his thought process.

LETHALITY ASSESSMENT:
When a client admits to having a “death wish” or suicidal 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 example, if the person plans to shoot
himself, does he have access to a gunand 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; a plan to take a 2-week supply of a tricyclic antidepressant is.)
• Has the client made preparations for death such as giving 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 important 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 underlying 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 coping skills that do not involve self-harm. Other
outcomes may relate to ADLs, sleep and nourishment needs, and problems specific to the
crisis such as stabilization of psychiatric illness/symptoms. commit suicide such as sharp
objects, shoelaces, belts, lighters, matches, pencils, pens, and even clothing with drawstrings.
Institutional policies for suicide precautions again vary, but usually staff members
observe clients every 10 minutes if lethality is low. For clients with high potential lethality,

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 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 may need to explain the purpose of such
supervision usually more than once.
SUICIDAL IDEATION:CLIENT STATEMENTS AND NURSE RESPONSES
CLIENT STATEMENT NURSE RESPONSES
“I just want to go to sleep and not think “Specifically just how are you planning to sleep and
anymore.” not think anymore?”
“By ‘sleep,’ do you mean ‘die’?”
“What is it you do not want to think of anymore?”
“I want it to be all over.” “I wonder if you are thinking of suicide.”
“What is it you specifically want to be over?”
“It will just be the end of the story.” “Are you planning to end your life?”
“How do you plan to end your story?”
“You have been a good friend.” “You sound as if you are saying good-bye. Are you?”
“Are you planning to commit suicide?”
“Remember me.” “What is it you really want me to remember about
you?”
“Hereis my chess set that you have always “What is going on that you are giving away things to
admired.” remember you by?”

“If there is ever any need for anyone to “I appreciate your trust. However, I think there is an
know this, my will and insurance papers important message you are giving me. Are you
are in the top drawer of my dresser.” thinking of ending your life?”

“I can’t stand the pain anymore “How do you plan to end the pain?”

“Tell me about the pain.”

“Sounds like you are planning to harm yourself.”

“Everyone will feel bad soon.” Who is the person you want to feel bad by killing
“I just can’t bear it anymore.” yourself?”
“What is it you cannot bear?”
“How do you see an end to this?” “

“Everyone would be better off without me.” “Who is one person you believe would be better off
without you?”

“How do you plan to eliminate yourself, if you think

everyone would be better off without you?”

“What is one way you perceive others would be

better off without you?”
Nonverbal change in behaviour from agitated “You seem different today. What is this about?”
to calm, anxious to relaxed, depressed to

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smiling, hostile to benign, from being “I sense you have reached a decision. Share it with
without direction to appearing to be goal-
me.”
directed
INITIATING A NO-SUICIDE CONTRACT
The nurse can implement a no-suicide contract at home as well as in the inpatient treatment
setting. 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). The urge to commit suicide
may return suddenly, so someone must always be available for support. A list of support
people who agree to be readily available should be generated. Most suicidal people adhere to
no-suicide contracts because they appeal to the will to live. These contracts are not, however, a
guarantee of safety. Clients make contracts with input from nurses or other health care
professionals. Contracts also can specify when clients will be re-evaluated. The literature
is divided on the effectiveness of such contracts or agreements (Potter & Dawson, 2001;
Miller, Jacobs & Gutheil, 1998). At no time should a nurse assume that a client is safe just
because a contract is in place.
CREATING A SUPPORT SYSTEM LIST
Suicidal clients often lack social support systems such as relatives, friends, or religious,
occupational, and community support groups. This lack may result from social withdrawal,
behavior associated with a psychiatric or medical disorder, or movement of the person
to a new area because of school, work, 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 suicide—as in the
case of someone who commits suicide to avoid lengthy legal battles or to save the family the

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financial 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 person did not seek their help or trust them, ashamed
that their loved one ended his or her life with a socially unacceptable act, and sad about
being rejected. Suicide is newsworthy, 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 feel 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 incompetent, 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
nonjudgmental tone of voice and monitors his or her body language 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 suicide can be devastating to the staff
members who treated him or her especially if they have gotten to know the person and his or
her family well over time. Even with therapy, 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 decisions related to the actions of Dr. Jack Kevorkian, a physician 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.

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COMMUNITY-BASED CARENurses in any area of practice in the community frequently
are the first health care professionals to recognize behaviours consistent with mood disorders.
In some cases, a family member may mention distress about a client’s withdrawal from
activities; difficulty thinking, eating, and sleeping; complaints of being tired all the time;
sadness; and agitation (all symptoms of depression), or of cycles of euphoria, spending
binges, loss of inhibitions, changes in sleep and eating patterns, and loud clothing styles and
colors (all symptoms of the manic phase of bipolar disorder).Documenting and reporting
these behaviours can help these people to receive treatment. Estimates are that nearly 40% of
people who have been diagnosed with a mood disorder do not receive treatment (Akiskal,
2000). Contributing factors may include the stigma still associated with mental disorders, the
lack of understanding about the disruption to life that mood disorders can cause, confusion
about treatment choices, or a more compelling medical diagnosis; these combine with the
reality of limited time that health care professionals devote to any one client.
People with depression can be treated successfully in the community by psychiatrists,
psychiatric advanced practice nurses, and primary care physicians. People with bipolar
disorder, however, should be referred to a psychiatrist or psychiatric advanced practice nurse
for treatment. The physician or nurse who treats a person with bipolar disorder must
understand the drug treatment, dosages, desired effects, therapeutic levels, and potential side
effects so that he or she can answer questions and promote compliance with treatment
(Bouchard, 1999).
MENTAL HEALTH PROMOTION
Several studies have been conducted to determine how to prevent mood disorders and
suicide. Adams (2000) describes a program called Insight that uses an educational approach
designed to address the unique stressors that contribute to the increased incidence of
depressive illness in women. Insight has succeeded in increasing self-esteem and reducing
loneliness and hopelessness, which in turn decrease the likelihood of depression. Researchers
in England have found that individualized postpartum care with home visits by nurses
significantly lowered the incidence of postpartum depression (Boyles, 2002).
Borowsky, Ireland and Resnick (2001) studied more than 13,000 adolescents in an
attempt to identify factors that predicted future suicide attempts. They suggest that promotion
of protective factors (those factors associated with a reduction in suicide risk) would improve
the mental health of adolescents. The protective factors include close parent child
relationships, academic achievement, family life stability, and connectedness with peers and

29
others outside the family. Likewise, screening for early detection of risk factors, such as
family strife, parental alcoholism or mental illness, history of fighting, and
access to weapons in the home, can lead to referral and early intervention.
SELF-AWARENESS ISSUES
Nurses working with clients who are depressed often empathize with them and begin also
to feel sad or agitated. They may unconsciously start to avoid contact with these clients to
escape such feelings. The nurse must monitor his or her feelings and reactions closely when
dealing with clients with depression to make sure he or she fulfills the responsibility to
establish a therapeutic nurse–client relationship.
People with depression are usually negative, pessimistic, and unable to generate new
ideas easily. They feel hopeless and incompetent. The nurse easily can become consumed
with suggesting ways to fix the problems
.Most clients find some reason why the nurse’s solutions will not work: “I have tried
that,” “It would never work,” “I don’t have the time to do that,” or “You just don’t
understand.” Rejection of suggestions can make the nurse feel incompetent and question his
or her professional skill.
Unless a client is suicidal or is experiencing a crisis, the nurse does not try to solve
the client’s problems. Instead, the nurse uses therapeutic techniques to encourage clients to
generate their own solutions. Studies have shown that clients tend to act on plans or solutions
they generate rather than those that others offer (Schultz & Videbeck, 2002). Finding and
acting on their own solutions gives clients renewed competence and self-worth.
Working with clients who are manic can be exhausting. They are so hyperactive that
the nurse may feel spent or tired after caring for them. The nurse may feel frustrated because
these clients engage in the same behaviours repeatedly, such as intrusiveness with others,
undressing, singing, rhyming, and dancing. It takes hard work to remain patient and calm
with the manic client, but it is essential for the nurse to provide limits and redirection in a
calm manner until the client can control his or her own behaviour independently.

NANDA Nursing Diagnoses: Suicide

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 1. Risk for Injury related to a recent suicide attempt and the verbalization, Next time I
won't fail.
2. Risk for Suicide related to stated desire to end it all and recent purchase of a
handgun
3. Risk for Violence: Self-directed related to multiple losses secondary to retirement
4. Hopelessness related to diagnosis of terminal cancer as evidenced by the statement,
I'd rather be dead.
5. Impaired Social Interaction related to alienation from others secondary to depressive
behaviour
6. Ineffective Coping related to inadequate psychological resources as evidenced by
impulsive, suicidal behaviour
7. Chronic Low Self-Esteem related to feelings of failure secondary to marital discord.

SUICIDE PREVENTION

primary prevention:identify and eliminate factors that cause or contribute to the

development of an illness or disorder that could lead to suicide.

Secondary prevention :attempts to identify and treat physical or emotional disorders in

the early stages before they become disturbing to an individual.

Tertiary prevention:Used to reduce residual disability after an illness. For example, a

residential treatment center, halfway house, or rehabilitation center may be used to treat a
recovering alcoholic client who previously attempted suicide and is recovering from severe
depression, but needs the supervision and support of others to avoid a relapse.

SUICIDE PRECAUTIONS

 Clients at risk for suicide need either constant (one-to-one visual supervision) or
close (visual check every 15 minutes) observation in a safe, secure environment.

 Constant or close monitoring of the client's behavior is important because a suicidal client's
mental state often fluctuates.

 suicidal intention rating scale (SIRS) that provides a guide for managing clients
considered to be self-destructive.

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 SUICIDE INTENTION RATING SCALE (SIRS) FOR HOSPITALIZED CLIENTS
RATING SYMPTOMS INTERVENTIONS
Zero No evidence of past or present suicidal Implement interventions per nursing plan of
ideation care
One Suicidal ideation but no attempt or Observe and evaluate for evidence of
plus threat development of a plan Provide routine care
Two plus Actively thinking about suicide or Protect from self-destructive impulses of
history previous attempt
Remove potentially dangerous personal items
from room
Three Suicidal threat verbalized Search client and room; remove potentially
plus dangerous items such as razor, mirror, or nail
file.
Provide protective care per protocol
Periodically check, at least every 30 minutes
Allow limited visits by family members
Confine to unit unless accompanied by a
member of staff
Four Actively attempted suicide or Implement protective care per protocol for a
plus hospitalized to prevent self-destructive high-risk suicidal client
impulses

SUMMARY

So far we have discussed different aspects of suicide,its prevention, and management

CONCLUSION

These are the aspects coming under suicide and its nursing management.

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