Suicide Intervention and Prevention

CONTACT HOURS: 6

Copyright © 2023 Wild Iris Medical Education, Inc. All Rights Reserved.

BY: 

Judith Swan, MSN, BSN, ADN

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this continuing education course, you will demonstrate an understanding of the complex nature of suicide, how to assess and determine risk for suicide, and appropriate treatment and management for at-risk individuals. Specific learning objectives to address potential knowledge gaps include:

  • Review the language and common beliefs regarding suicide.
  • Discuss the epidemiology and etiology of suicidal behavior.
  • Summarize the risk and protective factors for suicide.
  • Describe the process of assessment and determination of level of risk for suicide.
  • Outline the management and treatment modalities that may be used for persons at risk for suicide.
  • Identify public health approaches for suicide prevention.
  • Discuss ethical dilemmas that arise in relation to suicide prevention and intervention efforts.

TABLE OF CONTENTS

  • Understanding Suicide
  • Epidemiology
  • Suicide Etiology and Risk Factors
  • Suicide Screening and Assessment
  • Models of Care for Patients at Risk for Suicide
  • Treatment Modalities for Patients at Risk for Suicide
  • Suicide Prevention Strategies
  • Ethical Issues and Suicide
  • Conclusion
  • Resources
  • References

UNDERSTANDING SUICIDE


Suicide, the taking of one’s own life, has been the subject of deliberation throughout history, and making a judgment about whether life is or is not worth living is a question that underlies philosophical thought. Suicide is always controversial, raising questions of rationality and morality. Depending on one’s philosophical point of view, it is either acceptable at any time, acceptable under certain circumstances, or never acceptable.

The will to live arises from instinctual self-preservation, and it takes a great deal of willpower to overcome this natural instinct. Humans are motivated by the pursuit of pleasure and the avoidance of pain, and suicide is usually prompted by a desire to be rid of unbearable pain or distress, which can be ended by an impulsive act. Suicide is the culmination of many and varied interactions between biological, social, and psychological factors that operate at the levels of the individual, the community, and society.

Healthcare professionals play a critical role in the recognition, prevention, and treatment of suicidal behaviors, and the attitudes of these providers are paramount in how patients are treated. Historically, the stigma associated with suicide affects the attitudes of those who manage and treat these individuals.

Talk of suicide must always be taken seriously, recognizing that people with suicidal ideation are in physical and/or psychological pain and may have a treatable mental disorder. The vast majority of people who talk of suicide do not really want to die. They simply are in pain and want it to stop. Suicide is an attempt to solve this problem of intense pain when problem-solving skills are impaired in some manner, in particular by depression.

Many healthcare professionals express concern that they are ill prepared to deal effectively with a patient who has suicidal thoughts. By developing adequate knowledge and skills, these professionals can overcome feelings of inadequacy that may otherwise prevent them from effectively responding to the suicide clues a patient may be sending, thereby allowing them to carry out appropriate interventions. They can also develop a better understanding of this choice that ends all choices.

Changing the Language

The term committed suicide suggests that a person was involved in a criminal act. It implies that the person was a perpetrator and not a victim of a pathology that led to death. It ignores the fact that suicide is often the consequence of an unaddressed illness, such as depression, and it perpetuates a harmful stigma. It also implies that suicide is an act of free will, a choice one makes to live or die.

There is a great deal of evidence indicating that thought processes are gravely impaired at the time of death by the effects of trauma, mental health conditions, or substance use, and many have reported experiencing something akin to command hallucinations right before attempting to kill themselves. So, if a person cannot rationally choose due to impairment of the mind, the decision is not a choice.

Stigma surrounding mental illness, and suicidality in particular, has been documented as an immediate and profound barrier to help-seeking behavior. The following table provides recommendations for changing the language that surrounds the topic of suicide in order to remove the harmful stigma that can profoundly affect both the person with suicidal thoughts or behaviors and those closest to them.

CHANGING LANGUAGE ABOUT SUICIDE
Inappropriate Appropriate Why
(Canadian Psychiatric Association, 2022)
Commit/committed suicide
  • Died of or by suicide
  • Lose one’s life to suicide
 “Commit” implies suicide is a sin or a crime, reinforcing stigma.
  • Successful/completed attempt
  • Unsuccessful/failed attempt
  • Died by suicide
  • Survived a suicide attempt
  • Fatal/nonfatal suicidal behavior
  • Fatal/nonfatal suicide attempt
  • “Successful” or “completed” frames the result as a positive achievement.
  • “Unsuccessful” or “failed” implies a negative result.
  • <Name> is a suicide attempter
  • <Name> is suicidal
 <Name> has suicidal thoughts or behavior/is thinking of suicide/has experienced suicidal thoughts Avoids defining someone by their experience with suicide; a person is more than their suicidal thoughts.
Manipulative, suicidal gesture, cry for help Describe the behavior (e.g., nonsuicidal self-injury) Avoids dismissive labeling
LEXICON OF SUICIDAL BEHAVIOR

Aborted attempt

An act in which a person initiates a suicidal act but stops before sustaining any injury

Cluster suicides

A group of suicides or suicide attempts, or both, that occurs closer together in time and space than would normally be expected in a given community

Contagion

Suicide risk associated with the knowledge of another person’s suicidal behavior, either firsthand or through the media

Copicide, death-by-cop, suicide-by-cop, officer-assisted suicide

Acting in a threatening way so as to provoke a lethal response by a police officer

Copycat suicide

A suicide that may be at least partially caused by contagion

Euthanasia

From the Greek, meaning “good death”; the intentional causing of a death, usually in an incurably or terminally ill individual, to relieve pain or suffering; a mercy killing

Interrupted suicide attempt

When an individual is stopped by an outside force (person or circumstance) before making an attempt

Mass suicide

The deliberate ending of the lives of all or most of the members of an intact social group or aggregate by the members themselves, either directly through self-injurious behavior or indirectly by choosing a course of action that will likely be fatal

Murder-suicide

When a person kills another person(s) and then kills themself

Non-suicidal self-injury

Deliberate, direct destruction or alteration of body tissue without a conscious suicidal intent, such as cutting, burning, or bruising oneself

Obligatory suicide

A suicide completed because the victim felt a personal duty to perform the act to honor the family, a cause, or a nation (e.g., Japanese kamikaze pilots)

Preparatory suicidal behavior

Activities such as assembling pills, buying a gun, attaching a rope, or visiting a bridge in preparation for suicide, but without initiating suicide

Suicide

Death caused by self-directed injurious behavior with evidence, either implicit or explicit, of intent to die as a result of the behavior

Suicide attempt

Any non-fatal potentially injurious behavior with intent to end one’s life

Suicide attack

A violent terrorist act in which the attacker intends to kill others or cause destruction expecting to die in the process, such as suicide bombers

Suicide contagion

Exposure to suicide or suicidal behavior within one’s family, one’s peer group, or through media reports that can result in suicide and suicidal behaviors (copycat)

Suicidal ideation

Thinking about dying by suicide

Suicide pact

An agreement between two or more individuals to die by suicide at the same time and/or place

(APA, 2022)

Suicide Myths and Misunderstandings

Myths and misunderstandings abound concerning the subject of suicide. In order for a provider to be effective in intervening with a person who has suicidal thoughts, these myths and misunderstandings must be replaced with facts. Following are ten common myths and associated facts:

COMMON MYTHS ABOUT SUICIDE
Myth Fact
(Sharma, 2021; Samaritans, 2022)
People who talk about suicide are seeking attention, aren’t serious, and won’t go through with it. Attempted suicides are often not seen as genuine efforts to end one’s life but as a way to manipulate other people into paying attention to them. People who talk about suicide may be reaching out for help or support. They are looking for an escape and are unable to think of any other way than through death, and they do indeed, need attention. The majority of people who feel suicidal do not actually want to die; they just want the situation they’re in or the way they’re feeling to end.
Once a person has made a serious suicide attempt, that person is unlikely to make another. The opposite is often true. A prior suicide attempt is the single most important risk factor for suicide in the general population.
People who attempt or die by suicide are selfish, cowardly, or weak. Suicide is seldom about others. Indeed, it is selfish to make someone else’s suicide about you and demonstrates a lack of empathy and compassion for others. To overcome the instinct to live, one must be strong, not weak or cowardly.
All people with suicidal thoughts have access to help if they want it, but those who die by suicide do not reach out for help. The truth is, it is necessary to ask whether the individual was able to ask for help. Many seek support and help but do not find it. This is often due to negative stereotyping and the inability and unwillingness of people to talk about suicide. Financial barriers may include lack of access to help, especially for those in rural areas who might not be able to easily travel to another community to seek help. Additionally, prejudices and biases among healthcare professionals can make the healthcare system unfriendly.
Only people who are crazy or have a mental disorder consider suicide. One in five people have thought about suicide at some time in their life. Many people living with mental disorders are not affected by suicidal behavior, and not all people who die by suicide have a mental disorder. They may be upset, grief-stricken, depressed, or despairing, but extreme distress and emotional pain are not necessarily signs of mental illness.
Reaching out for help is the same as threatening suicide. People with suicidal thoughts are hurting, not threatening, and should be provided with the tools, support, and resources they need.
Suicide always occurs without any warning signs. There are almost always warning signs, such as saying things like “everyone would be better off if I wasn’t here anymore.”
Once people decide to die by suicide, there is nothing you can do to prevent it. Suicide is preventable. Most people with suicidal thoughts are ambivalent about living or dying. Most do not want death but simply want to stop hurting. Often, feeling actively suicidal is temporary. The impulse to “end it all,” however overpowering, does not last forever and can be overcome with help.
If you ask a person whether they are thinking about suicide or have chosen a method, it can be interpreted as encouragement or give them the idea. Evidence shows that asking someone if they’re having suicidal thoughts can be protective by giving them permission to talk about how they feel. Talking openly can give the person other options or time to rethink the decision.
When people with suicidal thoughts start to feel better, they are no longer suicidal. A person with suicidal thoughts sometimes begins to feel better because they have reached the decision to die by suicide and may have feelings of relief that their pain will soon be over.