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If you are thinking of hurting yourself, or if you are concerned that someone else may be suicidal, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).
John is a 52-year-old white male employed in a large steel mill. He has worked for the company for close to 20 years. John recently separated from his wife and is now living by himself in an apartment close to the foundry. He has no friends or family.

Over the past three weeks, John has visited the employee health clinic with ongoing complaints of fatigue and gastric distress. He told Carmelita, the nurse, that he was worried that he had some type of lingering flu.

On his last visit, John was particularly subdued. He avoided eye contact and spoke in a quiet monotone. He told Carmelita that he knew she liked animals and asked her to take his pet dog because he did not feel able to care for it since his separation.

Carmelita asked John how he was spending his time-was that what was interfering with his ability to care for his dog? John said that he watched a lot of TV and thought a lot. He said that he felt too "shaky" to go places other than work and that he didn't know anyone he could visit anyway. When Carmelita asked if John had thought about harming himself, he looked startled at first, and then admitted that he had; he just felt like he could not continue without his wife. Carmelita realized that John was in crisis. She asked the clinic secretary to sit with him while she discussed the situation with the physician and then made arrangements for an immediate assessment by the local mental health counselor.

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The Role of Nurses in Preventing Suicide

Since physical illness itself is a risk factor for suicide (Maris, Berman, & Silverman, 2000), nurses and other health care providers are highly likely to see people who may be at risk of self-harm.

Because nurses spend so much time with patients, a trusting relationship can develop, which may encourage patients to reveal their feelings to nurses even when they are reluctant to share this information with their family or their physicians. As a nurse, you are in a unique position to do several things:
  • Observe changes in the mood and behavior of your patients
  • Help patients recognize that the underlying source of their physical problems may be depression or another mental health concern
  • Let patients know that there are alternatives to feeling depressed and that you can help them find services that can relieve their pain
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Recognizing the Warning Signs

People who are considering harming themselves may try to reach out to you-sometimes directly, sometimes indirectly. Rarely will patients immediately volunteer the information that they are thinking of harming themselves. Instead, they often describe their concerns in terms of physical symptoms.

You should be especially alert for imminent warning signs of suicide, for example:
  • Talking about suicide or death
  • Giving direct verbal cues, such as "I wish I were dead" and "I'm going to end it all"
  • Giving less direct verbal cues, such as "What's the point of living?", "Soon you won't have to worry about me," and "Who cares if I'm dead, anyway?"
  • Isolating him- or herself from friends and family
  • Expressing the belief that life is meaningless or hopeless
  • Giving away cherished possessions
  • Exhibiting a sudden and unexplained improvement in mood after being depressed or withdrawn
  • Neglecting his or her appearance and hygiene
These signs are especially critical if the patient has a history or current diagnosis of a psychiatric disorder, such as depression, alcohol or drug abuse, bipolar disorder, or schizophrenia.

Age is also a factor. Elderly patients are at an increased risk of dying by suicide. Research indicates that many older adults who visited a primary care physician within a month of dying by suicide had an undiagnosed mental illness associated with suicide, such as depression (National Institute of Mental Health, 2003), or had a common medical condition associated with an increased risk of suicide, such as congestive heart failure, chronic obstructive lung disease, urinary incontinence, anxiety disorders, and moderate or severe pain (Juurlink, Herrmann, Szalai, Kopp, & Redelmeier, 2004). Nurses should pay careful attention to elderly patients who are physically ill and who exhibit any of the following warning signs of suicide (Holkup, 2002):
  • Stockpiling medications
  • Buying a gun
  • Giving away money or cherished personal possessions
  • Taking a sudden interest, or losing their interest, in religion
  • Failing to care for themselves in terms of the routine activities of daily living
  • Withdrawing from relationships
  • Experiencing a failure to thrive, even after appropriate medical treatment
  • Scheduling a medical appointment for vague symptoms
Adolescents are also at an increased risk of dying by suicide. School nurses, or other nurses working with adolescents, should be alert for these warning signs:
  • Volatile mood swings or sudden changes in their personality
  • Indications that they are in unhealthy, destructive, or abusive relationships, such as unexplained bruises, a swollen face, or other injuries
  • A sudden deterioration in their personal appearance
  • Self-mutilation
  • A fixation with death or violence
  • Eating disorders, especially combined with dramatic shifts in weight (other than those associated with a diet under medical supervision)
  • Gender identity issues
  • Depression
Recognizing the warning signs is the first step in preventing suicide.

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Responding to the Warning Signs

Your response to any warning signs should be targeted at keeping the patient safe, providing empathy and support, and ensuring that the patient receives the mental health and/or social services necessary to reduce his or her risk.

Science has not yet provided us with fail-safe methods of assessing the risk of suicide. However, if there's a chance that your patient may be at risk, you can ask the sometimes difficult questions that will provide you with more evidence about the patient's state of mind and intentions, for example:
  • Do you ever wish you could go to sleep and never wake up?
  • Sometimes when people feel sad, they have thoughts of harming or killing themselves. Have you had such thoughts?
  • Are you thinking about killing yourself?
You should act immediately if you have any reason to believe that the patient is in imminent danger or poses a grave danger to him- or herself. Immediate action should also be taken when warning signs are combined with any of the following risk factors:
  • Past incidents of suicidal behavior or self-harm
  • A family history of suicide
  • A history of psychiatric disorders or the abuse of alcohol or other drugs
  • The patient's admission that he or she has considered suicide
  • The patient's expressed wish to die
  • Any evidence of a current psychiatric disorder
In an inpatient or other clinical setting, mental health resources may be available on-site. In other cases, you may have to call a mental health clinic or emergency hotline to obtain assistance. Every health care facility, including private physician's offices, hospitals, and school health clinics, should have a procedure for responding to persons at risk of suicide and should know whom to call for assistance.

If you are alone with a client, as might be the case in a home care visit, a call to the local mental health crisis line, emergency department, or National Suicide Prevention Lifeline at 1-800-273-TALK (800-273-8255) can be helpful. Carry these numbers and have them readily available, especially if you are a home care or private duty nurse. You should also do the following:
  • Tell the patient why the call is important and have the patient talk with the crisis worker.
  • Stay with the patient until assistance arrives.
  • Call 911 if it looks like the patient is in an immediate crisis requiring hospitalization or medical intervention and the patient has no safe way to get to a hospital or emergency room or refuses to go voluntarily. Patients should never be permitted to drive themselves to the hospital.
  • Involve family members and significant others (when possible) in supporting any decision for hospitalization.
  • Err on the side of caution.
If you have any suspicions that a patient is seriously considering harming him- or herself, let your patient know that you care, that he or she is not alone and that you are there to help. You may have to work with the patient's family to ensure that he or she will be adequately supported until a mental health professional can provide an assessment. In some cases, you may have to accompany your patient to the emergency room at an area hospital or crisis center. If the person is uncooperative, combative, or otherwise unwilling to seek help, and if you sense that the person is in acute danger, call 911 or 1-800-273-TALK (800-273-8255). Tell the dispatcher that you are concerned that the person with you "is a danger to [him- or herself]" or "cannot take care of [him- or herself]." These key phrases will alert the dispatcher to locate immediate care for this person with the help of police. Do not hesitate to make such a call if you suspect that someone may be a danger to him- or herself. It could save that person's life.

As a nurse, you can play a powerful role in preventing suicides and detecting mental health crises among your patients-but you should not have to handle these emergencies alone. If your place of work does not have a crisis intervention plan or does not provide training for crisis intervention, advocate for the implementation of a clear, concise crisis intervention plan. Ensuring that all members of a health care team know what to do in a crisis situation helps to empower nurses and keep clients safe from self-harm.

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References

Holkup, P. (2002). Evidence-based protocol-Elderly suicide: Secondary prevention. Iowa City, IA: University of Iowa Gerontological Nursing Interventions Research Center. Retrieved March 23, 2005, from http://www.guideline.gov/summary/summary.aspx?
doc_id=3308&nbr=2534&string=Elderly+AND+suicide

Juurlink, D. N., Herrmann, N., Szalai, J. P., Kopp, A., & Redelmeier, D. A. (2004). Medical illness and the risk of suicide in the elderly. Archives of Internal Medicine, 164(11), 1179-1184.

Maris, R. W., Berman, A., & Silverman, M. M. (Eds.). (2000). Comprehensive textbook of suicidology. New York: Guilford Press.

National Institute of Mental Health. (2003). Older adults: Depression and suicide facts. Rockville, MD: National Institutes of Health. (NIH Publication No. 03-4593, revised May 2003.) Retrieved March 23, 2005, from http://www.nimh.nih.gov/publicat/elderlydepsuicide.cfm

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Resources

Resources for Nurses

Holkup, P. (2002). Evidence-based protocol-Elderly suicide: Secondary prevention. Iowa City, IA: University of Iowa Gerontological Nursing Interventions Research Center. Retrieved March 23, 2005, from http://www.guideline.gov/summary/summary.aspx?
doc_id=3308&nbr=2534&string=Elderly+AND+suicide

Office of Quality and Performance, Veterans Health Administration. (2000). Major Depressive Disorder (MOD) clinical practice guidelines: Module A. Primary care. Retrieved March 23, 2005, from http://www.oqp.med.va.gov/cpg/MDD/MDD_Base.htm
These guidelines were developed for clinicians by the Department of Veterans Affairs and the Department of Defense. They draw heavily from the American Psychiatric Association and Agency for Health Care Policy and Research Clinical Practice Guideline No. 5: Depression in Primary Care. The guidelines include information on assessment and treatment of potentially suicidal patients, patient handouts on depression, and guidelines for treatment of depression. The guidelines, supporting documents, and tools are available online at the URL listed above.

Quinnett, P. (2000). Counseling suicidal people: A therapy of hope. Spokane, WA: QPR Institute. Retrieved March 23, 2005, from http://www.qprinstitute.com/
This book was written for therapists, mental health workers, physicians, nurses, and others who are not clinical suicide counselors, but who might find themselves counseling people at risk of suicide. It provides tools and strategies for risk assessment and intervention.

Registered Nurses Association of Ontario. (2002). Crisis intervention. Toronto: Author. Retrieved March 23, 2005, from http://www.guideline.gov/summary/summary.aspx?doc_id=3718

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General Resources on Suicide and Suicide Prevention

Suicide Prevention Resource Center (http://www.sprc.org/). The Suicide Prevention Resource Center (SPRC) provides prevention support, training, and materials to strengthen suicide prevention efforts. Among the resources found on its website is the SPRC Library Catalog (http://library.sprc.org/), a searchable database containing a wealth of information on suicide and suicide prevention, including publications, peer-reviewed research studies, curricula, and web-based resources. Many of these items are available online.

American Association of Suicidology (http://www.suicidology.org/). The American Association of Suicidology is a nonprofit organization dedicated to the understanding and prevention of suicide. It promotes research, public awareness programs, public education, and training for professionals and volunteers and serves as a national clearinghouse for information on suicide.

American Foundation for Suicide Prevention (http://www.afsp.org). The American Foundation for Suicide Prevention (AFSP) is dedicated to advancing our knowledge of suicide and our ability to prevent it. AFSP's activities include supporting research projects; providing information and education about depression and suicide; promoting professional education for the recognition and treatment of depressed and suicidal individuals; publicizing the magnitude of the problems of depression and suicide and the need for research, prevention, and treatment; and supporting programs for suicide survivor treatment, research, and education.

National Center for Injury Prevention and Control (http://www.cdc.gov/ncipc/). The National Center for Injury Prevention and Control (NCIPC), located at the Centers for Disease Control and Prevention, is a valuable source of information and statistics about suicide, suicide risk, and suicide prevention. To locate information on suicide and suicide prevention, scroll down the left-hand navigation bar on the NCIPC website and click on "Suicide" under the "Violence" heading.

National Suicide Prevention Lifeline (http://www.suicidepreventionlifeline.org/). The National Suicide Prevention Lifeline provides immediate assistance to individuals in suicidal crisis by connecting them to the nearest available suicide prevention and mental health service provider through a toll-free telephone number: 1-800-273-TALK (800-273-8255). Technical assistance, training, and other resources are available to the crisis centers and mental health service providers that participate in the network of services linked to the National Suicide Prevention Lifeline.

Suicide Prevention Action Network USA (http://www.spanusa.org). Suicide Prevention Action Network USA (SPAN USA) is the nation's only suicide prevention organization dedicated to leveraging grassroots support among suicide survivors (those who have lost a loved one to suicide) and others to advance public policies that help prevent suicide.

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This effort has been funded in part with Federal funds from the National Institute of Mental Health, National Institutes of Health, under Contract No. N44MH22044.

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