Integration of a suicide risk assessment and intervention approach: the perspective of youth

The process of suicide risk assessment is often a challenge for mental health nurses, especially when working with an adolescent population. Adolescents who are struggling with particular problems, stressors and life events may exhibit challenging and self-harm behaviour as a means of communication or a way of coping. Current literature provides limited exploration of the effects of loss, separation and divorce, blended families, conflict and abuse on child and adolescent development and the increased vulnerability of at-risk youth. There is also limited research that provides clear and practical models for the assessment and management of youth suicidal ideation and behaviour. This paper will discuss the integration of a number of theories to establish a comprehensive assessment of risk. The research study described the perspective of youth and their families who had experienced this particular model; however, this paper will discuss only the youth perspective. In order for this model to be successful, it is important for mental health nurses to make a connection with the youth and begin to understand the self-harm behaviour in context of the adolescents' family, and their social and school experiences. It also requires recognition that adolescents with challenging and self-harm behaviour are hurting and troubled adolescents with hurtful and troublesome behaviour.     

The meaning of suicidal behaviour from the perspective of senior nursing undergraduate students

The meaning ascribed to suicidal behaviours may influence the quality of the care provided to people at risk of suicide. Such a phenomenon has yet to be properly investigated amongst nursing undergraduate students, the aim of this study being to gain an understanding of the meanings of suicidal behaviour for a particular group of nurses. The study, which utilized grounded theory, was conducted in Brazil in 2016–2017 with 30 undergraduate students. The findings indicated that suicidal behaviour, classified according to the individual beliefs and judgements of the participants, presented a significant barrier to the delivery of care and was complex and multifaceted care phenomenon. Participants were often reluctant to discuss the topic, seemingly wanting to distance themselves from the care of persons exhibiting suicidal behaviour, and to avoid professional engagements relating to suicide prevention. Significant work is required in raising both an awareness and knowledge of suicidal behaviour befitting the promotion of tolerance, emotional competency, resilience, and empathy amongst nursing students.     

'No suicide contracts' in community crisis situations: a conceptual analysis

'No suicide contracts' are commonly used in community crisis situations with suicidal people in New Zealand. These take the form of a 'guarantee of safety', along with a 'promise' to call specified persons if the suicidal ideation becomes unmanageable. This article describes the use of 'no suicide contracts' in community crisis situations, analyses the use of the tool within this context, and, in particular, argues that the theoretical base (transactional analysis) of the 'no suicide contract' is likely to be deleterious in the community crisis situation.     

Gender issues in youth suicidal behaviour

There are gender differences in youth suicidal behaviour that are evident in childhood and persist throughout adolescence and young adulthood. In Western countries, young females are twice as likely as males to report suicidal ideation and suicide attempt behaviour. However, despite the fact that females make more suicide attempts, males are three‐ to fourfold more likely to die by suicide than females. This paper reviews the epidemiological evidence for gender differences in suicidal ideation, attempted suicide and completed suicide among young people and explores possible reasons for the observed differences. These reasons include differences in methods, intent, ascertainment, the cultural acceptability of suicide, psychopathology (including substance abuse, mood disorder, externalizing behaviours and propensity to violence), and psychosocial differences between males and females. While it is often suggested that gender differences in youth suicidal behaviour may be explained solely or predominantly by method choice, careful examination suggests that the issues are much more complex. In fact, females may enjoy more protection from suicide than males in a number of areas. See Commentary, page 8.     

Nursing people who are suicidal on psychiatric wards in Taiwan: action/interaction strategies

Suicide is a major mental health problem in Taiwan. Estimations revealed that approximately 41% of people who committed suicide had a previous history of psychiatric inpatient care. To date, a suicide nursing care theory has not been developed. Consequently, the aim of this study was to formulate a suicide nursing care theory with the aim of enhancing and advancing the nursing care provided to people who attempt suicide or have suicidal thoughts. A qualitative approach using grounded theory was adopted. A total of 15 peoples who had either suicidal ideas or had attempted suicide and 15 psychiatric nurses were interviewed and observed. Data were analysed using open, axial and selective coding and the NUD*IST software program. A substantive theory of suicide nursing care was developed from the emergent findings. Four categories surfaced in the nursing care theory relating to the nurses' 'action/interaction strategies'. They were: the holistic assessment of people who are suicidal; providing protection; providing basic care; and providing advanced care. The findings from this study could be used to influence and advance nurse education and training, clinical practice, management and further research.     

Suicide in older people: Revisioning new approaches

This discussion paper identifies and examines several tensions inherent in traditional approaches to understanding older people's suicide. Predicted future increases in the absolute number of elderly suicides are subject to careful interpretation due to the underreporting of suicides in older age groups. Furthermore, a significant number of studies of older people's death by suicide examine risk factors or a combination of risk factors in retrospect only, while current approaches to suicide prevention in the elderly place disproportionate emphasis on the identification and treatment of depression. Taken together, such tensions give rise to a monologic view of research and practice, ultimately limiting our potential for understanding older people's experience of suicide and suicidal behaviour. New approaches are necessary if we are to move beyond the current narrow focus that prevails. Fresh thinking, which draws on older people's experience of attempting to die by suicide, might offer critical insight into socially‐constructed meanings attributed to suicide and suicidal behaviour by older people. Specifically, identification through research into the protective mechanisms that are relevant and available to older people who have been suicidal is urgently needed to effectively guide mental health nurses and health‐care professionals in therapeutic engagement and intervention.     

PROTECT: Relational safety based suicide prevention training frameworks

Preventing suicide is a global priority, and staff training is a core prevention strategy. However, frontline pressures make translating training into better care and better outcomes difficult. The aim of the paper was to highlight challenges in suicide risk assessment and management and introduce training frameworks to assist with mindful practice so professionals can strike a balance between risk and recovery. We combined the scientific literature with contemporary practice from two successful initiatives from Cambridgeshire, UK: 333 – a recovery‐oriented model of inpatient/community crisis care and PROMISE – a programme to reduce coercion in care by enhancing patient experience. The resulting PROTECT (PROactive deTECTion) frameworks operationalize ongoing practice of relational safety in these programmes. PROTECT is a combination of novel concepts and adaptations of well‐established therapeutic approaches. It has four training frameworks: AWARE for reflection on clinical decisions; DESPAIR for assessment; ASPIRE for management; and NOTES for documentation. PROTECT aims to improve self‐awareness of mental shortcuts and risk‐taking thresholds and increase rigour through time‐efficient cross‐checks. The training frameworks should support a relational approach to self‐harm/suicide risk detection, mitigation, and documentation, making care safer and person‐centred. The goal is to enthuse practitioners with recovery‐oriented practice that draws on the strengths of the person in distress and their natural circle of support. It will provide the confidence to engage in participatory approaches to seek out unique individualized solutions to the overwhelming psychological pain of suicidal distress. Future collaborative research with people with lived and carer experience is needed for fine‐tuning.     

Caring for patients with suicidal behaviour: an exploratory study

Patients presenting to the emergency department (ED) with suicidal behaviour is relatively common. While many of these patients may be referred on to specialist mental health services, many are either discharged with no psychiatric follow-up or leave before being seen. There is therefore an increasing onus on the staff of EDs to become involved in the assessment and initial management of this patient group. The aim of this study was to describe the experiences and challenges that nurses encounter when caring for patients who present to the ED with suicidal behaviour. Forty-two ED nurses completed a 15-item semi-structured questionnaire. Participants in this study identified risk assessment as part of their role but did not focus on psychosocial assessment or psychological management of this patient group. Feelings of sympathy and compassion were reported towards these patients; however, there was often a prior judgement of the perceived 'genuineness' of the presentation. Finally, challenges experienced included a lack of appropriate communication skills and insufficient resources within the ED to adequately care for this vulnerable patient group.     

Emergency Departments Treating Veterans for Suicide: Ensuring Quality Care for Veterans Outside of Department of Veterans Affairs Health Care Facilities

IntroductionVeterans die by suicide at higher rates than nonveterans. Given that the emergency department is often the first point of entry to healthcare following a suicide attempt, it would be beneficial for community providers to have knowledge of the characteristics, medical issues, and effective treatments most often associated with those having served in the military to ensure guideline concordant and quality suicide care. This study aimed to identify assessment and referral practices of emergency departments at rural community hospitals related to care for suicidal veterans and explore the feasibility and acceptability of identifying veterans in need of postdischarge aftercare.MethodsThis qualitative exploratory study involved content analysis of semistructured interviews. Ten emergency clinicians from 5 rural Arkansas counties with high suicide rates were interviewed about their experiences working with suicidal patients within the emergency department and perceptions of assessment, management, and referral practices.ResultsAlthough most of the emergency departments had a process for assessing for suicide risk, emergency clinicians did not always feel confident in their knowledge of assessing and caring for suicidal patients. Military history was not included in assessment, treatment, or aftercare planning, nor were brief interventions such as safety planning or lethal means safety education provided.DiscussionBest practices for suicide assessment and management of veterans exist; however, challenges specific to the emergency department regarding staff training and engaging the community to effectively link at-risk veterans to needed care hinder implementation. Veteran-inclusive assessment and intervention practices could enhance the quality of care provided in community emergency departments.     

Suicidal Behavior in Children Younger than Twelve: A Diagnostic Challenge for Emergency Department Personnel

Suicide is one of the leading causes of death in children younger than 12 years and is the fourth leading cause of death in 12 year olds. Increasing numbers of young children now present to the emergency department (ED) with mental health issues, and ED personnel must determine the most appropriate disposition options for these children, sometimes without the assistance of specialty mental health services. Much of the present body of literature describing suicidality fails to separate children from adolescents for analysis and discussion. This article reviews relevant literature pertaining to suicidal thoughts and behaviors in young children and discusses problems with available data, as well as epidemiology, risk factors, typical motivations, methods, assessment, and disposition for these patients. Suicidal children younger than 12 years are often clinically different from suicidal adolescents and adults and may require unique assessment and disposition strategies in the ED. A child who has ideation without a clear plan, or has made an attempt of low lethality, can sometimes be discharged home, provided that a supportive, responsible caregiver is willing to monitor the child and take him or her to outpatient mental health appointments. If the home environment is detrimental, or the child has used a method of high potential lethality, inpatient treatment is the most appropriate course of action. Mental health specialty services, when available, should be used to help determine the most appropriate disposition.     

The Self-Injury Questionnaire: evaluation of the psychometric properties in a clinical population

This paper presents the findings, from a clinical study, on the reliability and validity of a new measure for intentions in self-harm behaviour, the Self-Injury Questionnaire (SIQ). Eighty-three patients, who had presented to an emergency department with an episode of self-harm/suicidal behaviour, were given the SIQ as part of a battery of measures to evaluate differentiation in self-harm intentions based upon a history of childhood physical and/or sexual abuse. The internal consistency for the total scale was strong (alpha = 0.83). Construct validity demonstrated significant correlations with standardized measures. A principle component analysis of responses yielded a five-factor solution with 'affect regulation' items loading on the first factor. Cronbach's alphas were adequate for each subscale (alpha = 0.72-0.77). These preliminary findings indicate that the SIQ is a valid and reliable measure for research in an acute self-harming population.     

Self harm and attempted suicide in adults: 10 practical questions and answers for emergency department staff

Self harm is a complex behaviour that can be best thought of as a maladaptive response to acute and chronic stress, often but not exclusively linked with thoughts of dying. Patients presenting with self harm usually have current psychosocial difficulties, are likely to be suffering from mental health problems, and are at significant risk of further self harm and suicide. Recent guidelines suggest that all self harm attendees should receive an initial risk assessment at triage in the emergency department. A more detailed mental health assessment and an assessment of psychological and social needs should then be performed by trained staff, ideally specialist mental professionals experienced in this area. Risk of subsequent suicide is particularly high in those with high unresolved suicidal intent, depressive disorder, chronic alcohol and drug misuse, social isolation, and current physical illness. Patients with one or more of these risk factors should be offered enhanced care that may include inpatient or outpatient follow up care, a list of local support resources, and, where possible, self help material. Frequent repeaters, those with alcohol and substance use problems, those with physical or mental illness, and those who are isolated also require input from specialist mental health professionals. It is also recommended that adolescents and elderly people warrant a mandatory specialist assessment.     

Role of Primary Care in Suicide Prevention During the COVID-19 Pandemic

Primary care providers have an important role in suicide prevention, knowing that among people who die by suicide, 83% have visited a primary care provider in the prior year, and 50% have visited that provider within 30 days of their death, rather than a psychiatrist. The psychosocial impact of the coronavirus disease 2019 pandemic poses increased risk for suicide and other mental health disorders for months and years ahead. This article focuses on screening tools, identification of the potentially suicidal patient in the primary care setting, and a specific focus on suicide prevention during widespread, devastating events, such as a pandemic.     

The qualitative evaluation of a suicide prevention and management programme by general nurses

Aim. To evaluate the effect of an education programme on nurses’ knowledge, attitude and competence on suicide prevention and management for patients with suicide attempt or ideation and their family members; and to examine the strengths and weaknesses of the programme from the participants’ perspectives. Background. Providing care for patients with suicidal ideation or after suicidal acts in general hospitals often poses particular challenges for general nurses. Education programme may help these nurses acquire appropriate attitude, knowledge and competence in suicide prevention and intervention. Design. An 18‐hour education programme on suicide prevention and management was developed based on needs analysis and literature and was provided to the study group. Fifty‐four registered general nurses from the medical and surgical units of two general hospitals completed the education programme. Focus groups were used for process (n = 24) and outcome evaluation (n = 18). Results. Findings suggested that the education intervention had benefited the participants by improving their attitude, confidence and professional skills in responding to patients with suicidal intent. Conclusion. Barriers in the practice environment influenced nurses’ abilities to give optimal care to this group of patients and their family members. Relevance to clinical practice. This study identified the essential content in an education intervention for prevention and management of suicide by frontline nurses and helped to understand the difficulties that nurses’ encountered in practice.     

Factors associated with serious intent to die among suicide attempters in Hungary

As suicide attempts pose major risk for future suicide death, understanding the underlying factors of suicide attempts and suicidal behaviour is an important mental health imperative. The aim of this study was to examine suicide attempts with a special focus on the intention. A total of 2540 discharge summaries were collected between 2009 and 2011 in Miskolc, Hungary, and a content analysis was conducted. Data regarding the method, the reason for suicide attempts, the amount, the source, and the type of the medication taken were examined. Deliberate self‐poisoning was the most frequent method (73.8%) committed with more than 200 different types of drugs. 40.5% of the patients attempted suicide with an intent to die, whilst 35.6% of the patients wanted to escape from an unbearable situation. Older age groups, greater amount of taken pills, and affective disorders were associated with self‐reported serious intention to die. Our findings should be taken into consideration when monitoring drugs for older patients with depressive disorders.     

Chinese Version of the Positive and Negative Suicide Ideation: Instrument Development

Title. Chinese Version of the Positive and Negative Suicide Ideation: Instrument Development. Aim. This paper is a report of a study conducted to develop a Chinese version of the Positive and Negative Suicide Ideation Inventory and evaluate its psychometric properties. Background. Comprehensive assessment of suicidal behaviour in youths should incorporate both protective factors and risk factors. Methods. We recruited 2341 middle‐ and high‐school students for a longitudinal and prospective study, conducted between 2005 and 2007. To assess predictive validity, a convenience sample of 251 of the 2341 students was recruited 1 year later to follow‐up on suicide attempts during the preceding 2 weeks. To evaluate construct validity, a small convenience sample of 94 adolescent inpatients and outpatients was used as a comparison group. Instruments used included the Children’s Depression Inventory, the Self‐Control Schedule, and the Cognitive Triad for Children. Results. Cronbach’s α coefficients for the Chinese version of the positive and negative suicide ideation–negative suicide ideation and the Chinese version of the positive and negative suicide ideation–positive ideation were 0·94 and 0·86 respectively. Satisfactory test–retest reliability was evident. Convergent and divergent validities were demonstrated by statistically significant correlations among subscales and the other instruments used. Construct validity was evidenced by statistically significantly different scores on the subscales among the contrasted groups. Subscale scores in the first‐wave study statistically significantly predicted attempted suicide behaviour 1 year later, demonstrating evidence of predictive validity. Factor analysis showed a two‐factor structure. Conclusion. The Chinese Version of the Positive and Negative Suicide Ideation Inventory may be a reliable and valid instrument to measure the severity of suicidal ideation in adolescents, subject to further research to test the generalizability of the present findings.     

Is suicide assessment harmful to participants? Findings from a randomized controlled trial

There is considerable debate on whether suicide assessment carries an iatrogenic risk for participants/patients. A double‐blind randomized controlled trial (registration: R000022314) tested the emotional impact of suicide assessment on participants (n = 259) randomly assigned to experimental (n = 122) or control conditions (n = 137). The experimental condition included the Suicidal Affect‐Behavior‐Cognition Scale and intensive death‐related questions, the control condition a quality of life scale. Both included measures of depression, social support and loneliness. Affective states were assessed immediately before and after testing, and research biases minimized. Post‐test debriefing interviews collected qualitative reactions. Experimental participants ranged from nonsuicidal to highly suicidal. Between‐groups ANCOVAs and repeated measures ANOVAs showed no differences by study condition, and no pre‐post‐test affect changes for either condition or suicidal participants (P > 0.10), supporting the null hypothesis of no iatrogenic effects. However, depressive participants in both conditions showed significant decreases in positive affect (P < 0.05). Smallest real difference (SRD) scores approximated clinically meaningful differences and showed 20% of participants had a significant positive survey reaction, 24% a negative reaction, with the rest neutral. Linear regressions revealed depressive symptoms and perceived family support, but not suicidality or other factors, predicted negative affect changes, which was supported by qualitative findings. Social desirability bias was also found in qualitative survey responses. No evidence of iatrogenic effects of suicide assessment were found. Recommendations are made to counter possible negative assessment effects on depressive participants/patients, and nurses and other caregivers are encouraged to talk to patients about suicidal symptoms.     

Suicide and terminal illness

Suicide among persons with terminal illness has assumed increased importance, because new serologic tests have allowed for earlier diagnosis and better palliative care has rendered many terminal illnesses chronic, with the result that the dying phase is more protracted. In addition, there has been increased public interest in physician-assisted suicide and voluntary euthanasia. After an overview of the epidemiology of suicide among the terminally ill, the clinical assessment and management of suicidal terminally ill patients are discussed, with an emphasis on how assessment and management of these patients differ, from the strategies used to evaluate and treat other suicidal individuals. The methodological issues inherent in studying this area are also pointed out.     

精神分裂症患者的自杀倾向相关因素分析

目的探讨精神分裂症患者自杀倾向及危险因素,为制订相应的护理措施提供依据。方法抽取2010年8月至2012年11月在某医院住院的精神分裂症患者228例,根据患者是否有自杀倾向,分为有自杀倾向组和无自杀倾向组。采用Logistic回归分析,探讨精神分裂症患者自杀倾向的危险因素。结果精神分裂症患者有自杀倾向的占42.98%;家族自杀史、患者服药依从性、照护人员文化水平、照护人员收入状况、照护人员对疾病了解程度是主要影响因素。结论对存在自杀倾向的精神分裂症患者需要特别关注,及时加强患者及照护人员的健康教育,提高患者服药依从性,降低自杀率。