also standard practice to inquire about suicide or
self-harm thoughts in any setting where people seek
treatment for emotional problems.RISKY BEHAVIORS
A few people who commit suicide give no warning
signs. Some artfully hide their distress and suicide
plans. Others act impulsively by taking advantage of
a situation to carry out the desire to die. Some suici-
dal people in treatment describe placing themselves
in risky or dangerous situations such as speeding in a
blinding rainstorm or when intoxicated. This “Russian
roulette” approach carries a high risk of harm to both
clients and innocent bystanders. It allows clients to feel
brave by repeatedly confronting death and surviving.LETHALITY ASSESSMENT
When a client admits to having a “death wish” or sui-
cidal thoughts, the next step is to determine poten-
tial 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 gun
and 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 anniver-
sary 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 un-
derlying 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 nour-
ishment needs, and problems specific to the crisis such
as stabilization of psychiatric illness/symptoms.15 MOODDISORDERS ANDSUICIDE 363
3 months. Those with a relative who committed sui-
cide are at increased risk for suicide: the closer the
relationship, the greater the risk. One possible ex-
planation is that the relative’s suicide offers a sense
of “permission” or acceptance of suicide as a method
of escaping a difficult situation. This familiarity and
acceptance also is believed to contribute to “copycat
suicides” by teenagers, who are greatly influenced by
their peers’ actions (Roy, 2000).
Many people with depression who have suicidal
ideation lack the energy to implement suicide plans.
The natural energy that accompanies increased sun-
light in spring is believed to explain why most sui-
cides occur in April. Most suicides happen on Monday
mornings, when most people return to work (another
energy spurt). Research has shown that antidepres-
sant treatment actually can give clients with depres-
sion the energy to act on suicidal ideation (Roy, 2000).
WARNINGS OF SUICIDAL INTENT
Most people with suicidal ideation send either direct
or indirect signals to others about their intent to
harm themselves. The nurse neverignores any hint
of suicidal ideation regardless of how trivial or subtle
it seems and the client’s intent or emotional status.
Often people contemplating suicide have ambivalent
and conflicting feelings about their desire to die; they
frequently reach out to others for help. For example,
a client might say, “I keep thinking about taking my
entire supply of medications to end it all”(direct) or
“I just can’t take it anymore”(indirect). Box 15-3 pro-
vides more examples of client statements about sui-
cide and effective responses from the nurse.
Asking clients directly about thoughts of suicide
is important. Psychiatric admission assessment in-
terview forms routinely include such questions. It is
DRUG ALERT
ANTIDEPRESSANTS ANDSUICIDERISK
Depressed clients who begin taking an anti-
depressant may have a continued or increased
risk for suicide in the first few weeks of therapy.
They may experience an increase in energy from
the antidepressant but remain depressed. This
increase in energy may make clients more likely
to act on suicidal ideas and able to carry them out.
Also, because antidepressants take several weeks
to reach their peak effect, clients may become dis-
couraged and act on suicidal ideas because they
believe the medication is not helping them. For
these reasons, it is extremely important to moni-
tor the suicidal ideation of depressed clients until
the risk has subsided.