Reasons for Suicide

Individuals may consider or commit suicide for a complex interplay of reasons, often stemming from a desire to escape unbearable pain or resolve overwhelming problems. Common motivations include:

• Problem Solving: To escape seemingly insurmountable personal challenges such as:

  • Adultery or marital infidelity.

  • Poverty and financial hardship.

  • Stigma and discrimination due to social status, illness, or other factors.

• Interpersonal Harm: As a means to inflict emotional pain or distress on others, particularly in situations of:

  • Anger towards parents or family decisions, especially in children or adolescents feeling powerless.

• Desire to End Suffering: To terminate life in the face of terminal or debilitating illnesses, such as:

  • New diagnosis of HIV/AIDS.

  • Advanced cancer.

Conditions Predisposing to Suicide

Certain psychiatric and medical conditions significantly elevate the risk of suicidal behavior:

• Psychiatric Disorders:

  • Schizophrenia: A chronic psychotic disorder affecting thought, feeling, and behavior.

  • Hysteria (Conversion Disorder): A condition where psychological stress manifests as physical symptoms (note: ‘hysteria’ is an outdated term, often now referred to as conversion disorder or functional neurological symptom disorder).

  • Dementia: An organic, degenerative psychiatric disorder characterized by progressive decline in cognitive functions.

  • Post-Traumatic Stress Disorder (PTSD): An anxiety disorder following exposure to a traumatic event.

• Traumatic Experiences:

  • Rape and Sexual Defilement: Experiences of sexual violence.

Other Risk Factors for Suicide

Beyond specific conditions, other factors can increase suicide risk:

• Mental Health Issues:

  • Depression with Suicidal Ideation: Major depressive disorder accompanied by thoughts of suicide.

  • Other Mental Disorders: Various mental health conditions like anxiety disorders, bipolar disorder, and personality disorders.

• Personal History:

  • Family History of Suicide Attempts: Having family members who have attempted suicide.

  • Previous Suicide Attempts: Prior personal attempts to end one’s life.

  • Exposure to Violence: Witnessing or experiencing violence.

  • Impulsivity: A tendency to act rashly without considering consequences.

  • Aggressive or Disruptive Behavior: Patterns of aggressive or acting-out behaviors.

• Environmental Access:

  • Access to Firearms and Harmful Objects: Easy availability of lethal means.

• Social and Interpersonal Factors:

  • Bullying and Teasing at School or Workplace.

  • Feelings of Hopelessness or Helplessness: Pervasive negative outlook and lack of perceived control.

  • Acute Loss or Rejection: Experiencing significant losses such as:

    • Death of a loved one.

    • Loss of a romantic relationship (boyfriend or girlfriend).

    • Humiliation or public shame from family or friends.

  • Legal Troubles: Difficulties with the law or legal system.

  • Academic Failure: Significant setbacks or failures in school or education.

• Substance Abuse:

  • Alcohol and drug abuse or dependence.

• Harassment:

  • Sexual harassment or assault.

• Physical Health:

  • Chronic illness or debilitating medical conditions.

• Family Dynamics:

  • Family disruption or instability.

Methods of Suicide

Suicide can be attempted through various methods, including:

• Hanging

• Poisoning (ingestion of toxic substances)

• Intentional Accidents (e.g., self-inflicted car crashes)

• Gunshots (self-inflicted firearm injuries)

• Drowning

• Self-Inflicted Laceration of Major Arteries (e.g., radial artery)

• Drug Overdose (intentional ingestion of excessive medications)

• Self-Starvation (refusal to eat, leading to death)

Suicidal Tendencies/Behavior

This refers to an individual exhibiting suicidal ideation, gestures, or behaviors, indicating a risk of self-harm.

Suicidal Attempt

A suicidal attempt is a psychiatric emergency where an individual undertakes actions to commit suicide but survives the attempt.

MANAGEMENT OF SUICIDE ATTEMPT

A suicide attempt is a psychiatric emergency requiring immediate and collaborative interventions.

Aims of Management

The primary goals in managing a suicide attempt are:

1. Prevent Self-Harm: Ensure the immediate safety of the patient and prevent further attempts at suicide.

2. Restore Functional State: Help the patient regain their previous level of functioning and coping abilities.

3. Restore Self-Esteem: Address underlying feelings of worthlessness and hopelessness, and rebuild the patient’s self-esteem.

Management Steps:

1. Establish Nurse-Patient Relationship: Build a positive and trusting therapeutic relationship with the patient. This is crucial for:

   • Gaining the patient’s cooperation in treatment.

   • Earning the patient’s trust, which is essential for open communication and effective intervention.

   • Caution Card: Immediately implement a “caution card” protocol for the patient. This involves:

     • Flagging the patient’s chart for suicide risk.

     • Ensuring close and continuous observation by nursing staff.

     • Formal handover and physical transfer of patient responsibility between nurses using the caution card for clear communication.

2. Immediate Admission and Safe Environment:

   • Admission to Isolated Room: Admit the patient immediately to a secluded and secure room to minimize external stimuli and ensure safety.

   • Brief History and Doctor Notification: While admitting, gather a brief history of the event and immediately notify the physician for further evaluation.

   • Create a Safe Environment: Thoroughly remove all potentially harmful objects from the patient’s room and immediate vicinity. This includes:

     • Sharp objects (razors, knives, scissors).

     • Belts and cords.

     • Glass items (mirrors, glass containers).

     • Drug trays or medications not specifically prescribed for immediate use.

3. Immediate Patient Assessment: Conduct a rapid and thorough assessment focusing on:

   • Vital Signs: Monitor vital signs (pulse, blood pressure, respiration, temperature) to assess physiological stability.

   • Physical Injuries: Assess for any physical injuries resulting from the suicide attempt.

   • Life-Threatening Conditions: Prioritize and address any immediate life-threatening injuries with urgent emergency treatment:

     • Hemorrhage Control: Arrest hemorrhage in cases of self-inflicted wounds (e.g., ruptured arteries).

     • Oxygen Administration: Administer prescribed oxygen if the patient is cyanotic (showing signs of oxygen deprivation).

     • Gastric Lavage: Perform gastric lavage (stomach pumping) if poisoning by ingestion is suspected.

     • Immobilization: Immobilize fractures if injuries such as fractures are present.

4. Behavioral Observation: Closely observe and document the patient’s behaviors, noting any indicators of ongoing suicidal risk:

   • Verbal Cues: Listening for and documenting any statements about:

     • Expressing thoughts of ending their life or suicidal ideation.

   • Handling Dangerous Objects: Observe for the patient handling or hoarding potentially harmful objects.

   • Refusal of Food: Note any refusal to eat, as self-starvation can be a method of suicide attempt.

   • Medication Accumulation: Monitor for any attempts to accumulate or hoard medications.

   • Giving Away Possessions: Observe if the patient is giving away personal property or valuables, which can be a sign of suicidal intent.

   • Feeding and Sleep Patterns: Monitor feeding patterns (for self-starvation) and sleep patterns (for disturbances indicating distress).

5. Mental Status Assessment: Conduct a comprehensive mental status examination to:

   • Interview Patient: Directly interview the patient to assess their current mental state, thoughts, and feelings.

   • Collateral Information: Obtain information from attendants or family members to gain a broader understanding of the patient’s mental health history and recent behaviors.

   • Identify Underlying Mental Illnesses: Determine if there are any underlying mental health conditions that may have contributed to the suicide attempt (e.g., depression, psychosis).

6. Medication Administration and Reassurance: While administering prescribed medications, provide:

   • Reassurance: Reassure the patient (if conscious) and offer emotional support.

   • Prescribed Medications: Administer medications as prescribed by the physician, which may include:

     • Hydrocortisone: 100mg-200mg IV, 3-4 times daily, in cases of poisoning to manage potential adrenal insufficiency and support physiological stability.

     • Chlorpromazine: 100mg at night (nocte), in cases of psychosis-induced suicidal attempt, to manage psychotic symptoms.

     • Amitriptyline: 75mg at night (nocte), in cases of depression-induced suicide attempt, to begin addressing depressive symptoms.

     • Prophylactic Antibiotics: e.g., Cloxacillin 500mg four times daily (qid) for 5 days, in cases of self-inflicted wounds, to prevent infection.

7. Chemotherapy (Psychopharmacology): Recognize that a significant percentage (97%) of suicide attempts are linked to underlying depression. Therefore, psychopharmacological treatment is crucial:

   • Antidepressants: Prescribe antidepressant medications to address underlying depression:

     • Amitriptyline (Laroxyl): 25mg-75mg three times a day (ddd) or as prescribed.

     • Imipramine: 25mg-75mg three times a day (ddd) or as prescribed.

   • Mood Stabilizers: If bipolar disorder or mood instability is suspected or present, mood stabilizers may be prescribed:

     • Carbamazepine.

     • Lithium Carbonate.

     • Sodium Valproate.

8. Therapeutic Modalities (Psychiatric Interventions): The psychiatrist may order various therapeutic modalities, depending on the patient’s needs and underlying condition:

   • Electroconvulsive Therapy (ECT): In cases of severe, treatment-resistant depression with high suicide risk, ECT may be considered, typically administered 2-3 times per week.

   • Cognitive Therapy (Cognitive Behavioral Therapy – CBT): To address maladaptive feelings, negative thought patterns, and behaviors contributing to suicidal ideation.

   • Psychotherapy: Various forms of psychotherapy may be employed:

     • Group therapy: To provide peer support and shared experiences.

     • Cognitive therapy (CBT): As described above.

     • Individual therapy: One-on-one counseling to address personal issues and coping skills.

     • Family therapy: To involve family members in the therapeutic process and improve family dynamics.

     • Occupational therapy: To engage the patient in meaningful activities and divert their mind from negative thoughts and worries.

Nursing Concerns and Interventions

Specific nursing concerns and interventions are crucial for the care of suicidal patients:

1. Emotional Expression: Encourage the patient to express their feelings, including anger, sadness, hopelessness, and other emotions. This provides an outlet for emotional processing.

2. Enhance Self-Esteem: Focus on building the patient’s self-esteem by:

   • Highlighting and reinforcing their strengths and positive qualities.

   • Avoiding dwelling on weaknesses or failures.

3. Rehabilitation: Facilitate rehabilitation efforts to help the patient:

   • Acquire skills necessary to regain independence and earn a livelihood.

4. Occupational Diversion: Engage the patient in occupational and recreational activities to:

   • Divert their attention from suicidal thoughts and rumination.

   • Provide constructive outlets for energy and time. Examples include board games, sports (football), and arts/crafts.

5. Dietary Considerations: Provide foods that the patient likes to stimulate their appetite, especially if they are experiencing poor appetite or self-starvation.

6. 24-Hour Monitoring: Ensure continuous, around-the-clock close monitoring and direct observation of the patient to prevent self-harm.

7. Minimize Staff Changes: Minimize the number of different nurses caring for the patient to promote consistency, build trust, and facilitate a stable therapeutic relationship.

8. Therapeutic Nurse-Patient Relationship: Prioritize establishing and maintaining a strong and positive nurse-patient relationship, based on empathy, trust, and open communication.

9. Relaxation Techniques: Teach the patient relaxation techniques (e.g., deep breathing, mindfulness, progressive muscle relaxation) to help them manage stress and anxiety effectively.

10. Family Involvement: Actively involve family members in the patient’s management and care by:

    • Home Safety Advice: Advising them to remove or secure items at home that the patient might use to harm themselves (medications, firearms, sharp objects).

    • Supportive Home Environment: Advising family members to:

      • Avoid being discriminatory or judgmental towards the patient.

      • Be supportive and understanding to facilitate the patient’s adaptation to a suicide-free life.

Discharge Advice

Provide comprehensive discharge instructions and recommendations to the patient and family:

• Medication Adherence: Emphasize the critical importance of taking all prescribed medications as directed and consistently.

• Follow-Up Appointments: Ensure the patient understands the need to return for scheduled review appointments with their healthcare provider.

• Report Side Effects: Instruct the patient to report any side effects from medications to the nearest healthcare facility promptly.

• Stress Management: Advise the patient to avoid psychosocial stressors and situations that may trigger relapse or worsen their mental health.

• Substance Avoidance: Strongly advise the patient to avoid abuse of addictive drugs and alcohol, as these can significantly increase suicide risk and interfere with recovery.

• Family Support: Emphasize the crucial role of family involvement in supporting the patient in their ongoing recovery and suicide prevention efforts.

• Community Support: Advise community and family members not to isolate the patient but to provide social inclusion, acceptance, and support.

Prevention of Suicide

Preventive measures are essential at individual, community, and societal levels:

1. Hospital Management: Ensure proper and compassionate management of patients in hospital settings, demonstrating empathy and a supportive attitude.

2. Early Problem Identification: Promote early identification of problems that may contribute to mental health disorders, allowing for timely intervention.

3. Early and Proper Treatment: Ensure early and appropriate treatment of both physical and psychological health problems to reduce risk factors for suicide.

4. Community Education: Educate the community about the various factors that can contribute to both mental and physical illness, reducing stigma and promoting help-seeking behaviors.

5. Life Planning Skills: Encourage individuals to develop life planning skills and a sense of agency, rather than relying solely on others to plan their lives for them.

6. Job Creation Focus: Promote a shift in mindset towards job creation rather than solely job seeking, fostering economic independence and purpose.

7. Avoid Harsh Discipline: Advocate for avoiding harsh or punitive disciplinary measures towards children, as these can negatively impact mental health and increase vulnerability.

8. Coping Skills and Stress Management: Promote the development of effective coping mechanisms for dealing with difficult situations and teach stress management skills to build resilience.

9. Counseling for Social and Physical Health Problems: Provide accessible and effective counseling services for individuals facing social challenges and physical health problems, offering support and guidance.

10. Problem Sharing: Encourage people to share their problems and seek help rather than isolating themselves, promoting open communication and help-seeking behaviors.

11. Family Cohesion: Support and strengthen family units to promote family stability and cohesion, providing a protective factor against mental health challenges and suicide risk.

Complications of Status Epilepticus

Status epilepticus is a serious medical emergency with a high risk of severe and potentially life-threatening complications, including:

• Hyperthermia (dangerously elevated body temperature).

• Aspiration pneumonia (lung infection due to aspiration).

• Respiratory arrest (cessation of breathing).

• Rhabdomyolysis (muscle tissue breakdown).

• Cardiac arrhythmias (irregular heart rhythms).

• Sudden unexplained death in epilepsy (SUDEP).