Recognizing warning signs and preventing suicide
by Karon Brandt
Intervention. You can help prevent a suicide by getting a friend/family member to seek help from a doctor who will refer him/her to an inpatient unit of a psychiatric facility. This article will emphasize inpatient care from the viewpoint of a psychiatric nurse.
Many life events cause sadness - from the blues to grief to serious depression - which may become chronic and long-term.
Many people experience depression after the break-up of a long-term (or short-but-intense) relationship. Almost everyone has experienced the loss of a loved one or a pet, and they know the pangs of grief and the accompanying sadness. Many know depression resulting from job loss. Divorced persons often experience depression after cumulative losses of personal identity, loss of the family home, and loss of familiar life patterns.
We have all suffered losses, and we have all experienced depression at some time or another - if we've lived long enough. People handle depression differently. Some people "bounce back" much better than others. Some seem to be "stuck" in a state of unending, or worsening sadness, to the point in which caring loved ones realize they need help.
Of course, taking care of oneself properly while these life changes are taking place can go a long way towards helping one to recover more quickly. Such things as rest, relaxation, exercise, talking things out with a friend or professional counselor, meditation, anti-depressive medications, etc. can all work to some degree for different people.
What happens when someone begins to talk about suicide and really thinks "Life is not worth living" and "People would be better off without me"?
Any expression of suicidal thinking must be taken seriously. A friend or family member should strongly encourage the depressed person to seek help from a medical doctor. The doctor might decide to admit a suicidal-person to a psychiatric unit of a general medical center for evaluation and possible admittance.
This article is about the kind of care a patient receives who is seriously thinking about suicide and needs intervention. The symptoms, risk factors, and care of persons at "high risk for self-directed violence" are drawn from "Nursing Diagnoses in Psychiatric Nursing: A Pocket Guide for Care Plan Construction" by Mary C. Townsend, an Advance Registered Nurse Practitioner and Nursing Consultant in Wichita, Kansas.
Short-term and long-term goals are laid out along with the rationale behind the treatment.
There are six major symptoms to watch for when someone is seriously depressed:
(1) Affect. The person feels "worthless"; expresses feelings of helplessness and hopelessness; feels sad, dejected, gloomy and pessimistic;
(2) Thinking processes. The person has obsessive ideas and negative thoughts; his/her thinking seems slowed and (s)he finds it difficult to concentrate;
(3) Physical. The person finds it difficult to do normal activities and shows evident weakness and fatigue. [In major depression or the depressed phase of bipolar disorder, the person may show psychotic features like delusions and hallucinations.]
Some seriously-depressed people will eat and drink excessively while others may become anorexic and lose weight.
As the body slows down, the person may become constipated and retain urine.
Sleep disturbances are common, either sleeping too little or too much. In milder cases of depression, the patient may feel best early in the morning and worsen as the day progresses. This pattern is reversed in severe depression. (It's believed that this relates to the body's circadian rhythms.)
(4) The person's motor activity slows down noticeably. People with severe depression show lethargy and depleted energy levels. They find it very hard to perform daily activities. Some may show signs of regression, by withdrawing into themselves and going into a fetal position.
(5) Limited verbalizations. Depressed people may ruminate about the past and constantly dwell on having regrets. If psychosis is present, they may express delusional thoughts.
(6) Limited socialization. People with depression tend to be very self-focused, which discourages others from trying to communicate with them. The self-isolation increases their feelings of worthlessness, which begins a downward spiral into deeper isolation and more depression.
If there is a history of suicide attempts and if the person has already formulated a suicide plan, the person is considered to be at high risk for self-directed violence. Sometimes the person will "put his affairs in order" and give away personal possessions. He may express that he feels abandoned by a significant other; he feels worthless, helpless, and hopeless and he can't foresee a better future.
After being diagnosed and hospitalized for his own safety, a patient will begin to receive appropriate care.
As a patient, the short-term and long-term nursing goals are to protect the patient, but he must take some responsibility for himself. The patient must make a short-term verbal or written contract with each nurse on each shift and agree that he will not harm himself. He also agrees that he will seek help if he feels like he may harm himself.
Nursing treatments with rationales:
(1) The nurse must open communication and establish trust with the patient. She should ask him directly if he has thought about suicide and a way to do it. The staffers will take any suicidal thoughts very seriously.
(2) The number one priority for nurses is to create a safe environment for their patients. They will remove sharp items, glass, belts, etc. from patients' access.
(3) The nurse will make a short-term contract with the patient and will renew it upon expiration, as often as necessary. By discussing suicidal thoughts and feelings with the patient, nurses establish an accepting and trusting attitude and place some responsibility upon the patient for his personal well-being. Patients feel a sense of relief that someone cares about them, and they gain a feeling that they are worthwhile as individuals.
(4) Preventing crises. The nurse must get the patient to promise he will seek out a staff member if he feels like he might harm himself. With daily contact, by establishing trust and talking openly about feelings, intervention may help avoid a crisis because many potential suicides are ambivalent about their feelings.
(5) Communication through verbalization. The nurses will explore and discuss "honest feelings" and help the patient to regain hope.
(6) Suicidal feelings and serious depression are anger turned inwards. Nurses must encourage patients to safely express anger and hostility. Patients can be helped by resolving some of their negative feelings in a safe environment. Nurses can help patients recognize the real sources of their anger and learn new coping skills before the patient returns to the outside world.
(7) Nurses should try to reorient patients to reality without belittling their fears or indicating judgment or disapproval. If a patient shows misinterpretations or misperceptions of the environment, the nurse should do a reality check with the patient.
(8) Nurses should make patients feel they are worthwhile individuals by spending time with them and talking with them. Besides offering security and safety to these vulnerable people, the individuals regain self-esteem and value.
(9) Community resources. If the patient is made aware of outside resources that can support him during times when he feels suicidal, that may avert a crisis. A person should know that help is available and be given phone numbers with contact names or agencies.
By discharge, a patient should not have harmed himself, and he should not express any suicidal thoughts. All patients should be able to "verbalize" names and community resources they could turn to if they need help once they are discharged.
Source:
Nursing Diagnoses in Psychiatric Nursing: A Pocket Guide for Care Plan Construction, Third Edition, "Major Depression: Symptomatology. High Risk for Self-directed Violence." 1994. Mary C. Townsend. F.A. Davis Company, Philadelphia.