SUICIDAL THREAT -  PSYCHIATRIC NURSING & MANAGEMENT

In psychiatry, a suicidal attempt is considered to be one of the commonest emergencies. Suicide is a type of deliberate self-harm and is defined as an international human act of killing oneself.

ETIOLOGY

PSYCHIATRIC DISORDERS

• Major depression
  
• Schizophrenia
  
• Drug or alcohol abuse
  
• Dementia
  
• Delirium
  
• Personality disorder
  

PHYSICAL DISORDERS
            Patients with incurable or painful physical disorders like cancer and AIDS.

PSYCHOSOCIAL FACTORS

• Failure in examination
  
• Dowry harassment
  
• Marital problems
  
• Loss of loved object
  
• Isolation and alienation from social groups
  
• Financial and occupational difficulties.
  

RISK FACTORS FOR SUICIDE

• Age
  
  • Males above 40 years of age
  • Females above 55 years of age
    

• Sex
  
  • Men have greater risk of completed suicide
  • Suicide is three times more common in men than  in women
    
  • Women have higher rate of attempted suicide
    

• Being unmarried, divorced, widowed or separated
• Having a definite suicidal plan
  
• History of previous suicidal attempts
  
• Recent losses
  

SUICIDAL TENDENCY IN PSYCHIATRIC WARDS

Certain psychiatric disorders where the patient may develop suicidal tendencies include

• Major depression: this is one of the common conditions associated with a high risk of suicide. Suicide in a major depressive episode is due to pervasive and persistent sadness; pessimistic cognitions concerning the past, present and future; delusions of guilt, helplessness, hopelessness and worthlessness; and derogatory voices urging him to take his life. The risk of suicide is more when the acute phase has passed and the characteristic psychomotor retardation has improved. This is so because the patient has more energy to carry out his suicidal plans now, though he might have been harboring them for quite some time.
  
• Schizophrenia: the major risk factors among schizophrenics include the presence of associated depression, young age and high level of pre-morbid functioning. People in this risk group are more likely to realize the devastating significance of their illness more than other groups of schizophrenic patients do, and see suicide as a reasonable alternative.
  
• Mania: Manic patients may occasionally commit suicide. This is usually the result of grandiose ideation. The patient may believe that he is a great person, or wish to prove his supernatural powers. With this intent in mind, he may carry out some dangerous activity that can cost him his life.
  
• Drug or alcohol abuse: suicide among alcoholics can be due to depression in the withdrawal phase. Also, the loss of friends and family, self-respect, status and a general; realization of the havoc alcohol has created in his life can cause the individual to wish to die.
  
• Personality disorder: Individuals with histrionic and borderline traits may occasionally attempt suicide
  
• Organic conditions: Conditions such as delirium and dementia due to changes of mood like anxiety and depression may also induce suicidal tendency.
  

MANAGEMENT

• Be aware of certain signs which may indicate that the individual may commit suicide, such as:​
  
  • Suicidal threat
    
  • Writing farewell letters
    
  • Giving away treasured articles
    
  • Making a will
    
  • Closing bank accounts
    
  • Appearing peaceful and happy after a period of depression.
    
  • Refusing to eat or drink

• Monitoring the patient’s safety needs:
  
  • Taking all suicidal threats or attempts seriously and notify psychiatrist
    
  • Search for toxic agents such as drugs or alcohol
    
  • Do not leave the drug tray within reach of the patient make sure that the daily medication is swallowed
    
  • Remove sharp instruments such as razor blades, knives, glass bottles from his environment
    
  • Remove straps and clothing such as belts, neckties
    
  • Do not allow the patient to bolt his door on the inside, make sure that somebody accompanies him to the bathroom
    
  • Patient should be kept in constant observation and should never be left alone
    
  • Have good vigilance, especially during morning hours
    
  • Spend time with him, talk to him, and allow him to ventilate his feelings
    
  • Encourage him to talk about his suicidal plans or methods
    
  • If suicidal tendencies are very severe, sedation should be given as prescribed.
    
• Encourage verbal communication of suicidal ideas as well as his fear and depressive thoughts. A ‘no suicidal’ pact  may be signed, which is a written agreement between the patient and the nurse, that patient will not act on suicidal impulses, but will approach the nurse to talk about them.
  
• Enhance self-esteem of the patient by focusing on his strengths rather than weaknesses. His positive qualities should be emphasized with realistic praise and appreciation. This fosters a sense of self-worth and enables him to take control of his life situation.
  

MANAGEMENT OF ATTEMPTED SUICIDE IN THE IN-PATIENT UNIT

• Assess for vital signs, check airway, if necessary clear airway
• If pulse is weak, start IV fluids
  
• Turn patient’s head and neck to one side to prevent regurgitation and swallowing of vomits
  
• Emergency measures to be instituted in case of self-inflicted injuries
  

MANAGEMENT OF SHOCK

• Transfer the patient to medical center immediately
• If there is no evidence of life leave the body in the same position or room in which it was found
  
• In case the patient has attempted suicide by jumping, do not leave the body in a place which is visible to other patients of the ward.
  
• Inform authorities record the incident accurately
  
• Contact local guardian and inform them
  
• Place an attendant outside the room where the body is kept
  
• Once the patient is transferred to mortuary or police custody clean the place with disinfectant solution
  
• Hand over the patient’s properties to the concerned authorities or relatives
  
• Carry out the institutional formalities for death certificate
  
• The senior staff should discuss the incident in detail with all the staff and reassure them. The discussion should include possible lapses and preventive measures that need to be undertaken
  
• The care for other patients should include the following:
  • Transfer all the patients away from the incident location
    
  • Keep the patients in the center engaged by games and other recreational activities
    
  • Serve food and medication to the patients earlier than schedule
    
  • Observe for any change in the behavior inform the psychiatrist.