Suicide Prevention Nursing CE Course

o 19.5% (4.8 million people) in 2021. In addition, the prevalence of suicidal ideation (serious thoughts of suicide) was highest among 12 to 17-year-olds (13.4%) and 18 to 25-year-olds (13.6%; SAMHSA, 2023c).

Veterans are another high-risk population who are disproportionately affected by suicide. According to the US Department of Veterans Affairs (VA, 2023a) National Veteran Suicide Prevention Annual Report, veteran suicides have exceeded 6,000 each year between 2001 and 2021 despite the veteran population decreasing 27% during that time (25.8 million in 2001 to 18.8 million in 2021). In 2021, the veteran suicide rate was 71.8% higher than the rate for non-veteran adults, with an average of 17.5 veteran suicide deaths per day and a total of 6,392 deaths throughout the year (VA, 2023a). Researchers also cite differences in suicide means and methods. Among veterans, the latest data demonstrate that firearms account for 72% of all suicide deaths and are the most common means of death by suicide among individuals with and without mental health conditions. For veterans in 2021, firearms were the method in 73.4% of male suicide deaths and 51.7% of female suicide deaths (VA, 2023a).

The documented suicide rates are higher in many of the states with higher gun ownership (e.g., Alaska, Montana, Wyoming, and South Dakota; CDC, 2023; The RAND Corporation, n.d.). Given this finding, it is not surprising that western US states with the fewest firearm laws comprise the top four highest suicide rates: Wyoming (32.3 per 100,000), Alaska (30.8 per 100,000), Montana (32.0 per 100,000), and South Dakota (23.2 per 100,000). Following firearms (55%), the most common methods of suicide include suffocation (25.8%) and poisoning (11.6%). While men are more likely to die by suicide with a firearm (57.9% versus 33%), women are more likely to use suffocation (29.1% versus 26.7%) or poisoning (28.6% versus 7.8%; CDC, 2023; NIMH, 2023e). Substance use disorder (SUD) increases the risk of suicidal ideations, suicide attempts, and death. This is especially true in those who use alcohol or opioids, which are found in over 20% of suicide decedents (Rizk et al., 2021). Suicide and self-harm are also accompanied by a tremendous economic burden to society, costing more than $500 billion in 2020 in medical costs, lost wages, value of statistical life, and quality of life costs (CDC, 2023; NIMH, 2023e).

Self-injurious behavior accompanied by any intent to die is classified as a suicide attempt; HCPs and society should err deliberately on the side of caution by viewing debatable behaviors as suicidal. While males are more likely to die by suicide, females are more likely to attempt suicide. Still, it is challenging to determine the exact number of attempted suicides in the US since there is a lack of all-inclusive databases or tracking mechanisms. Data are primarily compiled through self-reported surveys and ICD-10-CM billing codes. Due to the high stigma associated with suicide attempts, they are greatly underreported. According to SAMHSA (2023c), over 13 million Americans aged 18 or older reported having serious thoughts of suicide, 3.8 million made suicide plans, and 1.6 million attempted suicide. Among adolescents (aged 12 to 17), the NSDUH indicates that 3.4 million had serious thoughts of suicide in 2022, 1.7 million made plans, and 953,000 attempted suicide. People who survive a suicide attempt may experience serious injuries that can have long-term health consequences. Many survivors experience high levels of psychological distress for lengthy periods after the initial exposure (CDC, 2023; SAMHSA, 2023c).

Risk Factors

HCPs must develop a keen awareness and understanding of the risk factors associated with suicide to identify individuals at risk. Assessing suicide risk in primary care offices, emergency departments, outpatient clinics, and other healthcare settings is essential to making appropriate care decisions regarding patients at risk. HCPs must also acquire the skills necessary to evaluate if an individual is in distress, depressed, in a crisis, or at imminent risk for suicide, prompting timely intervention. Warning signs are behavioral signs and symptoms that are statistically related to an individual's amplified risk for suicide. Risk factors may also include components of a person’s background, history, environment, and/or circumstances that increase their risk potential or likelihood of suicidal behavior. Individuals differ in the degree to which risk factors affect their propensity for engaging in suicidal behaviors, and the weight and impact of each risk factor will vary by person and throughout their lifespan (The Joint Commission, n.d.).

While a combination of situations and factors contribute to suicide risk, a prior suicide attempt is the strongest single factor that predicts future risk. The risk of dying by suicide is more than 100 times greater during the first year following an initial (index) suicide attempt. Studies have demonstrated a strong correlation between people who re-attempt suicide, those who complete it, and the timing of the re-attempt (Jason Foundation [JF], n.d.; Schreiber & Culpepper, 2023). In a prospective study evaluating 371 adult patients with a suicide attempt, 19% (70 people) re-attempted, and 60% of re-attempts occurred within the first 6 months (Irigoyen et al., 2019). In an observational study by Parra-Uribe and colleagues (2017), 1,241 first-time suicide attempters were followed over 5 years. The researchers concluded that most (88%) suicide re-attempts and completed suicides (93%) took place within the first 2 years. Olfson and colleagues (2017) determined that suicide risk was 37% higher in the first year after deliberate self-harm than in the general population. Results from a 32-year follow-up study of 1,044 patients recently published by Probert-Lindstrom and colleagues (2020) revealed that the risk of suicide following a suicide attempt persists for up to 32 years after the initial attempt. At the 32-year follow-up point, 37.6% of participants had died—7.2% by suicide—and 53% of these happened within the first 5 years following the suicide attempt (Probert-Lindstrom et al., 2020).

While risk factors increase the likelihood of suicide, they are not always direct causes. Even among those who have risk factors for suicide, most people do not attempt suicide. While it remains difficult to predict who will act on suicidal thoughts, the risk for suicide rises as the current number of contributing risk factors increases. Other than a prior suicide attempt, the most well-cited risk factors for suicide include the following:

• mental health conditions, such as:
  • SUD/substance misuse problems
  • bipolar disorder
  • major (unipolar) depressive disorder (MDD)
  • schizophrenia
  • anxiety disorders, including posttraumatic stress disorder (PTSD) or panic disorder
  • hallucinations, paranoia, delirium, delusions, and feelings of hopelessness
  • mood changes, recent or ongoing impulsive and aggressive tendencies and/or acts
  • persons aged 18 to 25 years prescribed an antidepressant
• persons institutionalized for a mental health condition
• stigma associated with mental illness and help-seeking
• serious physical health conditions, including chronic pain and traumatic brain injury (TBI)
• previous self-destructive behavior
• social isolation or alienation
• concerns related to sexual identity (LGBTQA+) and relationships
• problems linked to other personal relationships
• those in unskilled professions
• female nurses and military veterans
• increased access to lethal means, including firearms and drugs
• barriers to accessing healthcare and treatment
• prolonged stress, such as harassment, bullying, acculturation, discrimination, or unemployment
• stressful life events like rejection, divorce, financial crisis, other life transitions, or loss
• exposure to another person's suicide or graphic or sensationalized accounts of suicide (suicide cluster or unsafe media practices)
• community violence or historical trauma
• family history of suicide and/or psychiatric disorder(s)
• loss of a parent or loved one through any means
• history of trauma, abuse, violence, or neglect (e.g., adverse childhood experiences [ACEs]; CDC, 2022a; Schreiber & Culpepper, 2023)

 

Special populations with an increased risk for suicide include lesbian, gay, transgender, and queer/questioning (LGBTQ+) individuals; military personnel; and female nurses. Modifiable risk factors, such as mental health conditions, should be managed appropriately to lower a patient’s risk (CDC, 2023; Schreiber & Culpepper, 2023). Suicide among adolescents is most prominently associated with underlying psychiatric disorders such as MDD, bipolar disorder, and SUD. Any combination of psychiatric disorders further heightens the risk of suicide in adolescents. Previous suicide attempts are a key risk factor in adolescents as well as adults. Additional adolescent risk factors include impulsivity, genetic predisposition/family history, easy access to lethal means, the loss of a parent to death or divorce, physical and/or sexual abuse, a lack of a support network, low self-esteem, feelings of social isolation, and bullying. The stigma associated with asking for help is heightened among adolescents, exacerbating feelings of hopelessness and helplessness and driving intentional self-harm behaviors (Bilsen, 2018; JF, n.d.).

Protective Factors

Protective factors are key behaviors, environments, and relationships that may enhance resilience and decrease the risk that an individual will attempt suicide. Protective factors have been shown to safeguard individuals from suicidal thoughts and behaviors. Individuals differ in the degree to which protective factors affect their propensity for engaging in suicidal behaviors. Similar to risk factors, the impact of each protective factor on suicidality varies across the lifespan. Research demonstrates that some of the most well-established suicide protective factors include the following:

• presence of adequate social support and family connections (connectedness)
• being married and/or being a parent/pregnant
• supportive and effective clinical care from medical and mental health professionals
• positive learned skills in coping, problem-solving, conflict resolution, and other nonviolent ways of handling disputes
• cultural and religious beliefs that discourage suicide and support instincts for self-preservation (e.g., intentional participation in religious activities and spirituality)
• restricted access to lethal means, also known as protective environments (CDC, 2022a; Schreiber & Culpepper, 2023)

Warning Signs

Although statistical data demonstrate that most people who die by suicide received some form of healthcare services within the year preceding their death, suicidal ideation is rarely detected. HCPs must take all warning signs seriously and offer appropriate support quickly (The Joint Commission, n.d.). While a prior suicide attempt is the most predictive risk factor for completed suicide, the following warning signs are correlated with the highest likelihood of the short-term onset of suicidal behaviors:

• isolating oneself from others or referring to oneself as a burden, trapped, hopeless, or in unbearable pain
• changes in sleep habits (sleeping very little or much longer than baseline)
• feeling moody, uneasy, on edge, or angry
• threatening, talking, or thinking about hurting or killing oneself
• searching for ways to kill oneself, including seeking access to drugs or other lethal means (e.g., stockpiling or obtaining weapons, strong prescription medications, or items associated with self-harm)
• writing or posting on social media about death, dying, and suicide
• engaging in self-destructive behaviors, such as substance use or violence (CDC, 2022a; NIMH, 2023f)

These medical emergencies may warrant immediate attention, evaluation, referral, and hospitalization. Any individual who displays these warning signs is considered at a high level of risk for suicide and suicide crises, requiring immediate intervention to ensure their safety (for further details, refer to the section on suicidal crisis management). Frequently, warning signs of suicide in adolescents may mimic “typical teenage behaviors,” so parents may not readily identify behavior that raises concern for suicide in this age group. HCPs must watch for the distinct warning signs among this age group to identify at-risk youth and educate parents/caregivers on signs to monitor for at home. Prominent warnings in adolescents include signs that persist over time, several signs that appear simultaneously, and behavior changes that are “out of character.” Suicide threats may be direct or indirect statements (e.g., “I hate my life” or “I won’t be bothering you much longer”). Threats are not always verbal; adolescents may express themselves via text messages or social media accounts (e.g., Twitter, Instagram, TikTok). A preoccupation or obsession with suicide or death is a well-cited warning sign among adolescents. It can be expressed verbally through writing (e.g., poems or essays) or abstractly (e.g., artwork and drawings). Signs of depression that warrant increased attention include withdrawing from friends, a lack of hygiene, changes in eating and sleeping habits, irritability and aggressiveness, and a decline in school performance. Furthermore, problems with concentration, sudden difficulty staying focused, taking excessive risks (i.e., being reckless), and increased use of alcohol or drugs should raise clinical suspicion (JF, n.d.; United Health Foundation, n.d.).

Screening, Diagnosis, and Risk Assessment

The US Preventive Services Task Force (USPSTF, 2022, 2023) publishes screening guidelines for American HCPs. While their latest guidelines recommend universal screening for depression in adults and adolescents 12 and up, they found the evidence on suicide insufficient to recommend for or against universal screening for suicidality in adults, children, and adolescents. Please note that this recommendation applies to previously healthy patients, not individuals with a prior history of suicidality or those with a mental health disorder (Malfeo-Martin & Paul, 2022; USPSTF, 2022, 2023). The National Action Alliance for Suicide Prevention (Action Alliance, 2018) published an updated guideline, Recommended Standard Care for People with Suicide Risk, which supports two critical goals cited by the National Strategy for Suicide Prevention (US Department of Health & Human Services [HHS], 2021):

• goal 8: promote suicide prevention as a core component of healthcare services
• goal 9: promote and implement effective clinical and professional practices for assessing and treating those identified as being at risk for suicidal behaviors

Together, the Action Alliance (n.d.) and National Strategy, which was last updated in 2021, put forth the Zero Suicide (ZS) Model, which provides a framework through which to coordinate a multilevel approach to implementing evidence-based practices. ZS encourages the screening of all patients for suicide risk on their first contact with an organization and at each subsequent encounter. To screen a patient for suicidal thoughts, the HCP should inquire directly about thoughts of dying by suicide or feelings of engaging in suicide-related behavior. The distinction between NSSI and suicidal behavior is essential. HCPs should be direct when inquiring about any current or past thoughts of suicide and ask individuals to describe any such thoughts (Action Alliance, n.d., 2018; HHS, 2021).

Several options exist for those seeking to screen patients for suicidal ideations. The Beck Hopelessness Scale is a 20-item questionnaire that the USPSTF mentions as an option for this, but studies indicate the scale has a low specificity for suicidality. Alternatives include the Sex, Age, Depression, Previous attempt, Ethanol use, Rational thinking loss, Social supports lacking Organized plan, No spouse, Sickness Scale (SAD PERSONS Scale), and the Suicide Assessment Five-step Evaluation and Triage (SAFE-T; Schreiber & Culpepper, 2023; USPSTF, 2023). SAFE-T is a tool that incorporates the American Psychiatric Association (APA) Practice Guidelines for suicide assessment and is used most commonly in emergency departments by clinicians and nurses. SAFE-T can identify risk and protective factors; inquire about suicidal thoughts, behavior, and intent; and determine the patient’s risk level. It provides appropriate interventions directly to enhance safety. The five steps are outlined in Figure 1 (HHS, 2009).

Figure 1

SAFE-T Steps

(HHS, 2009)

A suicide risk assessment is a process by which an HCP gathers clinical information to determine an individual's risk for suicide. A risk assessment identifies behavioral and psychological characteristics associated with an increased risk for suicide, allowing for the implementation of effective, evidence-based treatments and interventions to reduce this risk. A risk assessment for suicide is an ongoing process, as suicidal behaviors can fluctuate quickly and unpredictably. Screening responsibilities are no longer limited to medical providers, as current health policy and suicide prevention guidelines call for the support and participation of all HCPs, regardless of their work setting (acute or non-acute) or specialty. This includes but is not limited to physicians, advanced practice providers, nurses, behavioral health specialists, social workers, and case managers (Action Alliance, n.d.). A complete risk assessment must include the following vital aspects:

• information about past, recent, and present suicidal ideation and behavior
• information about the patient's context and history
• prevention-oriented suicide risk formulation anchored in the patient's life context (Action Alliance, n.d.)

The core elements of the ZS model include ongoing risk assessment, collaborative safety planning, evidence-based interventions specific to the identified risk level, lethal means reduction, and continuity of care. Structuring a suicide risk assessment is not a straightforward task and involves asking difficult questions about suicidal ideation, intent, plan, and prior attempts. Individuals may openly respond to queries and engage in discussion or be limited in their replies and offer minimal information. The patient may bring up the topic independently, but research demonstrates this is rare (Brodsky et al., 2018; HHS, 2021; SAMHSA, 2017). The information below outlines the assessment of risk for suicide as compiled and adapted from the Action Alliance (n.d., 2018) and HHS (2021) guidelines:

• The suicide risk assessment should include consideration of risk and protective factors that may increase or decrease the patient's risk of suicide, including past suicidality and family history of suicidal ideations or behavior.
• Observation and the existence of warning signs and the evaluation of suicidal thoughts, intent, behaviors, and other risk and protective factors should be used to inform any decision about a referral to a higher level of care.
• Mental state and suicidal ideation can fluctuate considerably over time. Any person at risk for suicide should be re-assessed regularly, especially if their circumstances have changed.
• The HCP should observe the patient's behavior during the clinical interview. Disconnectedness or a lack of rapport may indicate an increased risk for suicide.
• The HCP should remain both empathetic and objective. A direct, non-judgmental approach allows the HCP to gather the most reliable information collaboratively and encourages the patient to accept help.

According to the Action Alliance (2018) and HHS (2021), a comprehensive evaluation of suicidal thoughts should include the following:

• onset (when did it begin)
• duration (acute, chronic, recurrent)
• intensity (fleeting, nagging, intense)
• frequency (rare, intermittent, daily, unabating)
• active or passive nature of the ideation (“wish I was dead” vs. “thinking of killing myself”)
• whether the individual wishes to kill themselves or is thinking about or engaging in potentially dangerous behavior such as cutting to relieve emotional distress
• lethality of the plan (no plan, overdose, hanging, firearm)
• triggering events or stressors (relationship, illness, loss)
• what intensifies the thoughts
• what distracts the thoughts
• association with states of intoxication (if thoughts are triggered only when the individual is intoxicated)
• understanding the consequences of future potential actions

To assess suicidal intent, the HCP should appraise past or present evidence (implicit or explicit) that the individual wishes to die, means to kill themselves, and understands the probable consequences of their actions or potential actions. This includes the following (Action Alliance, n.d., 2018; HHS, 2021):

• Patients should be asked the degree to which they wish to die, mean to kill themselves, and understand the probable consequences of their actions or potential actions.
• The evaluation of intent to die should be characterized by the strength of the desire to die, the determination to act, the impulse to act, or the resistance to act.
• These factors may be highlighted by querying how much the individual has thought about a lethal plan, can engage in that plan, and is likely to carry out the plan.

To assess for preparatory behavior, the HCP should evaluate if the patient has begun to prepare for engaging in self-directed violence, such as assembling a method or preparing for death. In addition to obtaining collateral information from the patient’s family members, medical records, and therapists, HCPs should assess preparatory behaviors by inquiring about the following:

• mentally walking through the potential attempt
• researching methods on the internet
• thoughts about the location they would consider and the likelihood of being found or interrupted
• seeking access to lethal means or exploring the lethality of means, such as:
  • walking to a bridge
  • handling a weapon
  • acquiring a firearm or ammunition
  • hoarding medication
  • purchasing a rope or blade
• taking action or other steps in preparing to end one's life, such as:
  • writing a will or suicide note
  • giving away possessions
  • reviewing a life insurance policy (Action Alliance, n.d., 2018; HHS, 2021)

HCPs should obtain information from the patient and other sources about previous suicide attempts. Historical suicide attempts may or may not have resulted in injury and may have been interrupted by the patient or another person before a fatal injury.

The risk assessment for suicide should include information from the patient and collateral sources about previous suicide attempts and circumstances surrounding the event (e.g., triggering events, the method used, consequences of behavior, and the role of substances of abuse) to determine the lethality of any previous attempt (Action Alliance, n.d., 2018; HHS, 2021). HCPs should inquire about the following:

• if the attempt was interrupted by the patient or another person
• whether there was evidence of an effort to isolate or prevent discovery
• if there have been previous and possibly multiple attempts (Action Alliance, n.d., 2018; HHS, 2021)

For patients who have a history of prior interrupted (by self or another) suicide attempt(s), obtain additional details to determine factors that enabled the patient to resist the impulse (if self-interrupted) and prevent future attempts (Action Alliance, n.d., 2018; HHS, 2021; SAMHSA, 2017).

A comprehensive suicide risk assessment may be complemented with a validated, evidence-based assessment tool consisting of directed questions. Evaluating the risk level and appropriate actions for each risk level is a critical aspect of suicide prevention. All HCPs must understand how to perform a proper risk assessment, ascertain risk level, and respond according to evidence-based guidelines. Several tools have been developed and are used throughout various clinical settings. Within the same facility or working environment, all staff members are encouraged to use the same tools and procedures to ensure that patients with suicide risk are identified and managed consistently. Similarly, HCPs must become familiar with and comfortable using the assessment tool to elicit open discussion with the patient. The standard of care in suicide risk assessment requires HCPs to conduct a thorough suicide risk assessment when a patient first screens positive (Action Alliance, 2018; Falcone & Timmons-Mitchell, 2018).

The Columbia Suicide Severity Rating Scale (C-SSRS) is a validated and evidence-based instrument in suicide risk assessment and is available in 114 languages. Several versions of the C-SSRS have been developed for clinical practice. The tool is supported by extensive evidence that reinforces the tool’s validity as a screening method for longitudinally predicting future suicidal behaviors. It screens for a wide range of suicide risk factors straightforwardly and concisely, using direct language to elicit honest responses. The C-SSRS provides a framework to assess suicide risk and NSSI, identify the risk level, and guide appropriate action according to the risk level. The C-SSRS is endorsed by several major organizations, including the Action Alliance, SAMHSA, CDC, World Health Organization (WHO), and the National Institutes of Health (NIH). When using this tool, the HCP asks a series of questions about the patient’s suicidal thoughts and behaviors. Some sample questions include the following (Brodsky et al., 2018; Columbia Lighthouse Project, 2016; HHS, n.d.):

• “Have you wished you were dead or wished you could go to sleep and not wake up?”
• “Have you been thinking about how you might kill yourself?”
• “Have you taken any steps toward making a suicide attempt or preparing to kill yourself, such as giving valuables away, getting a gun, or writing a suicide note?”

The HCP identifies risk factors, recent events (triggers), past history, family history, current emotional status, and any protective factors that may be present. The second page guides the user to clarify the patient's ideations further, including their intensity, frequency, duration, controllability, and deterrents. The tool also describes how to clarify any suicidal behavior/attempts. The creators of this tool suggest that users be trained and certified to administer it (Brodsky et al., 2018; Columbia Lighthouse Project, 2016; HHS, n.d.). While this tool is considered the gold standard for suicide risk assessment in clinical trials, critics describe it as labor-intensive and, therefore, inefficient for use in routine clinical practice (Schreiber & Culpepper, 2023).

Similarly, the SAFE-T screening tool determines if a person’s risk of suicide is low, moderate, or high. These risk levels, defining features, and interventions are summarized in Table 1. Suicide precautions should be implemented whenever a patient is deemed at risk. For patients determined to be at low risk of suicide, the HCP should make personal and direct referrals to outpatient behavioral health and other providers for follow-up care within a week of the initial assessment rather than leaving the patient to make the appointment (Columbia Lighthouse Project, 2016; HHS, 2009).

Table 1

Level of Suicide Risk, Defining Features, and Associated Interventions

Risk Level	Features	Interventions
Low	modifiable risk factors, strong protective factors no plan, intent, or suicidal behavior	make personal and direct referrals to outpatient behavioral health/other providers for follow-up (i.e., direct communication with the receiving provider) consider safety planning with the patient and any available family members provide emergency/crisis contacts and phone lines
Moderate	multiple risk factors, few protective factors suicidal ideation with a plan but no intent or behavior	consider inpatient admission to a hospital or mental health facility depending on risk assessment develop a crisis plan and involve the patient and family members in safety planning make personal and direct referrals to outpatient behavioral health/other providers for follow-up (do not leave the patient to make the appointment) provide emergency/crisis contacts and phone lines
High	individuals with psychiatric disorders displaying severe symptoms or who have endured acute precipitating events protective factors are unapparent or insignificant (i.e., do not offset risk) those who may have survived a potentially lethal suicide attempt or embrace persistent suicidal ideation with strong intent or prior suicide rehearsal	arrange immediate inpatient admission to a hospital or mental health facility for close monitoring with strict suicide precautions

 (Columbia Lighthouse Project, 2016; HHS, n.d.)

 

Diagnosis

The clinical diagnosis of suicidality is still debated. The APA's Diagnostic and Statistical Manual, 5th Edition, Text Revision (DSM-5-TR) proposes criteria for suicidal behavior disorder in its section on Conditions for Further Study. They describe:

• a suicide attempt in the last two years, defined as actions intending to end someone's life
• the actions referred to above were intended to cause death, not superficial or bodily injury (see NSSI definition above)
• this diagnosis is not applied to those with ideations and preparatory acts only
• the actions referred to above were not due to delirium or confusion
• the actions were not done only for religious or political objectives (APA, 2022a)

Reassessment

Reassessment of a patient’s suicide risk should occur when there is a change in their condition (e.g., relapse of alcoholism) or psychosocial situation (e.g., the end of an intimate relationship) that suggests increased risk. HCPs should update information about a patient’s risk factors when changes in their symptoms or circumstances indicate increased or decreased risk (Action Alliance, 2018).

Nonsuicidal Self-Injurious Behaviors

Self-injurious behaviors (self-harm) refer to actions aimed at directly and deliberately injuring oneself. NSSI is distinct from suicidal behavior as it lacks the intent to cause death. While individuals who engage in NSSI behaviors do not intend to die, there is an increased risk for suicidal behaviors. This is particularly challenging for HCPs, as deciphering the risk is complex, and there is a significant overlap between the behaviors. Therefore, keen awareness and risk assessments are critical to promoting safety. While research on NSSI is less extensive than on suicide and suicide prevention, there has been a tremendous surge in attention to the topic over the last decade (Falcone & Timmons-Mitchell, 2018; Moutier, 2023a).

The most common methods of NSSI include cutting, stabbing, or burning the skin or headbanging/hitting. Other forms include excessive scratching to the point of drawing blood, punching oneself or objects, infecting oneself, inserting objects into body openings, drinking or ingesting harmful fluids or items (e.g., bleach, detergent, or another poison), and intentionally breaking bones. Behaviors are often repeated (sometimes daily) and typically done in accessible but easily concealed areas (e.g., forearms, anterior thigh). NSSI most commonly affects adolescents (starting in early adolescence) and young adults, with an increased incidence between 12 and 14 years. A systematic review between 1998 and 2016 revealed prevalence rates of 7.5% to 46.5% in adolescents, 38.9% in university students, and 4% to 23% in adults. It is primarily associated with childhood trauma, other forms of emotional distress, and comorbid psychiatric conditions (Cipriano et al., 2017; Moutier, 2023a).

Patients who self-injure commonly report that it reduces tension and other negative feelings (sadness, pain), resolves interpersonal difficulties, or serves as self-punishment for the patient's perceived transgressions. It may also serve as a plea for help. It is often associated with borderline personality disorder (BPD) and other personality disorders, eating disorders, SUD, and autism spectrum disorders (Moutier, 2023a).

Evaluation or assessment is the first step in managing NSSI, followed by a recommended course of treatment to prevent the self-destructive cycle from continuing. As highlighted earlier in this module, the C-SSRS also serves as an evidence-based, validated tool to assess for NSSI (Brodsky et al., 2018). A lack of suicidal intent must be established first (Moutier, 2023a). While NSSI is only included in the section Conditions for Further Study, the DSM-5-TR proposes the following criteria for the diagnosis (APA, 2022a):

A. An individual who engages in purposeful self-harm on 5 or more days in the last year, causing pain or loss of blood (bleeding/bruising) by cutting, stabbing, hitting, burning, or similar actions without meaning to cause death (suicide) or serious/grave injury.

B. This is done to decrease unpleasant emotions or thoughts, increase pleasant emotions/thoughts, or resolve interpersonal conflict during or right after the self-harm.

C. This behavior is related to:

• interpersonal conflict or unpleasant emotions/thoughts before the behavior
• a consistent distraction or preoccupation with the behavior

D. This behavior is not otherwise related to body piercing, tattoos, religious/cultural practices, or limited to biting the nails or scab picking.

E. This behavior is significant in the distress or dysfunction that results directly or indirectly.

F. This behavior cannot be better explained by substance use/intoxication/withdrawal, another medical or mental condition, psychosis, delirium, etc.

Psychotherapy is the mainstay of treatment for NSSI, either as an individual or in a group setting, and outpatient or inpatient. The most well-studied options include cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and emotion-regulation group therapy. The goals are to recognize dysfunctional automatic thoughts and alter how the patient responds behaviorally to those thoughts. CBT works to disconnect the patterns of unpleasant emotions, thoughts, and NSSI behaviors. DBT typically takes a year of individual and/or group sessions to identify dysfunctional patterns and alternative methods of managing stress and unpleasant emotions. Emotion-regulation group therapy is a 14-week group endeavor to identify unpleasant emotions as a necessary part of life and thus improve the patient's behavioral reaction to those feelings. There are no pharmacological treatments approved for NSSI, although naltrexone (Vivitrol) and second-generation antipsychotics (SGAs) may be helpful in some patients when used off-label (Moutier, 2023a).

Suicide Prevention

Preventing suicide is the primary objective of suicide risk assessment and management. The most effective strategies focus on strengthening suicide protective factors, such as improving access to mental health services, counseling, and other psychosocial resources. Managing mental health conditions (especially MDD) is one of the most important interventions for suicide risk reduction and includes both nonpharmacological and pharmaceutical treatments based on individual needs (NIMH, 2023f).

Impulsivity and Access to Lethal Means

As described earlier, firearms are the most lethal and most common method of suicide in the US, and suicide attempts with a firearm are overwhelmingly fatal. Firearm owners are not more suicidal than non-firearm owners; instead, their suicide attempts are more likely to be fatal. The connection between impulsivity and access to lethal means dramatically enhances the risk of death by suicide (Harvard School of Public Health, n.d.; Suicide Prevention Resource Center [SPRC], n.d.-a). The majority of suicide attempts involve little planning and occur during a short-term crisis period by individuals who have access to lethal means. Therefore, there is a direct correlation between death by suicide and access to lethal means, such as firearms. If lethal means are made less available to impulsive attempters, and patients substitute less lethal means or temporarily postpone their attempt, the odds that they will survive increase. Studies have demonstrated that when access to a highly lethal suicide method is restricted, the overall suicide rate drops (Allchin et al., 2019).

The CDC (2022b) advocates for counseling on access to lethal means (CALM), a program designed to train HCPs to counsel patients on lethal means access and safe storage. The VA (2018) states in its National Strategy for Preventing Veteran Suicide that a reduction in access to lethal means at the population level should be implemented as a measure of suicide prevention (Goal 6). This may include firearm restrictions, reducing access to poisons/chemicals and medications commonly associated with overdose, barriers to jumping from lethal heights, ropes, belts, knives, and other objects. Such restrictions may be accomplished through lethal means safety counseling (LMSC). LMSC consists of a discussion between an HCP and a patient at risk for suicide. Firearm storage suggestions should be based on the patient’s risk level. Recommendations may include storing guns and ammunition separately, using a gunlock or removing the firing pin, storing firearms in a locked cabinet or safe, disassembling firearms, or keeping them at the home of a trusted individual. The Action Alliance (2018) suggests that HCPs arrange and confirm the removal or reduction of any lethal means when feasible before allowing an at-risk patient to be discharged or return home. Family members or caregivers should be involved to help suicide-proof the home (Action Alliance, 2018; American Academy of Pediatrics [AAP], 2023; CDC, 2022b; SAMHSA, 2017; VA, 2018).

 

Box 1-1. Critical Consideration

Strategies to prevent suicide and save lives: Safe storage of lethal means buys time and saves lives during impulsive moments and times of crisis. The engagement of supportive third parties enhances safety and preserves lives.

(Allchin et al., 2019)

Public Education and Gatekeeper Training

In addition to restricting access to lethal means, expanding options for HCP education and gatekeeper training has a positive impact on reducing suicide rates. Gatekeeper training is more commonly referred to as "recognition and referral training" (RRT), referring to the critical role that individuals without formalized psychosocial training have on suicide prevention. RRT educates individuals across the community (e.g., teachers, coaches, emergency responders, clergy), equipping them with the skills to identify people who may be at risk of suicide. It offers training on responding to these individuals and referring them to support services and treatment. Since most individuals at risk for suicide seek guidance and support from close contacts (i.e., "gatekeepers"), training these individuals on how to respond to mitigate a person’s suicide risk is vital. RRT strives to create an informed support network of people within communities that are equipped to connect suicidal persons with the right resources. Applied Suicide Intervention Skills Training (ASIST) is one of the most effective and well-cited RRT programs. The program "helps hotline counselors, emergency workers, and other gatekeepers identify and connect with individuals with suicidal thoughts and/or behaviors, understand their reasoning for living and dying, and assist with safely connecting those in need to available resources" (CDC, 2022b, p. 59). Gould and colleagues (2013) evaluated ASIST training’s role within the National Suicide Prevention Lifeline network of hotlines for 2 years in a randomized controlled trial. According to data compiled from 1,410 suicidal individuals who utilized the hotline, callers who spoke with ASIST-trained counselors were able to feel less depressed, less suicidal, less overwhelmed, and more hopeful by the conclusion of their call, compared to callers who spoke to non-ASIST trained counselors. Counselors trained in ASIST were also more skilled at keeping callers on the phone longer and establishing a connection with them (Gould et al., 2013).

Suicide Crisis Management

Inpatient and outpatient HCPs serve vital yet distinct roles in caring for individuals with suicide risk. Inpatient care offers medically supervised programs in a hospital setting with resources available around the clock. The average length of stay ranges from 48 hours to 10 days. The primary goal of inpatient care is to mitigate the imminent risk of suicide, initiate treatment, stabilize the patient, and prepare for discharge and outpatient continuing care services. In contrast, outpatient care focuses on preventing suicide and enhancing overall health and well-being (Action Alliance, 2019).

Suicidal patients typically experience strong feelings of abandonment, loneliness, guilt, and hopelessness. HCPs must be equipped to handle the stress of a suicide crisis in a calm, structured manner. As with any other emergency, HCPs should always remain with the patient. The goal of suicidal crisis management is to mitigate the patient’s acute risk for suicidal behaviors and maintain their safety. Individuals demonstrating warning signs and behaviors that raise suspicion of suicide crisis should be immediately referred for admission to an inpatient facility, as specialty care is urgently needed. If placement is not possible, refer patients to their local emergency department. Suicide precautions and one-on-one monitoring should be employed until the imminent risk declines. Aside from suicide hotlines, suicidal crisis management also includes other programs that provide assessment, crisis stabilization, and referral to an appropriate level of ongoing care. The following list highlights the priority actions HCPs should take to preserve the life of a patient in an acute suicidal crisis (Action Alliance, 2018; NIMH, 2023f; SPRC, n.d.-b):

• Keep patients in a "safe, monitored" environment until acceptable access to care is available.
• Arrange immediate access to care through an emergency department, inpatient psychiatric unit, respite center, or crisis center.
• Assess suicidal patients, visitors, and their environment for items or substances that could be used to attempt suicide or harm themself or others.
• Keep suicidal patients away from anchor points for hanging or materials that could be used for self-injury. Lethal means that are readily available in hospitals and have been used in suicides include bell cords, bandages, sheets, restraint belts, plastic bags, elastic tubing, and oxygen tubing.

The Suicide & Crisis Lifeline 

For those with suicidal ideation, each patient and their family members should be given information to access the Suicide & Crisis Lifeline at 988. Counselors are available via the national toll-free phone number, on a web-based live chat (988lifeline.org), by text, or through a mobile application. This service is available 24 hours a day and 7 days a week across the US. Furthermore, individuals should also be provided with contact information for local crisis and peer support contacts (Suicide & Crisis Lifeline, n.d.).

The Lifeline outlines their best practices, including a Safety Policy released in 2022. This policy informs their staff on assessing a caller/chatter's risk and safety. Their Safety Assessment model utilizes connection, active listening, and active engagement to connect with those in crisis during the first phase. This connection helps form a therapeutic alliance between the caller/chatter and the staff member helping them. The second phase involves active listening to clarify the level of risk and any specific details about the caller's current situation. The staff's primary goal is to collaborate with and empower the caller/chatter to secure their safety during this second phase (Suicide & Crisis Lifeline, n.d.). Their safety assessment tool, the Four Core Principles of Suicide Assessment 2.0, begins with two prompt questions:

• Have you had any thoughts of suicide in the past few days, including today?
• Have you taken any action to harm yourself today?

If the caller answers yes to the first question, the assessment must outline the four core principles: desire, intent, capability, and buffers. The staff should ask the caller about suicidal ideations and feelings of hopelessness to determine desire. Other elements of desire for suicide may include feelings of perceived burden, being trapped, self-loathing, pain (including psychological), and isolation (low belonging). The second core principle, intent, should be determined by asking about an attempt in progress (identified initially using the second question above), a plan with a known method, anticipatory or preparatory behaviors, and verbal or written expressions of intent to die. The third principle, capability, is defined by the caller's history of attempts or NSSI, immediate access to available means, and current state of dysregulation or intoxication. Additional elements that may comprise this third principle include recent exposure to another person's suicide, sleep disturbance, increased anxiety or other acute mental illness, substance use, or a history of violence. The fourth core principle is buffers, or safety features that may prevent suicide. These include immediate support, specific reasons to continue living, or feelings of ambivalence about ending one's life. Additionally, the staff may identify future plans, a sense of purpose for living, core beliefs that discourage suicide, a social support network, or engage the caller as a helper. The third phase of the Lifeline's safety assessment should conclude with a wrap-up and follow-up. If the counselor identifies that the caller/chatter is at imminent risk of suicide or an attempt in progress, they should work with the caller to actively increase their safety using the least invasive intervention. They avoid using emergency services, police officers, or 911 call centers when possible. These options are only engaged as a last resort (Suicide & Crisis Lifeline, n.d.).

Safety Planning

Safety planning is a necessary step in suicide prevention. It lowers the individual's imminent suicide risk following a risk assessment. It is a collaborative process of identifying coping strategies with the patient and providing resources for reducing risk. A safety plan is not a "no-suicide contract" (or "contract for safety"), as experts in the field of suicide prevention do not recommend this measure. Various safety planning tools are designed for specific clinical settings (e.g., emergency departments, acute care settings, outpatient mental health settings) and populations (e.g., adults and veterans). The safety planning intervention (SPI) is the most widely utilized clinical option. It yields an individualized, prioritized list of warning signs, coping strategies, and resources to use during periods of distress or crisis to prevent suicide. The SPI should begin internally and build toward seeking help from external resources. While the plan is devised as a step-wise approach, individuals may advance through the plan without completing prior steps. The major components of the SPI include the following:

• identifying warning signs
• utilizing coping strategies
• socializing with others as a distraction from suicidal thoughts
• contacting family or friends to seek help during a suicidal crisis
• contacting mental health professionals, agencies, or organizations for assistance
• restricting or reducing access to means for completing suicide (AAP, 2023; The Joint Commission, 2020; NIMH, 2023f; Schreiber & Culpepper, 2023; Stanley & Brown, 2012; Stanley et al., 2018)

The HCP should review and reiterate the patient's safety plan at every interaction until they are no longer at risk for suicide. In a large-scale cohort study, Stanley and colleagues (2018) found that the SPI was associated with a reduction in suicidal behavior and increased treatment engagement among suicidal patients following discharge from the emergency department. Safety planning is only one aspect of caring for a suicidal individual and must be used in combination with a complete risk assessment and other evidence-based treatments. Table 2 outlines the clinical use and application of the SPI.

Table 2

SPI Use and Application

Step	Questions to Consider	Note to HCP
Step 1: warning signs	How will you know when the safety plan should be used?	Using the patient’s own words, list thoughts, images, moods, situations, or behaviors that indicate a crisis may be developing.
Step 2: internal coping strategies	What can you do if you become suicidal again to help yourself not act on your thoughts?	List things the patient can do to take their mind off problems without contacting another person (relaxation techniques, physical activity).
Step 3 should be used if Step 2 does not resolve the crisis or lower the risk.
Step 3: social contacts (distraction)	Who or what social settings help take your mind off these problems?	List social settings and people that provide a distraction, including safe places to go and people to call.
Step 4 should be used if Step 3 does not resolve the crisis or lower the risk.
Step 4: family members or friends who can offer help	Among family and friends, who do you think you can contact in a crisis?	List several people (in priority order) to call in the event of a crisis.
Step 5 should be used if Step 4 does not resolve the crisis or lower the risk.
Step 5: professionals and agencies to contact	Which mental health professionals should be on your safety plan?	List professionals or agencies to contact during a crisis, including full names and telephone numbers (clinic number, cell phone, pager). Include local urgent care services and the Suicide & Crisis Lifeline: 988.
Step 6 should be used if Step 5 does not resolve the crisis or lower the risk.
Step 6: making the environment safe	Do you own a firearm, such as a gun or a rifle? What other means do you have access to and may use to attempt to kill yourself? How can we develop a plan to limit your access to these means?”	Determine which means the patient would consider using during a suicidal crisis, their level of access to those means, and how best to limit that access. Professionals should inquire about prescription medications and chemicals, removing or locking up firearms, other weapons, ligature risks, etc.
Step 7: outline reasons for living	What are the most important and meaningful things in your life to keep living for?	List things the patient feels are most important in their life currently.

(The Joint Commission, 2020; Stanley & Brown, 2012; Stanley et al., 2018)

              The AAP also highlights that patients who develop a safety plan on paper should be encouraged to take a picture of it on their phone to keep it handy and prevent misplacing it. Safety planning does not have to be done by a clinician; nurses and social workers trained in safety planning are also qualified. In addition to SPI (above), the Virtual Hope Box is a free smartphone app that can assist with safety planning on either an iOS or Android smartphone (AAP, 2023).

Documentation

Thorough documentation of each step in the decision-making process and all communication with the individual at risk for suicide, their family members, significant others, and caregivers is critical. HCPs must review and update the patient’s care plan and medical records as appropriate. Documentation should include why the patient is at risk for suicide and all care provided with as much detail as possible. Documentation should include the safety plan’s content and the patient's reaction to it, discussions, and approaches to lethal means reduction. HCPs should also document any follow-up actions to be taken for missed appointments (e.g., texts, postcards, and calls from crisis centers). Since documentation has become the primary communication method among providers, HCPs are encouraged to include detailed descriptions in all assessments and progress notes (Action Alliance, 2018). Additional documentation should consist of the following:

• the date and time the suicide risk assessment was initially completed, as well as any updated assessments
• the validated tool used to perform the suicide risk assessment
• the patient’s response to the suicide risk assessment
• any complications, questions, or problems that occurred during the suicide risk assessment, and if the treating medical provider was notified
• identified risk factors
• a copy of the patient’s safety plan
• education provided to the patient and their family regarding the suicide risk assessment, safety planning, response to education, and details regarding any communication barriers (Action Alliance, 2018)

Adapted from the Action Alliance (2018), Table 3 provides an overview of the recommendations for suicide identification, assessment, and accompanying interventions based on the setting.

 
 

Table 3

Summary of Recommended Standard Care Assessment and Interventions According to Setting

Setting	Identification & Assessment	Interventions
		Safety Planning	Means Reduction	Caring Contacts
Primary Care (PC)	Identify suicide risk among all PC patients using a standardized scale. Emphasize patients with mental illness/SUDs.	Complete the SPI. If a risk is identified, enhance safety and refer to specialized care (active referral to hospital or outpatient care). Obtain consent to discuss the safety plan with family. Provide caring contacts.	As part of the SPI, discuss any lethal means considered by and available to the patient. Arrange and confirm removal or reduction of lethal means if feasible. Involve family and close contacts so they can suicide-proof the home.	Make an appointment with a mental health professional. Complete one caring contact (phone call, text, e-mail) within 48 hours of the visit or the next business day.
Outpatient Mental Health/ Substance Misuse Care	Identify and assess suicide risk at admission and each time the patient is seen using a standardized scale. Provide treatment and support for individuals who may have elevated suicide risk.	Complete the SPI during the initial visit to enhance safety for those with risk. Update the safety plan at each visit if the risk remains high. Provide caring contacts.	As part of the SPI, discuss any lethal means considered by and available to the patient. Arrange and confirm removal or reduction of lethal means if feasible.	Initiate caring contacts during care transitions or if appointments are missed.
Emergency Department	Use a standardized scale to identify and assess patients who have harmed themselves, have mental health conditions (e.g., depression, SUD), or receive treatment (e.g., psychiatric medications).	Complete the SPI to enhance safety for those with risk. Obtain consent to discuss the safety plan with the family to gain support for safety activities. Refer the patient to a hospital or outpatient care if a risk is found. If an immediate transfer is not possible, provide a space for the patient that is safe, monitored, and clear of items that could be used to harm self or others.	As part of the SPI, discuss any lethal means considered by and available to the patient. Arrange and confirm the removal or reduction of lethal means if feasible.	Provide two caring contacts, one within 48 hours of the visit. Complete the second within 7 days of the visit. Refer to specialized care. Make an appointment with a mental health professional for the patient.
Inpatient Mental Health Care	Brief hospital treatment is needed for individuals who may have a high risk of suicide. A suicide attempt may precipitate admission. Identify and assess suicide risk at admission and daily during the patient’s stay—or more frequently as indicated by the level of risk—using a standardized scale.	Complete the SPI at admission and again before discharge, focusing on safety in the patient’s post-discharge environment. Work with the patient on a safety plan for their environment immediately post-discharge. Focus on keeping patients safe while in the hospital and immediately following discharge. Safety activities and suicide precautions should be implemented as per hospital policy. Discuss the safety plan with the family to gain support for safety activities.	As part of the SPI, discuss lethal means considered by and available to the patient. Arrange and confirm removal or reduction of lethal means where feasible before discharge.	Make an appointment with a mental health professional. Complete one caring contact within 48 hours of discharge and the second within 7 days of discharge.

(Action Alliance, 2018)

 
 

Long-Term Treatment and Management of Suicidality 

Outpatient HCPs serve ongoing roles in providing a vast array of services to help patients move beyond suicide. The goal of outpatient care is to prevent suicide and enhance overall health and well-being (Action Alliance, 2019). Continuity of care is critical for patients with suicide attempts or suicidal ideation. Effective clinical care should include monitoring patients for a suicide attempt after an emergency department visit or hospitalization and providing outreach, mental health follow-up, therapy, and case management. Many guidelines offer elements of evidence-based practice for suicide prevention as devised by several accredited organizations. While each guideline portrays varying degrees of intervention with appropriate evidence, overall differences in the principles guiding suicide risk assessment and its approach are marginal. The Joint Commission (2019) has released a special advisory report defining new requirements for the National Patient Safety Goal 15.01.01, which identifies how to manage patients at risk for suicide. Various psychosocial interventions have been beneficial for individuals experiencing suicidal ideation or behaviors. The healthcare team should provide evidence-based clinical approaches to reduce suicidal thoughts and actions to improve outcomes. Suicide-specific therapy approaches include the following:

• Brief CBT (BCBT)
• CBT for suicide prevention (CBT-SP)
• DBT
• Problem-solving therapy (PST)
• The collaborative assessment and management of suicide (CAMS)
• Caring contacts for post-discharge suicide prevention (Action Alliance, 2018; CDC, 2022b; NIMH, 2023f)

Cognitive Behavioral Therapy 

CBT was initially utilized for managing depression and was the first psychotherapy identified as evidence-based in most clinical guidelines (David et al., 2018). In addition to treating depression, CBT has demonstrated effectiveness for several other conditions, including anxiety, trauma (e.g., PTSD, childhood trauma, and sexual trauma), SUDs, eating disorders, and couples' discord. CBT may also help manage certain aspects of psychosis (e.g., psychotic episodes, schizophrenic delusions) and is validated across diverse demographics, including veterans and active service members (Stein & Norman, 2023).

BCBT and CBT-SP are both based on the CBT concept that individuals can first learn to recognize faulty thought patterns (the world would be better off without me) and then consider alternative conclusions. It teaches patients that they control their behaviors, which affect their thoughts, and their thought patterns also affect their behaviors. It has been proven to reduce repeat suicide attempts by roughly 50%. BCBT is a brief version (12 sessions) of CBT focusing on self-regulation and management and strengthening coping and communication skills. CBT-SP is a psychosocial intervention that has been shown to reduce suicide risk and prevent re-attempts. CBT-SP uses a risk-reduction, relapse-prevention approach that includes an analysis of the patient's risk factors and stressors (e.g., school or work-related difficulties, relationship problems) preceding and following the suicide attempt to create awareness and insight into behaviors. It includes safety planning, building coping skills, and improved communication skills through psychoeducation. CBT-SP can also be used to teach individuals new strategies for coping with stressful experiences, such as recognizing thought patterns and identifying alternative actions when thoughts of suicide arise. CBT-SP usually occurs in a one-on-one or group format and can vary in duration from several weeks to months, depending on patient needs. CBT-SP can also incorporate family support and communication patterns that focus on strengthening family dynamics and improving problem-solving and communication within the family unit. Furthermore, a treatment that fosters collaborative and integrated care has been shown to engage and motivate patients, increase retention in therapy, and decrease suicide risk (Bryan et al., 2019; CDC, 2022b).

Dialectical Behavioral Therapy (DBT)

DBT was initially intended to treat chronically suicidal patients who have BPD and its associated unstable moods, relationships, self-image, and behavior. Research has demonstrated that DBT serves a beneficial role in all forms of suicide prevention and is also effective in treating other disorders such as SUD, depression, PTSD, attention deficit disorder, bipolar disorder, and eating disorders. DBT is a multi-component CBT centered on treating disorders involving emotional dysregulation. It is most effective for people at high risk for suicide who also struggle with impulsivity. An RCT found a 50% reduction in suicide attempts in female patients and a significant decrease in suicidal ideations in adolescent patients treated with DBT at the 6-month follow-up mark. DBT assumes that many problems patients exhibit are caused by skills deficits, particularly impairments in regulating emotions and inadequate or maladaptive coping. It combines elements of CBT, skills training, and mindfulness techniques to help patients learn how to regulate their emotions, hone their interpersonal skills, and cope with stress. DBT includes four primary approaches to treatment delivery: individual psychotherapy, group skills training, between-session or "in-the-moment" telephone coaching, and a therapist consultation team. These approaches are implemented with an ongoing effort to maintain a dialectical balance between accepting reality and changing dysfunctional behaviors. DBT offers a range of skills training to bridge this gap, focusing on building emotional control and healthy coping behaviors to avert maladaptive behaviors during stressful situations, thoughts, and feelings. This involves mindfulness, distress tolerance, interpersonal effectiveness, and emotional regulation skills. The core goals of DBT include the following:

• improve the patient's skills and motivation
• extend the newly formed skills to the environment
• enhance and maintain the patient's motivation to change
• structure the environment to optimize the implementation of the treatment

SAFETY is a treatment approach based on DBT that enhances social support from family and others, teaches new skills to manage stress and regulate behavior, and includes means reduction and safety planning (CDC, 2022b; NIMH, 2023f; Prada et al., 2018)

Problem-Solving Therapy (PST)

PST is a structured cognitive-behavioral intervention that helps patients focus on developing specific coping skills for problem areas. Patients engage in active problem-solving activities through a collaborative relationship with the therapist. Patients learn to identify and prioritize key problem areas and break them into manageable tasks to develop appropriate coping behaviors and solutions. PST has been shown to reduce suicidality and feelings of hopelessness in those with MDD and poor problem-solving skills. PST empowers patients to solve problems on their own. PST may range from 4 to 12 sessions, depending on individual needs, and typically involves the following seven stages:

• selecting and defining the problem
• establishing realistic and achievable goals for problem resolution
• generating alternative solutions
• implementing decision-making guidelines
• evaluating and choosing solutions
• implementing the preferred solutions
• evaluating the outcome (CDC, 2022b; SPRC, 2017)

Collaborative Assessment and Management of Suicidality (CAMS)

CAMS offers a flexible approach through which the clinician and patient collectively develop a unique treatment plan. The framework focuses on the patient’s engagement and cooperation in assessing and managing suicidal thoughts and behaviors and the therapist’s understanding of the patient’s suicidal thoughts, feelings, and behaviors. CAMS sessions incorporate ongoing patient feedback on which aspects of treatment are working (or not working) to strengthen the therapeutic alliance and increase the patient’s motivation to continue therapy. The duration of the CAMS treatment varies, depending on the patient’s needs. CAMS has demonstrated efficacy across five randomized controlled trials between 2011 and 2020, conducted in inpatient and outpatient settings. It has been shown to reduce suicidal ideation quickly in as few as 6 to 8 sessions, reducing overall symptom distress, depression, and hopelessness. CAMS strives to alter suicidal thoughts, increase hope, and improve clinical care retention. The Joint Commission and the CDC have identified CAMS as one of the best evidence-based clinical approaches to reducing suicidal thoughts and behaviors. A version for teens (CAMS-4Teens) and children (CAMS-4Kids) are in development (CDC, 2022b; CAMS-care, n.d.).

Caring Contacts for Post-Discharge Suicide Prevention

The care transition period is challenging for many reasons. The hospital has discharged the patient and is no longer providing ongoing care. Since the outpatient provider has not yet seen the patient, there is a transition period during which no one is providing direct supervision (Action Alliance, 2019). Psychiatrist Jerome Motto introduced the concept of caring contacts in the 1970s. The intent was to reduce a suicidal person’s perception of isolation and enhance feelings of connectedness. The premise of caring contacts is facilitating long-term communication for the patient with someone who expresses ongoing support and concern about the individual’s well-being. The contact should be initiated by the concerned individual and place no demands on the recipient (i.e., the patient). A recent systematic review of six RCTs indicated a protective effect against suicide attempts for up to one year but did not demonstrate a clear impact on suicide deaths or emergency department visits/hospitalizations (Skopp et al., 2023).

The Action Alliance (2019) and the VA (2019b) support the utilization of caring contacts as the standard of care for all individuals with significant suicide risk after acute episodes or when ongoing services are interrupted (e.g., a scheduled visit is missed). Caring contacts has demonstrated efficacy in reducing self-harm and preventing suicide in high-risk individuals. Caring contacts can be implemented by staff in any program that has provided acute care (i.e., emergency department or inpatient programs), outpatient programs that provide ongoing care (during high-risk periods or when an appointment is missed), or crisis centers that can offer follow-up under contract with other services. Various contact methods (text, email, phone call, or postal mail) can be useful. A recommended schedule is to make the first contact within 7 days of discharge, or 24 hours if not using telephone contact, and to continue this for 12+ months (Action Alliance, 2019; VA, 2019b). An RCT enrolled 658 active-duty soldiers and marines at risk for suicide. Over 12 months, caring contact communications were delivered via text messaging. These brief interactions focused only on expressing care, interest, and support. The intervention led to a 44% decrease in the odds of reporting any suicidal ideation during the follow-up period and a 48% decrease in the odds of reporting one or more suicide attempts (Comtois et al., 2019).

Similarly, the AAP (2023) suggests that primary care providers ensure a warm handoff (direct handoff between HCPs conducted in front of the patient) to a mental health provider before the patient leaves their office. A follow-up by phone is recommended a few days later. If the family reports that the mental health appointment is delayed, the HCP should follow up with the patient in their office or via telehealth in the interim to check in. With permission, the nurse and other behavioral health professionals at an adolescent's school should be notified to provide support there as well (AAP, 2023).

Depression

Estimates from the NSDUH indicate an increase in the prevalence of depression, which was 7.8% in the US in 2019 and increased to 8.8% in 2022 amongst adults over 18. This trend also applies to adolescent respondents over 12, who reported a prevalence of MDE in the past year of 15.7% in 2019, increasing to 20.1% and 19.5% in 2021 and 22 (Goodwin et al., 2022; NIMH, 2023c; SAMHSA, 2023c). Suicidality among those with depression seems to correlate most with feelings of worthlessness and/or hopelessness. Concurrent personality disorder or anxiety disorder further increases this risk. Although most people who have depression do not die by suicide, having MDD does increase suicide risk compared to people without depression. The risk of death by suicide may, in part, be related to the severity of a person’s depression (APA, 2020; NIMH, 2023b; Schreiber & Culpepper, 2023). The most common signs and symptoms of MDD/MDE include the following:

• significantly reduced interest or enjoyment in most activities for the majority of the day, practically every day, self-reported or observed*
• poor or sad mood for the majority of the day most days; may include self-reports of unhappiness, unfulfillment, or despondency or tearfulness observed by others*
• psychomotor excitement or delay most days; must be obvious to others, not solely a self-report of symptoms
• reduced mental clarity, focus, or decision-making almost every day
• feelings of insignificance or extreme, unwarranted guilt most days; may be unrealistic
• substantial (at least 5% of total body weight) unintentional decrease or increase in weight in a month
• the inability to sleep at night or stay awake during the day despite getting an adequate amount of sleep the night before most days
• feeling lethargic, weary, or exhausted most days
• a preoccupation with death, consistent suicidal ideations with or without a specific plan, or an attempted suicide (APA, 2020, 2022a; NIMH, 2023b)

Depression Screening and Diagnosis

Best-practice guidelines recommend screening individuals for depression using the Patient Health Questionnaire­-2 (PHQ-2). The PHQ-2 asks the following priority questions (APA, 2022a; HHS, 2021; SAMHSA, 2017):

• Over the past 14 days, how often have you been bothered by any of the following problems?
  • little interest or pleasure in doing things
  • feeling down, depressed, or hopeless

Patients who respond ‘yes’ to either of the questions on the PHQ-2 should undergo additional screening with the PHQ-9—a multipurpose, 9-item symptom checklist used to screen for, diagnose, monitor, and measure the severity of depression. The PHQ-9 incorporates the DSM-5 diagnostic criteria for depression and a question that screens for the presence and duration of suicidal ideation. The tool is brief, easily used in clinical practice, and rapidly scored. It is also useful when monitoring for improving or worsening symptoms. In addition, HCPs should evaluate for any acute safety risks (e.g., harm to self or others, psychotic features) and assess the patient’s functional status, medical history, past treatment, and family history. While useful and validated for the screening of patients for potential depression, most contend that the PHQ-9 is an insufficient assessment for suicide risk and suicidal ideation compared to other tools, such as the C-SSRS and SAFE-T (Na et al., 2018). Table 4 reviews the DSM-5-TR diagnostic criteria for depression.

 

Table 4

DSM-5-TR Diagnostic Criteria for MDD

Criterion A (at least five signs are required over at least 14 days)	The presence of either (a) lack of interest/enjoyment or (b) depressed mood, in addition to the following: significantly reduced interest or enjoyment in most activities for the majority of the day, practically every day, self-reported or observed poor or sad mood for the majority of the day most days; may include self-reports of unhappiness, unfulfillment, or despondency or tearfulness observed by others psychomotor excitement or delay most days; must be obvious to others, not solely a self-report of symptoms reduced mental clarity, focus, or decision-making almost every day feelings of insignificance or extreme, unwarranted guilt most days; may be unrealistic substantial (at least 5% of total body weight) unintentional decrease or increase in weight in a month inability to sleep at night or stay awake during the day despite getting an adequate amount of sleep the night before most days feeling lethargic, weary, or exhausted most days preoccupation with death, consistent suicidal ideations with or without a specific plan, or an attempted suicide
Criterion B (required)	Symptoms create substantial anguish or dysfunction in essential settings, such as work, school, or around friends/family.
Criterion C (required)	The symptoms are unrelated to the effects of a physical illness or substance use.
Criterion D	Another mental health disorder cannot better explain the symptoms.
Criterion E	There is no history of a period of manic or hypomanic symptoms (unrelated to substance use or another physical illness).

(APA, 2022a)

Treatment and Management of Depression

An individualized treatment plan should be developed using shared decision-making (SDM) and will vary based on the patient’s severity level (mild, moderate, or severe). Treatment for depression may include psychotherapy and/or antidepressant medication. Adequate treatment can reduce the risk of suicide related to depression (APA, 2020; NIMH, 2023b; VA, 2022).

Non-Pharmacologic Treatments for Depression

Numerous non-pharmacological treatment options may be explored and discussed with patients who wish to avoid medications or desire adjunctive therapy (NIMH, 2023b). Psychotherapy is a successful, beneficial, and cost-effective treatment for depression. The APA (2022b) defines psychotherapy as any psychological service moderated by a trained professional (i.e., psychotherapist) that employs communication and interaction principles to assess, diagnose, and treat mental health disorders. Also referred to as talk therapy, psychotherapy is premised on establishing a supportive environment and collaborative relationship between a patient and a psychotherapist to foster open discussion in an objective, neutral, and nonjudgmental manner. A psychotherapist includes any individual professionally trained and licensed according to their respective governing state-licensing boards to treat mental health conditions (e.g., psychologist, psychiatrist, psychiatric nurse, advanced practice registered nurse [APRN], counselor, therapist, or social worker). Research demonstrates that depressed individuals who receive psychotherapy achieve more durable treatment responses (i.e., are less prone to relapse) and better symptom control than when medication is used alone. Although psychotherapy is effective, it is underutilized and can be difficult to access at times, depending on location, and may not be covered or only partially covered by medical insurance. Most forms of psychotherapy can be performed in private offices, community centers, inpatient or outpatient treatment programs, VA facilities, counseling centers, and educational settings. Traditional psychotherapy involves in-person sessions, but a growing number of therapists are providing online (remote) therapy sessions, as demand has dramatically risen during the COVID-19 pandemic with an increased reliance on technology. Research demonstrates that online psychotherapy has comparable efficacy to in-person approaches, and this continues to be a topic of investigation as more patients opt for online therapy (Luo et al., 2020).

While there are several types of psychotherapy, the most effective options for depression include CBT, mindfulness-based CBT (MBCT), PST, behavioral activation (BA), and interpersonal therapy (IPT). Each patient and psychotherapist are encouraged to set mutually agreed upon and realistic goals periodically reevaluated. Patient response varies based on the presenting issue, severity, complexity, interference with functioning, openness to receiving treatment, and specific interventions. If patient improvement does not occur within the planned duration of treatment, the intervention should be reassessed, and other therapeutic strategies should be considered. There is no universally effective approach to treating depression. Experienced psychotherapists typically blend modalities and tailor the treatment to meet each patient's needs, often altering the treatment course when underlying issues are revealed as the patient progresses through therapy (APA, 2019; Luo et al., 2020; Wampold, 2019).

MBCT integrates traditional CBT interventions with a mindfulness-based stress reduction (MBSR) modality into an 8-week program designed to help patients cope with health concerns and their physical and mental impact. MBCT helps patients focus on the present in a nonjudgmental and accepting manner. It does not seek to modify or eliminate dysfunctional thoughts. Instead, it focuses on assisting patients to become more detached and observe their thoughts objectively without necessarily attempting to change them. MBCT focuses on developing mindfulness through meditation, imagery, experiential exercises, and relaxation techniques (Craske, 2017; Stein & Norman, 2023).

Behavioral Therapy/Behavioral Activation (BT/BA). BA is chiefly indicated for those suffering from depression, presupposing that cognitions are sources of avoidance that sustain depressive symptoms. Research demonstrates that when people feel depressed, they tend to disengage from (or avoid) everyday routines and withdraw from social environments. Over time, avoidant behaviors worsen depression as people isolate themselves and lose opportunities for positive reinforcement. BA effectively treats depression by generating a balance of goals centered on values, pleasure, and proficiency. Patients track their activities and identify the affective and behavioral consequences of such actions. Activity monitoring creates awareness and insight into underlying behaviors that negatively impact mood. It explores three fundamental elements of behavior change: the patient's values (i.e., things they find meaningful), pleasures (i.e., enjoyable activities or hobbies), and mastery (i.e., actions such as work or sports that involve the development of new skills, a sense of accomplishment, and a feeling of mastery over the environment; Craske, 2017; Stein & Norman, 2023).

Interpersonal Therapy (IPT). IPT focuses on improving problems within personal relationships as a core component of depression. While an event or a relationship may not always cause depression, depression affects relationships and can create interpersonal problems. IPT is a short-term (6-20 sessions) treatment that focuses on interpersonal issues as a factor in psychological distress. IPT is derived from attachment theory, and it treats depression by focusing on improving interpersonal functioning and exploring relationship-based difficulties (IPT Institute, n.d.).

Brain Stimulation Therapy. Brain stimulation therapies may be considered when other treatments for depression have proven ineffective. Brain stimulation therapy includes electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS; NIMH, 2023a).

             ECT. ECT involves transmitting short electrical impulses into the brain. These controlled electric currents provoke a brief period of seizure-like activity. It has been cleared by the US Food & Drug Administration (FDA) for the treatment of severe MDD or bipolar disorder in patients over the age of 12. ECT is typically performed in a series of 4-6 treatments before an improvement can be expected, with 6-12 total treatments administered over 2-6 weeks; monthly maintenance treatments are sometimes required. The patient is placed under general anesthesia for the treatments (i.e., an anesthetic and a muscle relaxer) and can resume normal activity about an hour following the procedure. ECT can have significant adverse effects, such as headaches, muscle pain, nausea, confusion, and memory loss. These can be minimized by using unilateral ECT (versus bilateral electrode placement) and brief or ultra-brief pulses. It is only utilized in severe depression (i.e., with catatonia, suicidality, or anorexia), depression with psychosis, or bipolar disorder that has not responded to more conventional treatment methods (i.e., medication and psychotherapy). ECT's potential risks and benefits must be explained to the patient before beginning treatment (NIMH, 2023a). Most patients treated with ECT reported complete resolution in their suicidal ideations after 2 weeks of therapy (61%), and 4 out of 5 reported full resolution by the end of treatment (Salik & Marwaha, 2022). The VA guidelines on the treatment of MDD state that ECT should be considered for those with severe or treatment-resistant MDD with catatonia, suicidality, psychosis, prior response to ECT, or another feature that makes a rapid response to treatment with ECT favorable (VA, 2022).

rTMS. rTMS is a relatively new type of brain stimulation that uses a magnet instead of an electrical current to activate the brain. The FDA has cleared it for the treatment of moderate to severe MDD and obsessive-compulsive disorder (OCD). rTMS creates rapidly alternating magnetic fields using a large magnetic coil placed on the patient’s forehead (over the left prefrontal cortex). Patients may need to complete daily sessions of 30-60 minutes, 5 days per week, over 4-6 weeks to see improvement, although accelerated protocols are being established. rTMS is contraindicated in patients with pacemakers or metal objects in their heads. The patient remains alert throughout the treatment, and general anesthesia is not required. rTMS must be used with caution in patients with a history of seizures, as it is possible to induce seizure activity (although rare). Mild adverse effects include muscle contractions or tingling in the face/jaw/scalp, headaches/discomfort where the magnet is placed, dizziness, and lightheadedness (NIMH, 2023a). The VA guidelines on the treatment of MDD suggest that rTMS be considered for those with treatment-resistant MDD after a trial of two or more pharmacological agents (VA, 2022).

Complementary and Alternative Medicine. Complementary and alternative medicine treatments can be used as an adjunct to other evidence-based treatments for depression. When these interventions are combined with evidence-based treatment options, such as prescription medications and psychotherapy, they can contribute to the overall treatment plan for depression. Some complementary and alternative treatments with evidence of positive contributions to the treatment of depression are described below.

            Exercise. Exercise increases endorphins and stimulates the secretion of norepinephrine, which can improve a person's mood. According to a 2021 report by Harvard Health Publishing, the hippocampus in the brain (the region responsible for regulating mood) is smaller in people with depression. Low-intensity exercise sustained over time stimulates the release of proteins that cause nerve cells to grow and generate new connections. This improves brain function, supports nerve cell growth in the hippocampus, and improves nerve cell connections. All these processes help to alleviate depressive symptoms (Harvard Health Publishing, 2021). Exercise is a recommended adjunct treatment in the VA's current clinical practice guideline on MDD (VA, 2022).

Yoga. Yoga is a mind and body practice founded in ancient Indian philosophy. It centers on achieving a relaxation response through spirituality and meditation, an integral component of yoga. The National Center for Complementary and Integrative Health (NCCIH, 2023) reports that a 2017 review of 23 studies found yoga reduced depression symptoms in 14 of the studies reviewed. A 2020 review that included seven studies (n= 260 patients diagnosed with MDD) found that adjunct yoga might provide a little additional benefit to patients when incorporated into a comprehensive treatment plan (NCCIH, 2023).

Acupuncture and music therapy may reduce symptoms of depression. Music therapy has shown short-term benefits, and acupuncture has shown a reduction in depression symptoms compared to no treatment or control. Omega-3 fatty acids may have a small effect as an adjunctive treatment for depression symptoms; the evidence in randomized trials of omega-3 fatty acids as a monotherapy for depression is inconclusive. Some studies suggest that St. John's wort (Hypericum perforatum) may affect mild to moderate MDD, but the evidence is not definitive. There are important safety concerns with this supplement due to several known drug interactions. There is no evidence to support the use of S-adenosyl-L-methionine (SAMe) or inositol in the treatment of depression (NCCIH, 2021). The VA's practice guideline on MDD treatment suggests St. John's wort (Hypericum perforatum) as monotherapy in those with mild MDD who are not pregnant or breastfeeding and who prefer an herbal treatment to first-line psychotherapy or pharmacotherapy. They found insufficient evidence to suggest the use or avoidance of acupuncture, biofeedback, or meditation. The VA guidelines for MDD recommend against the use of vagus nerve stimulation, deep brain stimulation, psilocybin, 3,4-methylenedioxymethamphetamine (MDMA), cannabis, and other unapproved pharmacologic treatments outside of a research setting. They also recommend against using vitamin D or omega-3 fatty acids to treat MDD (VA, 2022).

Pharmacologic Treatments for Depression

Antidepressant medications are the pharmacological treatment of choice for depression. Medication therapy aims to help reduce or control the symptoms of depression. The bulk of medications currently FDA-approved for treating depression target the three neurotransmitters historically associated with depression: serotonin, norepinephrine, and dopamine. Most agents must be initiated at low doses, tapered up slowly when starting, and tapered down before discontinuing. Antidepressants should not be abruptly stopped due to the risk of withdrawal and return of depressive symptoms. If they are stopped abruptly, withdrawal-like symptoms may ensue, such as dizziness, headaches, flu-like syndrome (tiredness, chills, muscle aches), agitation, irritability, insomnia, nightmares, diarrhea, and nausea. Regardless of the medication prescribed, patients must be counseled that antidepressants take several weeks to have an effect and 12 weeks to achieve full benefits. While mild-to-moderate depression can often be treated with therapy alone, moderate-to-severe cases of depression often require the addition of medication. Women of childbearing age should be advised that most antidepressants were previously assigned to pregnancy category C by the FDA and fetal risk cannot be ruled out (NIMH, 2022; Sheffler et al., 2023; VA, 2022).

Monoamine oxidase inhibitors (MAOIs) were the first type of antidepressant medications developed. They impair the metabolism of serotonin, norepinephrine, and dopamine by blocking monoamine oxidase, an enzyme that also breaks down excess tyramine in the body. MAOIs include tranylcypromine (Parnate), phenelzine (Nardil), isocarboxazid (Marplan), and a transdermal skin patch (selegiline [Emsam]). Due to the risk of serious adverse effects, the use of MAOIs for the treatment of depression should be reserved for patients who have failed all other treatment options (not first-line). MAOIs have dangerous drug and food interactions. Selective serotonin reuptake inhibitors (SSRIs) are usually the safest initial choice and cause the fewest side effects. SSRIs include drugs such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox CR), paroxetine (Paxil), and sertraline (Zoloft). Serotonin-norepinephrine reuptake inhibitors (SNRIs) include duloxetine (Cymbalta), venlafaxine (Effexor), desvenlafaxine (Pristiq), levomilnacipran (Fetzima), and milnacipran (Savella). Atypical antidepressants include bupropion (Wellbutrin), which can cause insomnia and lower the seizure threshold, and mirtazapine (Remeron), which can cause sedation and weight gain. Tricyclic and tetracyclic antidepressants (TCAs) are an older class of medications, including amitriptyline (Elavil), nortriptyline (Pamelor), clomipramine (Anafranil), imipramine (Tofranil), and desipramine (Norpramin). They also inhibit norepinephrine and serotonin reuptake but carry significantly more adverse effects than SSRIs or SNRIs (Rush, 2023; Sheffler et al., 2023).

The American Geriatrics Society (AGS) Beers Criteria of potentially inappropriate medication use in older adults publishes medications that should be avoided in older patients (65 years and older). The most recent version indicates that TCAs should be avoided when possible due to their strong anticholinergic effects (i.e., sedation and orthostatic hypotension). They also caution that TCAs, SNRIs, and SSRIs may increase the risk of falls in older adults. Mirtazapine (Remeron), TCAs, SSRIs, and SNRIs can also cause or exacerbate syndrome of inappropriate antidiuretic hormone (SIADH) and should be used with caution in those at increased risk (AGS, 2023).

Antidepressants can increase serotonin levels in the body, posing a risk of serotonin syndrome, which is characterized by agitation, anxiety, confusion, high fevers, sweating, tremors, lack of coordination, dangerous fluctuations in blood pressure, and rapid heart rate. Serotonin syndrome is a potentially life-threatening condition for which patients must seek immediate medical attention. Drug interactions with other medications that increase serotonin levels, such as triptans used to treat migraines, can cause serotonin syndrome (NIMH, 2022; Sheffler et al., 2023). The most common adverse effects of antidepressants include sexual dysfunction, weight changes, sedation or insomnia, dizziness, headache, anxiety, dry mouth, nausea, blurry vision, tremor, rash, asthenia, and fatigue. Sometimes, antidepressants can cause hyperprolactinemia, SIADH, or hyponatremia as well. Other adverse effects are listed in Table 5 by class.

Table 5

Common Side Effects of Antidepressants by Medication Class

	SSRIs	SNRIs	TCAs	MAOIs
Possible Side Effects	headaches, sexual dysfunction, appetite change leading to weight change, QTc prolongation (citalopram [Celexa], escitalopram [Lexapro])	Gastrointestinal (GI) toxicity, headaches, hypertension, diaphoresis, bone resorption, sexual dysfunction (venlafaxine [Effexor])	dry mouth, urinary retention, constipation, drowsiness, weight gain, sexual dysfunction, cardiac effects (QRS prolongation and orthostatic hypotension), seizures	orthostatic hypotension, weight gain, sexual dysfunction
Warnings and Monitoring	serotonin syndrome, suicide risk, withdrawal symptoms if stopped abruptly

 (Rush, 2023; Sheffler et al., 2023)

A newer group of antidepressants work as serotonin modulators, inhibiting the reuptake of serotonin. Vortioxetine (Trintellix) is also a mixed antagonist/agonist of specific serotonin receptors. Vilazodone (Viibryd) is also a partial serotonin receptor agonist. Trazodone (Oleptro) antagonizes serotonin and alpha-1 adrenergic receptors. Similarly, nefazodone (Serzone) antagonizes serotonin receptors and blocks the reuptake of norepinephrine and serotonin. These medications tend to cause drowsiness and orthostatic hypotension (trazodone [Oleptro] and nefazodone [Serzone]), GI upset, and sexual dysfunction. Finally, new research on antidepressants for treatment-resistant MDD has centered around esketamine (Spravato), a non-selective, non-competitive N-methyl-D-aspartate (NMDA) antagonist. Instead of serotonin, norepinephrine, and dopamine, this medication alters the brain's glutamate and gamma-aminobutyric acid (GABA) activity. It is administered twice or once weekly as a nasal spray in combination with an oral antidepressant. It can cause perceptual changes, sedation, and dissociation, and there is significant potential for misuse. It is contraindicated in those with aneurysmal vascular disease (NIMH, 2022; Rush, 2023; Sheffler et al., 2023). The VA guidelines on the treatment of MDD suggest that ketamine (Ketalar)/esketamine (Spravato) be considered for those with treatment-resistant MDD after a trial of two or more first-line pharmacological agents (VA, 2022).

Antidepressants and the Risk of Suicidal Thoughts. In 2004, the FDA required a warning to be printed on the labels of all antidepressant medications regarding the risk of increased suicidality among children and adolescents taking these medications. The warning was expanded in 2007 to include all young adults, especially those under the age of 25, stating that these individuals may experience an increase in suicidal thoughts or behaviors during the first few weeks of taking an antidepressant. Before starting the medication, the individual may have been too paralyzed by depression to make a suicide plan. For that reason, the risk of suicide rises while the depressive symptoms start to improve. An increase in suicidal thoughts has also been documented in patients taking antidepressants for other conditions or indications. As antidepressants became more commonly prescribed for anxiety and OCD, the reports of patient's suicidal thoughts and actions became more worrisome to physicians and family members. If a depressed person on antidepressants becomes suicidal, it is cause for concern. However, if someone who was not previously depressed and taking antidepressants for another indication becomes suicidal, it raises additional questions about these medications’ safety. Researchers found evidence that individuals taking antidepressant medication may have an even higher risk of suicide than individuals whose depression is improving for other reasons (Fornaro et al., 2019). The FDA also requires manufacturers to provide a Patient Medication Guide (MedGuide), which is given to patients receiving these medications to advise them of the risks and precautions that can reduce the risk of suicide. Further, clinicians are advised to ask about suicidal thoughts before prescribing antidepressants to young persons (FDA, 2018). Table 6 lists the points that must be included in the boxed warning.

Table 6

FDA Antidepressants Boxed Warning Points

Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with MDD and other psychiatric disorders.

Anyone considering the use of an antidepressant for a child or adolescent for any clinical use must balance the risk of increased suicidality with the patient’s clinical need.

Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior.

Families and caregivers should be advised to observe the patient closely and communicate with the prescriber.

A statement must be provided on whether the particular drug is approved for any pediatric indication(s) and, if so, which one(s).

 (FDA, 2018)

For more information on depression and mental health pharmacology, refer to the following NursingCE courses: Depression and Mental Health Pharmacology.

Suicide and Suicide Prevention in Veterans

Veterans, active military members, and their family members are more likely to suffer from mental health disorders than those who have never served in the armed forces. According to the 2021 NSDUH, 3.1 million adult veterans reported a mental illness in the past year (most common amongst veterans between 18 and 49), and 617,000 adult veterans had serious thoughts of suicide. In addition, 1.7 million adult veterans received mental health services during 2021. Despite the significant consequences and disease burden associated with mental illness, the SAMHSA report indicates tremendous treatment gaps. For example, mental health services were received by only 56.4% of adult veterans with mental illness and only 46.6% of adult non-veterans (NIMH, 2023d; SAMHSA, 2023a).

Between 14% and 16% of service members returning from deployment in Iraq and/or Afghanistan have PTSD or depression. Others return with TBI or related comorbid conditions such as SUD. The impact of deployment, the demands, dangers, and traumas of combat, and the separation of families often provoke deep-rooted and ongoing challenges for veterans and their families (Inoue et al., 2023). According to the VA, 7% of veterans will have PTSD at some point in their life. Among those who served in Iraq or Afghanistan, this rate is 15% to 29% (VA, 2023b).

According to statistics from the National Veteran Suicide Prevention Annual Report (VA, 2023a), the number of veteran suicides was 6,392 in 2021. Between 2001 and 2021, the suicide rate amongst veterans peaked at 33.9 per 100,000 in 2021, following a fall of 9.7% from 2018 to 2020. This sharply contrasts the rate for non-veteran US adults of 16.7 per 100,000 in 2021. Between 2001 and 2020, the veteran suicide rate exceeded the rate for non-veteran adults each year, with a differential ranging from 12% (in 2002) up to 66% (in 2017). Firearms were the method of suicide in 73.4% of male veteran suicide deaths and 51.7% of female veteran suicide deaths in 2021. Overall, a firearm was the method involved in 72% of veteran suicides versus just 52% of non-veteran suicides (VA, 2023a).

The stigma regarding mental health is still evident within the military culture. Many veterans view seeking mental health care as a weakness or fear that seeking help will interfere with their future military career or promotions. For this and other reasons, many veterans opt to seek treatment in civilian hospitals, clinics, and primary care settings. HCPs serve a vital role in dispelling the stigma and should engage with veterans without inadvertently reinforcing these misconceptions. All HCPs must be prepared to care for military members and veterans across primary care, urgent care, emergency, and hospital settings. The veteran suicide rate is at least 1.5 times the rate for non-veteran adults, with firearms accounting for a disproportionately large percentage of veteran suicide deaths. To care adequately and effectively for veterans and their families, HCPs must complete training on the unique challenges this population faces (SAMHSA, 2023b; VA, 2019a, 2019b).

The VA (2019a, 2019b) has identified risk factors for suicide that are associated with a veteran's military service, and these largely mimic the general risk factors listed previously, such as:

• prior suicide attempts and current suicidal ideations
• recent psychosocial stressors
• exposure to extreme stress (e.g., frequent deployments, especially to hostile environments or for long periods)
• access to lethal means (e.g., firearms)
• physical or sexual assault while serving
• service-related injury
• prior diagnosis and treatment for mental illness, especially hospitalization (VA, 2019a, 2019b)

The VA (2019b) lists many of the same protective factors previously mentioned, such as strong coping skills, reasons for living, and relative psychosocial stability. The VA endorses the use of the PHQ-9 as a valid screening tool. According to the Veterans Crisis Line (n.d.), veterans who are considering suicide often show signs of depression, anxiety, or low self-esteem.

Military Cultural Competence

The unique needs and challenges veterans and their families face are well-cited across medical literature. The need for a culturally competent approach to mental health services and treatment continues to be of the utmost importance. HCPs should convey to veterans that they recognize the importance of their military background and have taken the time to acquire a foundational understanding of military culture. The ability to tailor clinical practice based on a knowledge of and appreciation for the veteran’s background is imperative to establish rapport and build effective therapeutic working relationships. Resilience—the ability to regroup and recover—is a crucial facet of military life, especially during and after deployment. Military ethos is vital to military culture and the foundation for resiliency. Conversely, military ethos can create a vulnerability when these beliefs serve as a barrier to resources, support, and hope. Comprised of six traits, Table 7 illustrates each aspect of the military ethos and its impact (SAMHSA, 2023a; Uniformed Services University [USU], n.d.).

Table 7

Military Ethos: Strengths and Weaknesses

Trait	Why This is a Strength	How This Could Become a Weakness
Selflessness	placing the welfare of others above personal welfare	not seeking help for health problems because personal health is not a priority
Loyalty	committing to accomplishing missions and protecting comrades in arms	feeling survivor’s guilt and complicated bereavement after losing friends
Stoicism	displaying toughness and an ability to endure hardships without complaining	not acknowledging significant symptoms and suffering after returning home
Moral Code	following an internal moral compass to choose right over wrong	feeling frustrated and betrayed when others fail to follow a moral code
Social Order	achieving meaning and purpose when defending societal values	losing meaning or feeling betrayed when rejected by society
Excellence	becoming the best and most effective professional possible	feeling ashamed of or not acknowledging imperfections

(USU, n.d.)

Suicide Warning Signs in Veterans

The Veterans Crisis Line (n.d.) and the VA (2019b) have identified the following warning signs that may indicate a veteran is at increased risk of suicide:

• performing poorly at work or school
• acting recklessly or engaging in risky activities that could lead to death (e.g., driving at fast speeds or running red lights)
• showing unusual rage, anger, frustration, or violent behavior (e.g., punching holes in walls or getting into fights)
• giving away prized possessions, putting affairs in order, or tying up loose ends
• anxiety, agitation, sleeplessness, or mood swings
• hopelessness, feeling that there is no way out or reason to live
• increasing alcohol or drug abuse
• withdrawing from family and friends (Veterans Crisis Line, n.d.; VA, 2019b)

Risk Assessment in Military Personnel and Veterans

Veterans may not share information regarding their military service with HCPs without prompting. Therefore, a core component of all health history-taking and clinical assessments is to ask, “Have you ever served in the military?” Family members may have also been impacted by military service and should be screened by asking, “Do you have a close family member who has served in the military?” Once military service is confirmed, the HCP should ask about the service period for a more detailed assessment of the veteran’s mental health. The VA (2019b) clinical practice guidelines suggest that all HCPs should adhere to the following guidelines when inquiring about military health history:

• ask questions in a safe and private area
• maintain eye contact
• use a supportive tone of voice
• ask permission before delving into the specifics of the veteran’s experience (e.g., ”May I ask you about stressful experiences that people can have during their military service?”)
• thank veterans for disclosing any stressful or traumatic experiences
• never leave someone alone who is suspected to be in an acute suicidal crisis (VA, 2019a, 2019b)

Military service may have included chemical or biological exposures (e.g., pollutants, solvents, chemical weapons, infectious diseases, biological weapons), psychological trauma (e.g., mental or emotional abuse, moral injury, combat casualties), physical injury (e.g., TBI, bullet wound, shell fragment, motor vehicle collision, radiation, noise injury), or unwanted sexual experiences (e.g., military sexual trauma [MST]). According to the VA (2019a, 2019b), a comprehensive mental health assessment must include screening for PTSD, depression, and suicide risk. Screening for these conditions requires more than asking straightforward questions or completing a checklist. Instead, it involves open-ended queries that offer insight into possible symptoms associated with each condition. These assessments can be eye-opening to veterans who may not have formally acknowledged their symptoms as a component of an illness (VA, 2019a, 2019b).

The VA (2019b) guidelines advise that the following components should be included in veterans’ suicide risk assessment:

• current suicidal ideation
• prior suicide attempt(s)
• current psychiatric conditions (e.g., mood disorders, SUDs) or symptoms of any preexisting psychiatric condition (e.g., hopelessness, insomnia, agitation)
• prior psychiatric hospitalization(s)
• recent biopsychosocial stressors
• availability of firearms and other lethal means (VA, 2019b)

Table 8 outlines several central aspects of veteran mental health screening assessments (VA, 2019a, 2019b)

 

Table 8

Mental Health History Screening: Questions to Ask

Concern	Questions
PTSD	Are you concerned that you might have PTSD? Indications may include re-experiencing symptoms such as nightmares or intrusive thoughts, hyperarousal/being “on guard,” avoiding situations that remind you of the trauma, and/or numbing of your emotions.
MDD	Have you been experiencing sadness, feelings of hopelessness/helplessness, a lack of energy, difficulty concentrating, and/or poor sleep?
Suicide	Have you had thoughts of harming yourself or others?
MST	Did you have any unwanted sexual experiences in the military, such as threatening or repeated sexual attention, comments, or touching? Did you have any sexual contact against your will or when unable to say no, such as when forced, asleep, or intoxicated?

 (VA, 2019a)

The HCP should inquire about recent or upcoming transitions and note other indicators of change (e.g., retirement physical and overseas duty screening). The HCP should facilitate enhanced social support during the transition if other risk factors are present (Action Alliance, n.d., 2018; VA, 2019a, 2019b).

If not already enrolled, all veterans should be provided with information about applying for benefits from the VA to ensure full coverage for treatment of any identified mental health disorders. Regarding interventions specifically for veterans, the VA (2019a, 2019b) recommends a crisis response plan for veterans with suicidal ideation or a history of suicide attempts, which mirrors the SPI detailed earlier. They also recommend restricting access to lethal means as a protective measure. They suggest considering the utility of notifying an active service member’s commander if the provider feels this would be helpful or protective. The VA strongly suggests the use of CBT or a similar approach focused on suicide prevention for those with a recent history of self-directed violence. For veterans with BPD, they recommend DBT (VA, 2019b).

Regarding medication, the VA endorses the use of intravenous ketamine (Ketalar) in patients with acute suicidal ideations and depression, which was shown to resolve suicidal ideation in 55% to 60% of patients 1-7 days after a single dose. For those with diagnosed bipolar disorder, they endorse treatment with lithium (Lithobid) or similar and suggest clozapine (Clozaril) for those with diagnosed schizophrenia or schizoaffective disorders. Caring contacts, as described above, are also recommended for 12 to 24 months following any hospitalization for suicidality. Home visits should be scheduled if a patient misses an outpatient visit. For veterans who present to the emergency department following a suicide attempt, the VA endorses the Brief Intervention and Contact (BIC) treatment plan. This includes an individual information session for an hour before discharge and several follow-up contacts via telephone or in-person visits for up to 18 months afterward. The BIC plan is performed under the supervision of a qualified and licensed mental health clinician (VA, 2019b).

MDD in Veterans

In veterans, depression may be triggered by life crises, especially trauma, combat injury, natural disasters, or MST. However, life changes—including the loss of a loved one or fellow soldier, retirement, deployment, financial problems, job change, or divorce—are also linked to veterans’ stress and depression. Exposure to trauma can alter the body’s response to fear and stress, leading to depression. While not every veteran exposed to trauma or life changes will develop depression, it is nearly 3-5 times more likely in those with PTSD than those without PTSD (National Center for PTSD, 2022; VA, 2019b, 2022). The VA (2022) recommends that all veterans be screened for depression. Treatment in the primary care setting should be collaborative/integrated and tailored based on the following factors:

• patient preference
• safety and side effect profile
• history of prior response to a specific medication
• presence of concurrent medical illnesses
• concurrently prescribed medications
• cost of drugs
• provider competence (VA, 2019a, 2019b, 2022)

Treatment for mild to moderate MDD should begin with either psychotherapy (e.g., acceptance and commitment therapy [ACT], BT/BA, CBT, IPT, MBCT, PST, or short-term psychodynamic psychotherapy) or pharmacotherapy. Treatment response should then guide the decision to augment therapy, provide combination treatment, or use a non-first-line treatment. Clinician-guided computer/internet-based CBT may be a reasonable option for mild to moderate depression. Psychotherapy is preferred over pharmacotherapy as a first-line treatment in those who are pregnant (unless already stable on pharmacotherapy) or over the age of 65. If pharmacotherapy is to be trialed, the VA guidelines recommend the use of an SSRI/SNRI, bupropion (Wellbutrin), mirtazapine (Remeron), trazodone (Oleptro), vilazodone (Viibryd), or (Trintellix) vortioxetine. These should be continued for 6+ months to avoid relapse of symptoms. The VA does not recommend esketamine (Spravato)/ketamine (Ketalar) for initial pharmacotherapy to treat depression unless the patient is acutely suicidal. MAOIs, TCAs, and nefazodone (Serzone) are also not recommended for initial pharmacotherapy. They recommend combination therapy (psychotherapy and pharmacotherapy) for severe MDD (PHQ-9 > 20), persistent depressive disorder (duration > 2 years), or recurrent MDD. rTMS and ketamine (Ketalar)/esketamine (Spravato) should be considered for those with treatment-resistant MDD after a trial of two or more pharmacological agents. ECT should be considered for those with severe or treatment-resistant MDD with catatonia, suicidality, psychosis, prior response to ECT, or another feature that makes a rapid response to treatment with ECT favorable. Light therapy should be considered for those with a seasonal pattern. Couples therapy should be considered for those with significant relationship distress. Exercise should be encouraged as an adjunct treatment in those with MDD (VA, 2022).

PTSD

PTSD is characterized by neural functioning changes in response to overwhelming stress, trauma, or horror (e.g., war, physical assault, or natural disaster). PTSD may be related to either direct or indirect exposure to the trauma, including bearing witness to or hearing about horrific events. The symptoms are not due to medication, substance use, or any other identifiable illness and cause significant distress or functional impairment. Combat stress is often confused with PTSD; however, there are key distinctions. Combat stress typically occurs for brief periods and is considered a natural reaction to the traumatic events endured during a deployment. These symptoms usually resolve after a service member returns home. The initial symptoms of PTSD may be similar, but PTSD is more severe and can manifest weeks, months, or years after the traumatic event. PTSD often impacts an individual's ability to meet daily life responsibilities (APA, 2022a; National Center for PTSD, 2022; VA, 2023b).

 Acute PTSD lasts for at least a month but no longer than 3 months, whereas chronic PTSD lasts for longer than 3 months. Less commonly, some cases of PTSD may occur years or even decades after the traumatic event(s). According to the DSM-5-TR, the main symptoms of PTSD include concerning intrusions about, and avoidance of, memories associated with the traumatic event (APA, 2022a). According to the VA (2022, 2023b), the percentage of veterans affected by PTSD varies by service era as follows:

• Approximately 15 of every 100 veterans who served in Operations Iraqi Freedom (OIF) or Enduring Freedom (OEF) have been diagnosed with PTSD in the past year, and 29/100 at some point in their lifetime.
• About 14 of every 100 Gulf War (Desert Storm) veterans have been diagnosed with PTSD in the past year, and 21/100 at some point in their lifetime.
• An estimated 10 of every 100 Vietnam War veterans developed PTSD in their lifetime

Various screening instruments are used to evaluate for PSTD, such as the PTSD Checklist for DSM-5 (PCL-5), which is a 20-item tool. The VA suggests using the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5; APA, 2022a; VA, 2023c). The diagnosis should then be confirmed using a validated, structured clinician-administered interview tool, such as the Clinician-Administered PTSD Scale or PTSD Symptom Scale- Interview Version. Disease severity should be monitored regularly using the PCL-5 or the Clinician-Administered PTSD Scale. While no preventative treatment is recommended for veterans exposed to trauma, those diagnosed with acute stress disorder following a trauma can be managed with trauma-focused cognitive behavioral psychotherapy to prevent the development of PTSD. The VA (2023c) recommends engaging patients in SDM, including educating patients about effective treatment options and developing a treatment plan based on individual needs and preferences. Individualized, trauma-focused psychotherapy is the recommended treatment for PTSD in veterans. Trauma-focused psychotherapy addresses the memory of the traumatic event. Veterans undergoing this type of psychotherapy typically attend 8 to 16 sessions exploring the traumatic event. Trauma-focused psychotherapy utilizes various techniques, such as visualizing and analyzing the trauma (i.e., through talk or reflection) and altering unhelpful beliefs about the trauma. Trauma-focused therapies with the most robust evidence for PSTD treatment in veterans include the following (VA, 2023c):

• Prolonged exposure (PE) includes relaxation skills, recalling details of the traumatic memory, reframing negative thoughts about the trauma, writing a letter about the traumatic event, or holding a farewell ritual to leave the trauma in the past.
• Cognitive processing therapy (CPT) teaches the veteran to reframe negative thoughts about the trauma by talking with the mental health provider about negative thoughts and completing short writing assignments.
• Eye-movement desensitization and reprocessing (EMDR) helps the veteran process trauma by calling it to the mind while paying attention to a bilateral external stimulus (i.e., a back-and-forth movement or sound).

In addition, the VA also recommends MBSR, which combines meditation and yoga to manage stress. They could not find sufficient evidence to suggest other similar mind-body interventions or mindfulness training/interventions, such as traditional yoga, Transcendental Meditation, MBCT, etc. Secure video teleconferencing technology can be used to administer the psychotherapies described above. They found insufficient evidence to recommend for/against capnometry-assisted respiratory therapy, hyperbaric oxygen therapy, neurofeedback, NightWare©, rTMS, stellate ganglion block, or transcranial direct current stimulation. They advise against ECT or vagus nerve stimulation therapy for PTSD (VA, 2023c).

When individual trauma-focused psychotherapy is not readily available, not preferred, or ineffective, the VA (2023c) recommends sertraline (Zoloft), paroxetine (Paxil), or venlafaxine (Effexor) for PTSD monotherapy. Prazosin (Minipress) is recommended for the treatment of nightmares related to PTSD. The VA found insufficient evidence to suggest for/against the use of most other antidepressants for the treatment of PTSD, as well as the psychedelics psilocybin, ayahuasca, dimethyltryptamine (DMT), ibogaine, or lysergic acid diethylamide (LSD). The VA does NOT suggest the use of divalproex (Depakote), guanfacine (Intuniv), ketamine (Ketalar), prazosin (Minipress, except in the treatment of nightmares related to PTSD), risperidone (Risperdal), tiagabine (Gabitril), vortioxetine (Trintellix), benzodiazepines, cannabis or cannabis derivatives for the management of PTSD. The VA also does not suggest the use of antipsychotics to augment the pharmacotherapy of PTSD. They found insufficient evidence for/against the augmentation of psychotherapy with MDMA(VA, 2023c).

Suicide Resources

All HCPs must be equipped to offer realistic, practical, and useful information to those affected by suicide. Below is a list of some valuable and applicable suicide resources for patients and families.

US Suicide & Crisis Lifeline (formerly the National Suicide Prevention Lifeline)

www.988lifeline.org

As described earlier, lifeline support is available 24/7 via online chat, telephone, and text (#988). It is a network of over 200 local crisis centers.

Crisis Text Line

www.crisistextline.org

This 24/7 resource allows users to connect instantly with help and support by texting HOME to #741741 or through the chat feature on their site. They can also connect via WhatsApp.

 

Resources for Teens and Young Adults

 

The Trevor Project

http://www.thetrevorproject.org/

The Trevor Project offers suicide crisis intervention and prevention services to LGBTQ youth aged 13 to 24 years. The website explains the signs of suicide and offers an online connection with other LGBTQ youth. Trained counselors can provide support 24 hours, 7 days a week, via the TrevorLifeline (1-866-488-7386). Services are offered around the clock via TrevorChat, an online crisis messaging service (www.thetrevorproject.org/chat), and TrevorText (text START to 678-678)

 

Society for the Prevention of Teen Suicide

https://sptsusa.org/teens/

This website offers information to help teens who are struggling with suicidal thoughts and explores how to cope when a friend dies by suicide.

Resources for Veterans and Families

 

Veteran Health Benefits and Services

www.myhealth.va.gov

This website can be accessed by veterans, family members, and caregivers, providing information on veteran health benefits and services.

Veterans Crisis Line

https://www.veteranscrisisline.net/

The Veterans Crisis Line is a VA resource that connects veterans and service members in crisis, their families, and friends with information and qualified, caring responders through a confidential toll-free hotline, online chat, and text messaging service. Veterans and their families can call 988 (Press 1), chat online at https://www.veteranscrisisline.net/get-help-now/chat/, or send a text message to 838255 to receive support from specially trained professionals 24 hours a day, 7 days a week, 365 days a year. Veterans and their families do NOT need to be enrolled in VA benefits or obtain care from a VA center to use this service (Veterans Crisis Line, n.d.).

VA Mental Health Services

https://www.va.gov/health-care/health-needs-conditions/mental-health/

Veterans are entitled to free mental health care for at least a year after separation, regardless of their discharge status, service history, or eligibility for VA health care. This resource offers training via online self-help portals geared toward overcoming everyday challenges (e.g., anger management, parenting, and problem-solving skills), smartphone apps, telehealth services, or assistance with referrals to nearby VA health facilities. They also offer BeThere, a service that provides peer assistance to veterans and their families for one full year following separation from any military branch (including National Guard and reservists).

 

Military OneSource

https://www.militaryonesource.mil/health-wellness/mental-health/mental-health-resources/

Military OneSource provides a list of confidential resources and support for veterans and their family members based on area of need, including sexual assault, PTSD, TBI, domestic abuse, and child abuse (2022).

 

Wrap-Up Exercises

The following section includes case scenarios to hone critical thinking skills and apply the various strategies reviewed within this course. Read through the case studies and consider the risk factors and warning signs for suicide. Suicide cannot be predicted by age or demographic profiling, and each individual has unique circumstances and risk factors.

 

Case Scenario #1
A 15-year-old patient whose parents recently divorced, forcing them to move to a new community of only 3,000 people. They dislike the small-town atmosphere and have not made any new friends. They refer to a sibling as their “only” friend. The sibling will leave for college in the upcoming months, making the patient feel even more alone. They are having trouble sleeping, their grades are falling, and they are crying almost every day. They attempted to tell a parent how awful they felt, but the parent said that things would get better in time. The patient gave their sibling their grandparent's watch because they "do not need it anymore."

 

What signs of suicide did the adolescent exhibit?

Assessment of warning signs indicates:

• Trouble sleeping
• Falling grades
• Extreme mood change (crying daily)
• Feeling isolated
• Giving away a prized possession

Assessment of risk factors indicates:

• Social isolation due to moving and loss of previous friends/support system
• Loss of a parent through divorce
• Problems tied to relationships and relocation

Assessment of protective factors:

• Positive social support from family

How should the HCP proceed?

• Assess the risk for suicide utilizing a validated assessment tool, such as the C-SSRS or SAFE-T. The patient does not verbalize a suicide intent or plan, and they do not disclose any suicidal behaviors.

This patient has a low risk for suicide. The following measures are indicated:

• Provide the patient and family with direct referrals to outpatient behavioral health and other providers for follow-up care within a week of the initial assessment.
• Consider safety planning with the patient and family so supportive third parties are aware of the safety plan and lethal means can be monitored/reduced.
• Provide emergency/crisis contacts and phone lines.

Case Scenario #2

An older adult who lives independently in their home recently lost their spouse to cancer. They were previously active within the community. They routinely attended church and the Lions Club but have stopped all these activities over the last month. They also stopped socializing and talking to their neighbors. The couple's 60th wedding anniversary is approaching, and the patient has told friends that life is not worth living without their spouse.

Assessment of warning signs indicates:

• Feelings of hopelessness

• Withdrawing or expressing feelings of isolation

• Loss of interest in former interests

Assessment of risk factors indicates:

• Social isolation
• Stressful life events
• Loss of a loved one

The patient lost their spouse and alienated their social group, removing their most substantial protective factors.

How should the HCP proceed?

• Assess the patient's risk for suicide using a validated assessment tool, such as the C-SSRS and SAFE-T.

The patient admits to suicidal ideations and a plan but no intent, and they do not disclose any suicidal behaviors. The patient has a moderate risk for suicide.

• Consider inpatient admission to a hospital or mental health facility since they live alone.
• Develop a crisis plan; involve the patient and a close friend (if available) in safety planning to ensure potential lethal means are removed and monitored closely.
• Make personal and direct referrals to outpatient behavioral health providers for follow-up. Do not leave the patient to make the appointment.
• Provide emergency/crisis contacts and phone numbers.

About the Author

The author of this module has a Bachelor of Science degree in biology and nursing and a master’s degree in nursing. She received mental health training during her undergraduate and graduate nursing coursework with dedicated inpatient and outpatient mental health clinical rotations.

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