Stigma also affects those bereaved by suicide. Research shows that those bereaved by suicide have higher rejection, shame, and blame levels than other bereaved people. This may partly be due to friends and family avoiding or feeling uncertain about approaching someone about their grief and loss. People bereaved by suicide may also find themselves avoiding the conversation about the cause of death due to anticipated stigmatized responses. 35 Protective Factors in the General Population According to the Center for Disease Control, there are several factors that can mitigate the risk in a person with a moderate to low risk for suicide. These include 14 : • Effective coping and problem-solving skills. • Self-esteem and a sense of purpose and meaning in life. • Cultural and religious beliefs that discourage suicide. • Connections to family, friends, and community support. • Supportive relationships with care providers. • Availability of physical and mental healthcare services. • Limited access to lethal means among people at risk. Healthcare Professional Consideration: Safety planning and assessment of patients at increased risk for suicide should also include an examination of that patient’s protective factors that serve to reduce suicidal acts.
• Talking about feeling trapped or being in unbearable pain. • Talking about being a burden to others. • Talking about great guilt or shame. • Increasing the use of alcohol or drugs. • Acting anxious, agitated, or reckless. • Sleeping too little or too much. • Withdrawing or feeling isolated. • Daring or risk-taking behavior. • Experiencing severe mental pain. • Depression. • Severe anxiety, panic attacks. • Displaying extreme mood swings. • Showing rage or talking about seeking revenge. • Giving away prized possessions. • Saying a final goodbye to family and friends. • Putting affairs in order. • Lack of interest in future plans. Youth warning signs include 5 : • Talking about or making plans for suicide • Expressing hopelessness • Displaying severe emotional pain or distress • Showing worrisome behavioral cues or marked changes in behavior, such as: °
Suicide Warning Signs Since suicide is a relatively rare event, it is challenging to predict suicide based on risk factors. A recent meta-analysis found that predicting suicide is no better than chance and has not significantly improved over the last fifty years. The goal of identifying warning signs or clinical situations that warrant a suicide assessment is not a prediction but rather to determine an individual’s suicide risk (i.e., “low”, “medium”, or “high”) and to plan for informed interventions. 5 Examples of clinical situations that warrant a suicide assessment include 5 : • Crisis evaluations in the emergency department. • Intake evaluations for all patients, especially those with severe mental illness. • Patients with depression; someone who is either anticipating or experiencing significant loss or stress. • Patients with certain physical illnesses, especially if life-threatening or associated with severe or chronic pain or loss of function. • Significant clinical change (increase in suicide ideation, suicidal behavior, change in mental status, unstable mood, impulsiveness, trauma victimization) • Regarding inpatient care settings, a change in privilege level, when there is a deterioration in mental status, and before discharge. Warning signs are verbal expressions, changes in behaviors, or new behaviors that may indicate that a person is suicidal. The more of these warning signs a person displays, the greater the risk of suicide. 36 Adult warning signs include 5 : • Talking about wanting to die. • Looking for a way to kill oneself. • Talking about feeling hopeless or having no purpose.
Withdrawal from or change in social connections, including extracurricular activities and school performance Anger or hostility that is out of character or out of context Recent increased agitation or irritability Changes in sleep Risk-taking behavior or alcohol/drug use
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Healthcare Professional Consideration: It is important to note that the risk of suicide is greater if the warning sign is new, has increased, is after a perceived or experienced emotionally challenging event, or is associated with the acute onset of mental illness 5 .
PLEASE COMPLETE CASE STUDY 2.
Case Study 2
Instructions: Spend 5-10 minutes reviewing the case below and considering the question and discussion that follows.
While seeing patients in your primary care office, you are happy to see that Laura is your next patient. She has recently returned to the area - you had been her physician for several years in the past. Laura is a veteran who recently was discharged from the military after serving for the last 10 years. During a training exercise, she suffered a traumatic brain injury for which she currently receives partial disability. You know from your previous relationship with Laura that she identifies as lesbian, and you have also cared for her partner in the past. As you enter the room, you are somewhat surprised by Laura’s appearance. She appears slightly disheveled, which is out of character for her. She tells you that recently, a close friend from her previous unit committed suicide. Laura does have a history of depression and recently has been having difficulty sleeping.
1. Which of Laura’s risk factors is least likely to predict suicidal behavior?
Discussion: Research has shown that insomnia is only weakly associated with suicide risk. Veterans, those with history of traumatic brain injuries, lesbian, gay, and bisexual, and those with a history of depression are shown to be at increased risk. Finally, those that are bereaved by suicide contribute to the highest risk for suicide among bereavement groups.
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