Chapter 25: Suicide & Nonsuicidal Self-Injury

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Welcome to the Deep Dive.

Today we're really immersing ourselves in a very critical area of health and well -being.

The dynamics of suicide and also non -suicidal self -injury, or NSSI.

This is sensitive stuff, obviously, but vital.

And our goal here is to distill the key concepts, psychiatric, biological, and really importantly, the immediate nursing interventions, just to give you a focused, practical review.

It's absolutely necessary knowledge, because while suicide is largely seen as a never event, something we should always be able to prevent, the reality is quite stark.

I mean, tragically, a life ends by suicide roughly every 11 minutes in the US.

Wow, every 11 minutes.

Yeah, that's about 129 people every single day.

But here's the statistic that really should grab every health care professional.

54 % of those individuals who died by suicide, they did not have a known mental health diagnosis.

54%.

That's staggering.

It completely shifts the focus, doesn't it?

It means risk assessment has to happen everywhere, in all health care settings, not just specialist clinics.

Precisely.

If we're just waiting for a psychiatric referral, well, we're missing more than half the people potentially at risk.

Okay, so before we dive deeper into that risk, let's just quickly nail down the terminology.

We talk about suicidal ideation.

That's the thinking part, right?

Contemplating death, wishing to be dead, maybe starting to plan.

Then there's a suicide attempt that's actually engaging in behavior that could be self -injurious with the specific intent to die.

And suicide, of course, is the intentional act of ending one's life.

And just a quick but important note on language.

We really discourage using the term commit suicide.

It has that historical link to crime, to sin.

The better phrasing is that people die by suicide.

That's a really important distinction.

Language matters.

And thinking diagnostically, I know the field has proposed something called suicidal behavior disorder.

It's not official yet in the DSM -5, but what's the idea there?

Right, it's for further study.

But the core idea is to identify individuals who've made a suicide attempt within the last, say, 24 months.

Recognizing this group is critical because, well, their risk for another attempt is significantly higher.

Okay, let's talk about the scope of this.

The numbers are honestly shocking.

We know suicide is the 10th leading cause of death overall, but then you look at younger people, ages 10 to 34, and boom, it's the second leading cause.

And the trend between 1999 and 2017, the rate jumped 33%.

That's a huge increase.

It really is.

And that suggests bigger forces at play, often involving comorbidities.

Major depressive disorder, for instance, is associated with about half of all completed suicide.

Half?

Wow.

And substance use is another massive factor.

Alcohol is present in something like 41 % of deaths by suicide.

You mentioned comorbidity.

Is there any specific population where this risk is particularly concentrated?

Absolutely.

For individuals living with schizophrenia, suicide is actually the leading cause of premature death.

The risk is highest early on, often within the first few years after diagnosis.

It hits about 10 % risk after 10 years and climbs to maybe 15 % after 30 years.

So the risk clearly has psychiatric roots and environmental ones we'll get to, but there's also a biological piece here, right?

What are the key biological takeaways?

Well, the most consistent finding really involves serotonin, specifically low levels of serotonin or its breakdown products, its metabolites.

We see this pattern in cerebrospinal fluid studies of people with suicidal behavior, and it's confirmed in postmortem brainstem exams.

It seems like there's a physical lack of this key neurotransmitter, plus there are genetic links, too.

Twin studies point towards it, and researchers have actually identified four specific gene variants associated with higher risk.

That low serotonin finding is fascinating when you put it next to the core cognitive factor Aaron Beck identified,

which is hopelessness.

It feels like a really dangerous combination, doesn't it?

A potential physiological issue affecting mood, combined with this crushing belief that things will never get better.

That's really the crux of it.

Hopelessness is that central emotional driver, and it often comes with very rigid thinking patterns.

You know, black and white, all or nothing thinking.

If there's no perceived future, and the only options seem to be unbearable pain or escape,

well, the risk skyrockets.

And we can't ignore the environment, adverse childhood experiences,

ACEs.

The material says they significantly increase risk up to 2 .7 times higher.

That's right.

Early adversity casts a long shadow, and we also have to be really aware of social factors like contagion.

The chapter talks about cluster suicide, sometimes called copycat suicides.

These happen when suicides occur closer together in time and location than you'd expect by chance.

Adolescents seem particularly vulnerable.

And social media plays a role there too, right?

Both potentially positive and negative.

Definitely.

It can spread awareness and support, but it can also amplify negative messages or even sensationalize self -harm, like with dangerous online games or challenges we sometimes hear about.

The context changes across cultures too.

What kind of nuances did the sources mention there?

Yeah, it varies.

For example, in some Hispanic cultures in the U .S., you might see factors like strong extended family ties or religious views like Catholicism that discourage suicide.

Sometimes this connects with a philosophy called fatalismo.

But then, conversely, in some Asian cultures, there might be historical contexts where suicide could be seen, tragically, as a way to prevent bringing shame on the family.

And in places like South Korea, the actual rates might be much higher than reported because of intense cultural stigma and the idea of familism leading to underreporting.

Given all these complex risks—biological, cognitive, social, cultural—let's shift to the nurse's role.

Assessment and intervention.

What's the absolute, single most important thing a clinician can do?

Ask.

Ask directly about suicidal thoughts.

It's the single most important assessment and intervention.

The evidence is just overwhelming on this.

Asking does not plant the idea in someone's head.

Right.

It does the opposite.

Exactly.

It provides relief, it reduces that feeling of isolation, and it opens the door.

It gets permission to talk about it.

So when we ask what kinds of things are we listening for, the material mentions two types of statements.

Yeah.

We need to differentiate between overt statements.

Those are the really clear ones, like I wish I were dead or I'm going to kill myself.

But then there are the covert statements, which are more subtle, more insidious, things like soon everything will

Don't worry, I won't be a problem much longer.

Implies finality without saying it directly.

Precisely.

Or even just giving away prized possessions, saying goodbyes.

Those actions can be covert clues, too.

And what about nonverbal signs?

Are there behavioral red flags we should watch for?

One big one, paradoxically, is a sudden, noticeable improvement in mood.

Really?

That seems counterintuitive.

It does, but think about it.

If someone has been deeply depressed, maybe paralyzed by it, and they suddenly seem calm, peaceful, maybe even energetic,

especially after starting an antidepressant, it could mean they've made the decision to die and now they feel relief and have the energy to actually carry out the plan.

Ah, I see.

That makes sense.

Other major flags are things like giving away things they love, putting their financial affairs in order, making a will,

settling accounts, essentially.

Okay.

So once we suspect risk, how do we actually measure it more objectively?

We use validated tools.

The chapter mentions the suicide assessment, five -step evaluation, and triage, or safety.

That helps clinicians sort of benchmark the risk level.

Is it high, moderate, or low?

And determine the appropriate intervention.

Okay.

Then there's the Columbia Suicide Severity Rating Scale, the CSSRS.

That one's pretty comprehensive.

It measures not just ideation, but the severity, frequency, planning involved.

It really gets into the details.

These tools help us move beyond just a gut feeling.

And if ideation is confirmed, the next immediate step is the lethality assessment.

What are the key parts of that?

Right.

You need to assess three things immediately.

Does the person have a specific plan?

How lethal is the proposed method?

And do they have access to that method right now?

Okay.

Plan, lethality, access.

And how do we think about method lethality?

We generally categorize them.

Higher risk or hard methods are things like using a gun, hanging, and jumping from a significant height.

These are often quickly fatal.

Lower risk or soft methods might include things like cutting risks superficially, or ingesting a small number of pills.

Though crucially, any attempt needs to be taken seriously.

Absolutely.

But that distinction helps gauge immediate danger level.

If someone has a specific plan, access to a gun, and says they intend to use it tonight, that's maximum immediate risk.

Exactly.

That requires immediate, intensive intervention.

Let's talk about that intervention, especially in an inpatient setting.

Millieu safety.

For someone at high risk, what are the non -negotiables for suicide precautions based on the source?

Safety has to be absolute.

First and foremost, constant one -to -one observation.

The patient cannot be out of the staff member's direct line of sight ever.

Not even for a second.

Not even in the bathroom.

Okay.

Constant 1 .1.

And frequent charting, documenting mood, behavior, any statements the patient makes, verbatim if possible, usually every 15 to 30 minutes.

And the environment itself needs to be secured.

What does that look like specifically?

The chapter mentions environmental guidelines, like in box 25 .4.

You described that safe environment.

Sure.

It means locking all utility rooms, kitchens, anywhere potential hazards might be stored.

Windows need to be locked and shatterproof or screened.

In bathrooms, you need things like breakaway shower rods and shower heads.

Not solid fixture someone could use for hanging.

And you have to meticulously search the patient's belongings and remove anything potentially harmful.

Belts, shoelaces, drawstrings, cords, razors, glass items, metal cutlery.

The list is extensive.

And even medication administration needs care.

You have to watch the patient take and swallow every single dose to prevent hoarding pills for a later overdose attempt.

It's about controlling the environment completely.

Beyond that immediate physical safety, what about planning for the future?

What's the tool used to help patients manage crises after leaving the hospital?

That's the patient safety plan.

The chapter describes it.

I think there's even a figure showing it.

Figure 25 .1.

It's basically a written collaborative plan.

The key is that the patient develops it with the clinician and takes ownership.

It usually has about six steps.

Six steps.

What do they cover?

It starts with the patient identifying their own personal warning signs.

Thoughts, feelings, situations that indicate a crisis might be starting.

Then listing internal coping strategies they can use on their own, like relaxation techniques or distracting activities.

After that, identifying people or safe social settings that can offer distraction or support.

And finally, listing professionals or agencies to contact in an emergency, including phone numbers, crisis hotlines.

Like the new 988 number is a great resource to include.

It's essentially a personalized roadmap for navigating future urges.

That sounds incredibly practical.

Biologically, what treatments support this nursing care?

Well, SSRIs are common for underlying depression or anxiety, but we have to be careful when starting them or changing doses.

Because of that potential energy surge you mentioned.

Exactly.

That initial period can sometimes paradoxically increase risk before the mood fully lifts, so close monitoring is essential.

But one medication with really strong evidence specifically for reducing suicide risk long -term is lithium.

Ah, lithium.

Yes, particularly in patients with bipolar disorder, but also evidence in major depressive disorder.

Long -term lithium treatment significantly cuts down suicide incidents and attempts.

It's a key pharmacological tool for protection.

Okay, that's important to know.

Now, let's shift gears slightly to non -suicidal self -injury or NSSI.

It's related but distinct, right?

Also mentioned for further study in DSM -5.

That's right.

NSSI is defined as deliberate damage to one's own body tissue.

Things like cutting, burning, scratching, hitting, but, and this is the crucial difference, without the conscious intent to die.

So the motivation isn't suicide.

What is it then?

Primarily, it seems to be about regulating intense negative emotions, feeling overwhelmed by anxiety, anger, sadness, emptiness.

The physical pain provides a release, a distraction.

There's also a fascinating physiological component called pain offset relief.

The act can trigger a release of the body's natural opioids, leading to a brief feeling of calm or even euphoria right after the pain stops.

So they're essentially using physical pain to cope with emotional pain and getting a bit of a physiological reward for it.

In a way, yes, and it's common.

The chapter notes high prevalence, especially among adolescents, maybe 15 % and even higher in college students, sometimes up to 35%.

It seems to peak in the early 20s.

But even though it's non -suicidal by definition, it's still a serious risk factor, isn't it?

Absolutely.

A history of NSSI actually doubles the likelihood of a future suicide attempt.

It's a significant marker of distress and risk.

And like suicide, there's a risk of social contagion, especially in settings like inpatient psychiatric units or through online communities where these behaviors might be shared or normalized.

So how does the nursing care approach differ for NSSI compared to acute suicidal risk?

Well, the priority nursing diagnoses would shift towards things like risk for self -mutilation or self -mutilation.

The core interventions involve building a strong therapeutic alliance showing acceptance, not judgment.

You also need to provide meticulous wound care, matter of factly.

But the main focus is teaching alternative coping skills, helping the person find healthier ways to manage those intense emotions without resorting to self -injury.

The chapter mentions a six -step recovery plan for NSSI.

Yes, it outlines a general path.

First, limiting access to means for self -injury, then working on self -esteem, helping the person understand their motives for the behavior, learning self -control techniques, actively replacing the self -injury with other coping strategies, and finally maintaining those changes.

And what about specific treatments?

Psychological therapies are key.

Cognitive behavioral therapy, CBT, is helpful.

And dialectical behavior therapy, DBT, is often considered the gold standard as it specifically targets emotion dysregulation and teaches distress tolerance skills.

Medications might be used for comorbid conditions like depression or anxiety.

Sometimes opioid antagonists like Naltrexone are tried, theoretically, to block that euphoric reward from the pain -offset relief, though evidence is mixed.

Okay, that makes sense.

Finally, let's touch on care after a suicide loss.

The chapter called this postvention, Support for the Survivors.

Yes, and the scale of need here is enormous.

For every person who dies by suicide, it's estimated there are around 60 survivors left behind, family, friends, co -workers, classmates, 60 people grappling with intense grief, often complicated by guilt, anger, confusion, and stigma.

The source specifically notes that surviving parents are at a higher risk for significant health problems themselves, both mental and physical.

So for healthcare professionals working with these survivors, what's the key advice?

The absolute focus needs to be on the survivor.

They are the patient now.

Listen without judgment.

Understand that the hardest time might not be right away.

Sometimes the shock carries people initially.

The deep grief, the why questions can hit hardest months or even years later.

And importantly, encourage them to talk about their lost loved one.

Don't shy away from mentioning the person's name or sharing positive memories.

Reducing the silence helps combat the intense isolation and stigma that so often surrounds suicide loss.

That's incredibly important guidance.

Well, that brings us toward the end of this really essential deep dive.

I think the key takeaways are pretty clear.

Assessment is paramount.

And asking directly is crucial.

It saves lives.

Suicide is largely preventable.

Millie safety in high -risk situations is absolutely non -negotiable.

And NSSI, while different, requires specific therapeutic approaches focused on building alternative coping tools.

Exactly.

And perhaps a final thought, something for you, the listener, to maybe reflect on as you integrate this into your practice.

Consider that connection we discussed the biological finding of low serotonin, often coinciding with the profound cognitive state of hopelessness.

It really poses a challenge, doesn't it?

How do we best weave together treatments that address the biology, like maybe lithium, with therapies that rebuild thinking patterns and coping skills like DBT?

How do we ensure individuals get both the physiological support and the psychological tools they need to not just survive a crisis, but to actually build lasting resilience for the future?

That's a powerful and necessary question to keep asking.

Thank you for joining us for this vital deep dive into these psychiatric mental health concepts.

We truly hope this review is helpful for your learning and your practice.