The evidence says no; in fact, as discussed below, encouraging patients to talk about their thoughts and feelings may lessen the risk. Although many adolescents do not openly talk about how bad they are feeling, those who do are just as likely to carry out a suicide attempt. Be especially concerned if adolescents are making efforts to get their affairs in order or giving away personal items. There is a common perception that suicide happens without warning, but patients thinking about suicide frequently give clues. There is often a sense of ambivalence in suicidal patients, right up until they engage in self-destructive behavior.
Suicidal patients may not actually want to die but cannot see any way to continue because of their intolerable pain. This is why patients who have made the decision to end their lives often seem at peace and less distressed. They now have a plan to escape the pain. Reports of changes, positive as well as negative, in baseline behavior of suicidal patients should alert nurses to be extra vigilant with assessments and supervision.
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These changes should also be discussed with patients. Let them know that although you are glad they are more interactive with others and seem to be less depressed, you are concerned that these changes can sometimes occur when patients have a plan to end their suffering. Do not be afraid to ask patients if that is how they are feeling at this time. Regardless of their response, supervise them based on the institutional suicide protocol and Joint Commission standards.
Avoid the misperception that asking patients to talk about suicidal feelings and ideas or trying to redirect their thinking is harmful. On the contrary, it is important to reflect what you are hearing because patients are less likely to act on feelings if they can discuss them openly with a caring person. Most patients are comforted when someone is willing to try and understand what they are going through. This decreases the isolation they may be feeling and increases the chance of finding alternatives to the stresses they are experiencing. Be aware that the time of day, the day of week, and the time of year can influence those who are contemplating suicide.
The beginning of spring and the happiness others experience as a result can leave a patient feeling depressed and even more isolated.
The holidays can also increase stress and isolation, especially for those not connected to family or friends. The idea of confronting another day or week of misery is overwhelming to some. If patients are unable to sleep, they may be up all night obsessing about their problems, which makes facing another day less appealing.
Adolescent/Adult Differences in Suicidal Behavior and Outcome
Keep in mind that some patients come into the hospital planning to end their lives there in order to spare their families from the trauma of finding them deceased. They can easily figure out when staff members are occupied, so monitor them closely during shift changes and other times when fewer staff are available or are busy, as these are high-risk times.
Although adolescents may exhibit various signs of depression, the persistent presence of five or more signs or symptoms see Signs and symptoms of depression represents the most serious concern. Nurses should be aware of the additional risk factors for suicide that have been identified by the American Psychiatric Association see Risk factors for suicide. When interacting with adolescents who are depressed or suicidal, assess the level of lethality or how suicidal they may be. Remember that although problems and concerns may seem minimal to others, they may be overwhelming and devastating to the adolescents who experience them.
Nurses working with these patients should utilize suicide -screening tools that have been validated for use with adolescents with psychiatric concerns see Risk of suicide questionnaire and Ask Suicide -Screening Questions. Begin an assessment by reflecting any of the patient's behaviors or statements that are concerning. Some patients may respond that they think about suicide but would not take action because of religious beliefs or how it would impact their family. However, any patients who report thinking about suicide should be assessed further.
If patients indicate they are having suicidal thoughts, ask if they are having any thoughts or plans to hurt themselves at the present time. Specifically, ask patients if they have thought about how they would end their lives. If patients have a specific plan, ask if they have collected or have access to the materials needed to complete the act.
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Adolescents have less life experience handling stress, they may be impulsive, and current life challenges may seem insurmountable. Screening is just the beginning of this process; all adolescents presenting with a psychiatric concern will need further assessment by a skilled psychiatric provider.
When caring for a patient with suicidal ideation, be aware that anything in the environment can be used for self-harm sharp items, socks, pajama tops and bottoms, sheets, cords, gowns, shoelaces, plastic bags, etc. Nurses should remove any objects that could be used for self-harm from patients with suicidal ideation. The room itself should meet Joint Commission standards regarding ligature-resistance and safety.
The Suicidal Adolescent - Sunrise Residential Treatment Center
All objects that could be used for self-harm should be removed from the room and any visitors. Avoid trying to create an artificially cheerful environment and do not offer false or trite reassurances that everything will be better with time. Do not change the topic if you are uncomfortable because doing so will shut down therapeutic interactions. The simple task of listening, sitting with adolescents when they are hurting, and reminding them that they are not alone may offer hope and perspective. Let patients know that depression, anxiety, hopelessness, and thoughts of suicide are all treatable conditions.
Emphasize that medications are available that can help restore brain chemicals that get depleted with stress and that talking things over with a skilled therapist can greatly decrease feelings of isolation and pain. If adolescents are worried that they will be seen as crazy, emphasize that depression is a brain disease that can be regulated just like some people have diabetes and need to make adjustments to keep blood glucose levels stable. Once suicidal adolescents begin taking antidepressants they may feel more physical energy, which can result in them having the capacity to complete a suicide attempt.
They may also experience even more thoughts of suicide. Supervision during this time may need to be increased. If patients exhibit any abrupt changes from what has been their baseline, begin a discussion and ask directly if they have decided to end their life. Even if they say no, continue to monitor them closely.
Patients may look peaceful when they have made a decision to alleviate their pain by ending their lives. Educate patients and families about these risks and discuss the boxed warnings noted in all the antidepressant medications. Let them know that it may be several weeks or more before the full effect of the medication can be experienced.
Ideally, adolescents should receive mental health counseling along with pharmacotherapy to help them develop strategies for coping and to provide ongoing support and evaluation. Evaluate suicidal adolescents for signs and symptoms of psychosis, such as hearing self-depreciatory voices telling them they do not deserve to live. If a patient reports hearing voices, ask what the voices are saying. Adolescents with psychosis are at higher risk for suicidal ideation and attempts compared with those without psychotic symptoms.
Psychosis controls the mind and no matter how much rapport the nurse has with these patients, the nurse cannot be sure that patients will not act on their thoughts. Early recognition and treatment of depression and psychosis are necessary to prevent suicide attempts.
Carefully monitor that patients are taking their medications because some may attempt to stockpile their medication for the purpose of overdosing once they have enough. Ask patients to open their mouths so you can check under their tongue and visualize the entire cheek area. Be open with patients about why you are doing this. This model was validated using a large cohort of British children and showed similar sensitivity and specificity. Notably, we found that the early life factors linked to suicidal thoughts were also predictive of a range of adverse outcomes in adolescence including antisocial behaviour, substance misuse, poor physical health, poor mental health, risky health behaviours, and poor academic performance.
The range of factors in early life that were the most predictive were primarily markers of adversity or signaled the experience of stress during early childhood. There were some unexpected results, including one subgroup that did not experience many of the prominent early-life risk factors.
In this group, the only risk factors were maternal smoking and non-participation in religious activities. For the other high risk subgroups, measures of prenatal, postnatal, and early childhood adversity were found to increase risk of later suicidal thoughts.
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