1. Davis, Charlotte BSN, RN, CCRN
  2. Shuss, Stacy RN
  3. Lockhart, Lisa MHA, MSN, RN


Can you recognize the warning signs of suicidal ideation? We show you how to keep your patients safe.


Article Content

A suicide attempt is the unsuccessful act of directing violence at oneself with the intent to end one's life. When a person is contemplating ending his or her life, it's referred to as suicidal ideation. Although most individuals with suicidal ideation don't ultimately commit suicide, the extent of suicidal ideation must be determined, including the presence of a suicide plan and the means to commit suicide.

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If a patient has both a concrete plan to end his or her life and the means to complete the plan, it's a medical/psychiatric emergency. Even when the patient voices suicidal ideation and doesn't have the means to complete the task, it can still be an emergency because the patient may opt for a more readily accessible avenue to complete the suicide.


As nurses, we spend the most time with our patients at the bedside, so we're the most likely candidates to notice the warning signs of a suicidal patient. In this article, we show you how to recognize a patient at risk for suicide and the steps you can take to ensure his or her safety.


By the numbers

Suicide is a serious problem in the United States. In 2010, an average of 105 people committed suicide each day (38,364 deaths per year) in the United States. In 2011, over 487,700 people were seen by ED healthcare personnel for self-inflicted injuries. Suicide attempts can cause devastating injuries that may leave the patient physically and/or mentally disabled. Suicide and self-inflicted injuries resulted in an estimated $41.2 billion in combined medical and work loss costs in 2012.


According to the CDC, suicide is the third-leading cause of death among individuals ages 15 to 24, the second for ages 25 to 34, the fourth in those ages 35 to 54, and the eighth for ages 55 to 74. Suicide is the 10th-leading overall cause of death in the United States. Annual suicide rates among American adults ages 35 to 64 increased from 13.7 to 17.6 suicides per 100,000 people between 1999 and 2010.


Suicidal ideation can occur in both men and women; however, women are more likely to have suicidal thoughts than men. According to the CDC, 8 million Americans reported suicidal thoughts in 2012. The prevalence of suicidal thoughts, suicide planning, and suicide attempts is significantly higher among young adults ages 18 to 29 than among adults ages 30 and older. Other groups with higher rates of suicidal behavior include American Indian and Alaska Natives, rural populations, and active or retired military personnel.


Across the generations

Baby boomers (1946-1965). The greatest increases in suicide rates were among people ages 50 to 54 (48%) and ages 55 to 59 (49%). However, the CDC states that the suicide rates among Vietnam veterans (enlisted 1959 to 1975) are the highest of any particular generation. The CDC cites the recent economic downturn, loss of peer support, and a rise in intentional overdoses because of increased availability of prescription opioids as common reasons for the increase in suicide rates among this generation (see Recognizing depression in older patients).


Generation X (1966-1976). There are approximately 41 million Generation Xers currently residing in the United States. According to the latest CDC research, suicide is the fourth-leading cause of death for this age group. Considering the impulsive nature and inward focus that are said to define this generation, it's understandable why depression, disappointment, or perceived failure could result in a downward spiral. In addition, this group has now reached "middle age"-a time in an individual's life that may be marked by a decline in health, children leaving the home, loss of parents and siblings, and an end to perceived career alteration choices.


Generation Y (1977-1994). As previously mentioned, suicide is the third-leading cause of death among people ages 15 to 24 and the second among those ages 25 to 34. Recent CDC research states that Generation Y suicide rates may be due to technology, financial distress, and family dynamic problems. The rise of social media technology has meant that many teenagers and young adults are vulnerable to meeting people who don't have their best interests in mind. They may be victims of cyber bullying, which has been directly linked to major depression and increased suicide rates. Combine this with the normal turbulent emotions associated with puberty and young adulthood, self-esteem issues, career choices, young family struggles, learning to survive successfully in an adult world, and the failures that often accompany life's journey.


Generation Z (1995-2013). Suicide has become much more common for American children. Suicide is the fourth-leading cause of death for children ages 10 to 14. For children under age 15, about 1 to 2 out of every 100,000 will commit suicide. For those 15 to 19, about 11 out of 100,000 will commit suicide. According to the latest research, evidence suggests that children ages 15 to 19 are at a higher risk for suicide that children ages 10 to 14 because of increased substance abuse rates, access to guns, and social relationship problems. This generation has had increased exposure to violent video games, media coverage of ongoing wars and terrorist attacks, and other distressing news. When added to the naturally emotionally charged state that accompanies puberty, the results can be impulsive outbursts. It's important to remember that this age group doesn't yet have the benefit that comes with age and experience; they may not readily understand that situations can and do change.


A note on social media

In recent years, electronic technology has greatly improved our ability to maintain frequent contact with family and friends. However, with the expansion of social media, cyber bullying has become an increasing problem that can cause great distress to all age groups, especially teenagers.


Cyber bullying refers to the intentional harassment or targeting of a person via social media or other Internet outlets or by the sharing of unfavorable pictures, thoughts, rumors, or negative suggestions via electronic devices. If your patient is suicidal, the healthcare team may remove electronic devices until his or her mental health has improved or stabilized.


Although most family members and friends utilize electronic devices and social media outlets to convey their positive support for the patient, there may be instances in which harassment can be continuously evolving while the patient is under the multidisciplinary team's care. Follow your facility's policy regarding removal of electronic devices, such as computers, cell phones, or other devices that have the capability of interacting with others outside the healthcare team.


At risk

Risk factors for suicide include:


* history of violence or previous suicide attempts


* psychiatric illness


* recent loss of a relationship, family member, or pet


* recent diagnosis of a serious medical condition


* alcohol or substance abuse


* financial stress


* exposure to a perceived traumatic event


* victim of physical or sexual abuse.



These risk factors may predispose patients to suicide; however, just because a patient has one of the above risk factors doesn't mean that he or she will become suicidal. It simply means that the patient may be predisposed to thoughts of self-harm.


Heed the warning signs

Warning signs of suicidal ideation include:


* observation of the patient looking for ways to kill him or herself


* seeking access to pills, weapons, or other means of harm


* rage, anger, or revenge-seeking behavior


* voicing hopelessness


* acting reckless or engaging in risky activities seemingly without thinking


* feeling trapped like there's no way out


* increasing alcohol or drug use


* withdrawal from friends, family, and social activities


* anxiety or agitation


* sleep disturbances or sleeping all the time


* dramatic mood or personality changes


* talking or writing about death, dying, or suicide


* making statements such as "there's no purpose in life" or "there's no reason for living"


* saying goodbye to people as if the patient won't be seen again.



Ask the right questions

Many nurses struggle with how to begin a suicide risk assessment. Start with these nine simple questions:


* How are you coping with what's been happening in your life?


* Do you ever feel like just giving up?


* Are you thinking about dying?


* Are you thinking about hurting yourself?


* Are you thinking about suicide?


* Have you thought about how you would do it?


* Do you know when you would do it?


* Do you have the means to do it?


* Have you ever attempted to harm yourself in the past?



Assess for nonverbal signs that may potentially indicate the patient is considering self-harm, such as avoiding eye contact, tearfulness, crying, or an abrupt change in behavior. Examples of abrupt changes in behavior include:


* A patient is typically severely depressed, expressing no hope for the future, and he or she suddenly becomes happy and jubilant. This may signal that the patient's stress is relieved because he or she has solidified the plan to commit suicide.


* A patient is typically very social and interactive with family and staff and he or she suddenly becomes reclusive.


* A patient begins to give away cherished mementos or possessions.



If you observe a notable change in behavior, consult with the interdisciplinary team immediately. The multidisciplinary team may need to complete an in-depth suicide risk assessment.


Don't leave the patient alone if you suspect he or she is experiencing suicidal ideation; ensure that the patient is being adequately monitored. This can be accomplished by having a staff member continuously monitor the patient on a 1:1 basis to minimize the risk of self-harm.


Some facilities encourage staff members to place the patient in paper scrubs to ensure his or her safety. Unlike cloth scrubs or a cloth gown, a set of paper scrubs can't be twisted to make a ligature. Follow your healthcare facility's policies on how to safely manage the care of a suicidal patient.


Clinical interventions

Suicidal patients require the skills of a multidisciplinary team to safely manage their care. Common members of the multidisciplinary team include:


* psychiatrists


* social workers


* nurses


* physicians


* psychologists


* unlicensed assistive personnel.



During the evaluation period, the mental health expert may request that the patient be held against his or her wishes. Each state has specific legal guidelines that direct this process. Typically, the physician must complete a legal document that will hold the patient for 72 hours. This legal document is often called a 6404, 5150, or Baker Act document, and it must be recorded with the local court system. Its primary goal is to provide an individual with emergency medical services and temporary detention for mental health evaluation and treatment, either on a voluntary or involuntary basis.


Before the 72-hour observation period has expired, the multidisciplinary team must complete the patient evaluation and determine if he or she is at risk for harming him or herself or others. If the patient is considered to be at high risk for harming him or herself or others, the multidisciplinary team must complete additional legal documents to hold him or her beyond the initial 72 hours.


The multidisciplinary team may need to evaluate the patient's social support system, which can include spouses or partners, parents, children, siblings, extended family members, friends, or coworkers. A strong social support system may act as an anchor, giving the individual a sense of belonging and release. Remember, suicide is often an impulsive, spontaneous act. A strong support system that's involved and present can often deflect an impulsive response to anger, depression, or disappointment.


A patient's social support system is an integral part of his or her safety plan. Developed by the healthcare team with the patient, the safety plan sets clear instructions, interventions, and expectations, and the patient agrees not to harm him or herself. Items in the safety plan include stressors to avoid, specific people to call if the patient needs to talk to someone, and when to call a suicide hotline if needed.


Be aware that some social support systems may be toxic to the immediate and long-term mental health of the patient. In these situations, a multidisciplinary team approach should be utilized to ensure that appropriate support services are provided to limit, restrict, or improve the healthiness of the patient's current social support system.


Immediate response needed

If a patient voices suicidal ideation, maintain visual sight of him or her at all times. Notify the healthcare team by activating a call light and requesting the presence of another staff member or supervisor at the bedside. Keeping the patient within your visual field will reduce the chance of self-harm until he or she can receive a full psychiatric evaluation by the healthcare team.


Carefully assess the healthcare environment and the patient's personal possessions for items that could be used as a weapon, such as:


* call light cord


* belt


* glass


* mirrors


* shoelaces


* syringes


* scalpels


* glass medication vials


* metal utensils


* lanyards (even the type with break-away clasps can be used as a ligature).



These items should be removed from the patient until he or she has been deemed not at risk for self-harm.


Stay vigilant!

We must continue to fine-tune our clinical and psychosocial assessment skills to maintain our patients' safety. If your patient exhibits warning signs of suicidal ideation, immediately consult with the multidisciplinary team to ensure an optimal, safe outcome.


Recognizing depression in older patients

Red flags include:

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* sadness


* fatigue


* abandoning or losing interest in hobbies or other pleasurable pastimes


* social withdrawal and isolation (reluctance to be with friends, engage in activities, or leave home)


* weight loss or loss of appetite


* sleep disturbances (difficulty falling asleep or staying asleep, oversleeping, or daytime sleepiness)


* loss of self-worth (worries about being a burden or feelings of worthlessness or self-loathing)


* increased use of alcohol or other drugs


* fixation on death, suicidal thoughts, or suicide attempts.



memory jogger

To remember the risk factors for suicide, think SAD PERSONS.

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Sex (men at higher risk)


Age (highest-risk age groups are younger than 19 and older than 45)




Previous suicide attempt(s)


EtOH (excessive alcohol consumption)


Rational thinking (loss of)


Social support (lacking)


Organized plan


No spouse/children


Sickness (chronic) or stated intent


key points

Nursing considerations


* Observe for physical signs that the patient has attempted to harm him or herself, such as self-inflicted cuts to wrists or hesitation cuts in other visible areas.


* Conduct a personal belongings search for the presence of medications, caustic liquids or powders, weapons, or items that could be modified to cut, stab, or fashion into a ligature device if the patient has voiced suicidal ideation.


* Notify the healthcare team immediately if the patient voices suicidal ideation, and have one employee within arm's length of the patient until the team can evaluate his or her safety.


* Assess the patient each shift for suicidal ideation and/or behavior.


* Assess the patient's environment at least every shift and remove all potentially dangerous items.


* Observe the patient for decreased communication, disorientation, dependency, and concealing potentially dangerous items, and notify the healthcare team of significant changes.


* Monitor the patient daily for adequate nutrition, hydration, and elimination.


* Encourage the patient to identify positive self-aspects and determine stressful life situations that may precipitate suicidal thoughts to develop alternative coping techniques.


* Encourage the patient to have a balance of rest, sleep, and activity.


* Advise the patient regarding follow-up care.


* Ask yourself, have I documented expressed suicidal ideation, environmental risks, nutritional status, activity level, and patient education?


On the web


* American Association of Suicidology:


* American Foundation for Suicide Prevention:


* Mayo Clinic:


* Suicide Prevention Resource Center:


Learn more about it


CDC. Understanding suicide.


Crosby AE, Han B, Ortega LAG, Parks SE, Gfroerer J. Suicidal thoughts and behaviors among adults aged >=18 years-United States, 2008-2009.


Gliatto MF, Rai AK. Evaluation and treatment of patients with suicidal ideation.


Kuehn B. Preventing suicide's ripple effects takes coordinated effort. JAMA. 2013;310(6):570-571.


Romer D.As the national adult suicide rate increases, news stories about suicides during the holidays grow in number.


World Health Organization. World report on violence and health.