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TEXT STEP #1 Build a solid foundation. 422
UNIT 3 ■ Care of Patients With Psychiatric Disorders
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and o Thes from ity di disor psych cal c iors associ cess and r ■■ Have obs object sub ■■ Is anger t priately? 59 actions have tives of care the depresse information ■■ Has self-h ■■ Have suic ■■ Does the outside th ■■ Has the p and famil ■■ Is the pati ■■ Does the ■■ Is the pa about self pects, incl ■■ Can the p are contro ■■ Is the pati practices them? ■■ Is the pati appropria ■■ Does the no eviden ■■ Is the pat sions conc ■■ Is the pati
■■ Sleeps 6 to 8 hours per night and reports feeling well rested. ■■ Bathes, washes and combs hair, and dresses in
clean clothing without assistance. Planning and Implementation
Communication Exercises 1. Hal, a patient on the psychiatric unit, has a diagnosis of schizophrenia. He lives in a halfway house, where last evening he began yelling that “aliens were on the way to take over our bodies! The message is coming through loud and clear!” The residence supervisor became fright- ened and called 911. As Hal was being admitted to the psychiatric unit, he told the nurse, “I’m special! I get mes- sages from a higher being! We are in for big trouble!” How would the nurse respond appropriately to this statement by Hal? 2. The nurse notices that Hal is sitting off to himself in a cor- The role of patient teacher is important in the psy- chiatric area, as it is in all areas of nursing. A list of topics for patient and family education relevant to depression is presented in Box 16–5. Evaluation of Care for the Depressed Patient ner of the dayroom. He appears to be talking to himself and tilts his head to the side as if listening to something. How would the nurse intervene with Hal in this situation? 3. Hal says to the nurse, “We must choose to take a ride. All alone we slip and slide. Now it’s time to take a bride.” How would the nurse respond appropriately to this statement by Hal? CHAPTER 4 ■ Psychopharmacology Table 16–2 presents a plan of care for the depressed patient. Selected nursing diagnoses are presented, along with outcome criteria, appropriate nursing interventions, and rationales for each. Some institutions use a case management model to coordinate care (see Chapter 6 for more detailed explanation). In case management models, the plan of care may take the form of a critical pathway. Concept Care Mapping Antianxiety Agents Background Assessment Data Indications The concept map care plan is an approach to plan- ning and organizing nursing care (see Chapter 6). It is a diagrammatic teaching and learning strategy that allows visualization of interrelationships between medical diagnoses, nursing diagnoses, assessment data, and treatments. An example of a concept map care plan for a patient with depression is presented in Figure 16–3. Patient and Family Education Relieves anxiety In the final step of the nursing process, a reassess- ment is conducted to determine whether the nursing
TABLE 4–2 Effects of Psychotropic Medications on Neurotransmitters—cont’d ACTION ON NEUROTRANSMITTER EXAMPLE OF MEDICATION AND/OR RECEPTOR DESIRED EFFECTS
CHAPTER 15 ■ Schizophrenia Sp SIDE EFFECTS
Antianxiety: buspirone
5-HT 1A agonist D 2 agonist D 2 antagonist
Nausea, headache, dizziness Restlessness
Communication Exercises let you practice your communication skills with vignettes and questions that prepare you for clinical and practice.
5-HT, 5-hydroxytryptamine (serotonin); ACh, acetylcholine; ADHD, attention deficit-hyperactivity disorder; BZ, benzodiazepine; D, dopamine; EPS, extrapyramidal symptoms; GABA, gamma-aminobutyric acid; H, histamine; MAO, monoamine oxidase; MAO-A, monoamine oxidase A; MAOI, monoamine oxidase inhibitor; NE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor.
anoth order ■■ Nursi comp ■■ Nurs symp proce sonal world ■■ Symp tive (a negat ■■ Antip treatm choti treat ciently hig weight an
One of the Quality and Safety in Nursing Educa- tion (QSEN) criteria identified by the Institute of Medicine (IOM) (2003) stresses that the patient must be at the center of decisions about treatment (patient-centered care), and this type of assessment tool provides an opportunity to actively engage the patient in describing what medications have been effective or inef- fective and identifying side effects that may impact will- ingness to adhere to a medication regimen.
AU: Ok to add here?
Antianxiety drugs are also called anxiolytics and his- torically were referred to as minor tranquilizers. They are used in the treatment of anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation. They are most appropriate for
Quality and Safety Education for Nurses (QSEN) activities and content, highlighted with a special icon, help you attain the knowledge, skills, and attitudes required to fulfill the initiative’s quality and safety competencies. BOX 4-1 Medication Assessment Tool Date __________________________ Client’s Name __________________________________ Age ______________________ Marital Status ____________________ Children __________________________ Occupation ___________________________ Presenting Symptoms (subjective & objective) _______________________________________________________________ _____________________________________________________________________________________________________ Diagnosis (DSM-5) _____________________________________________________________________________________ Current Vital Signs: Blood Pressure: Sitting ________/________ ; Standing __________/__________; Pulse____________ ; Respirations ____________ Height ___________________ Weight _______________________ CURRENT/PAST USE OF PRESCRIPTION DRUGS (Indicate with “c” or “p” beside name of drug whether current or past use): Name Dosage How Long Used Why Prescribed By Whom Side Effects/Results ____________ ____________ _______________ _______________ _____________ ___________________ ____________ ____________ _______________ _______________ _____________ ___________________ ____________ ____________ _______________ _______________ _____________ ___________________ MOVIE CONNECTIONs I Never Promised You a Rose Garden (Schizophrenia) • A Beautiful Mind (Schizophrenia) • The Fisher King (Schizophrenia) • Bennie & Joon (Schizophrenia) • Out of Darkness (Schizophrenia) • Conspiracy Theory (Paranoia) • The Fan (Delusional disorder) • The Soloist (Schizophrenia) • Of Two Minds (Schizophrenia) “The anhedonia, psychomotor retardation, and anergia in acute depression can make assessment a challenge. It’s important to offer hope to a client who may be uncer- tain about how to navigate their present state of deep depression and to remain diligent while not making the patient feel pressured to speak. Paraphrasing what the patient has said to you conveys understand- ing and provides validation. Open-ended questions encourage the patient to elaborate rather than just answer ‘yes’ or ‘no.’” —Larry Johnson, RN phren file th ■■ Have som Treatment Interperso Research ha satisfactory a sion with o the lowest q 2013). With ■■ Indiv integ other vidua thera ily th For th ■■ Does the feeling re ■■ Does the grooming Real Nurses, Real Advice shares helpful tips from practicing nurses to help you navigate clinical situations and provide the best possible care to your patients. Real Nurses, Real Advice
Summary and Key Points ■■ Of all of the mental illnesses, schizophrenia un- doubtedly results in the greatest amount of per- sonal, emotional, and social costs. It presents an enormous threat to life and happiness. ■■ For many years, there was little agreement as to a
ment medi ■■ Some
chotherapy sonal relatio depressed p
CURRENT/PAST USE OF OVER-THE-COUNTER DRUGS (Indicate with “c” or “p” beside name of drug whether current or past use): Name Dosage How Long Used Why Prescribed By Whom Side Effects/Results ____________ ____________ _______________ _______________ _____________ ___________________ ____________ ____________ _______________ _______________ _____________ ___________________ 4576_Ch16_p402-444.indd 422
based which lems mode
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UNIT 3 ■ Care of Patients With Psychiatric Disorders
Real People, Real Stories: Dr. Fred Frese
Author's review (if needed) Dr. frese: Like one time when they perceived I was spend- ing too much time interacting with patients, they assumed I was “going off again,” and next thing I knew, they called a “blue alert” and wanted to hospitalize me. But that time, the medical director just told me to take some time off. I never did find out why they called that blue alert. Initials Date OK Correx ISBN# 2/C Karyn: So you haven’t been hospitalized for a very long time, and you are internationally renowned for all of your work and advocacy in the field of mental health. What do you think has contributed most to your recovery? Date Check if revision 7678 11/19/18 Editor's review Initials Date OK Correx 2nd color PMS Dr. frese: Not always. It seemed like even among my cow- orkers, when something strange happened, they thought it was something wrong with me. Karyn: What do you mean by “something strange”? me. During the last attempt to hospitalize me, I actually escaped and ran away, even though I was in pretty bad shape. Karyn: So since you were knowledgeable about the laws, you could essentially be your own self-advocate and argue your case, so to speak? Dr. frese: Yes, and by that time, I was in grad school and had secured a job at what is now the Department of Men- tal Health and Addiction Services. I remember I was living in the hallway of some university housing, and one of the students, who saw me day after day just hanging around and not really doing anything, suggested that I might be eligible for a government job because of my military back- ground. When I applied, the receptionist saw my history of mental health commitments and said I would never get the job, but I did. The last time I went to the hospital, I went voluntarily because I knew I needed more medica- tion, but they thought I needed to be hospitalized and I didn’t; so I ran away. Karyn: Sounds like you were managing a lot of stuff—grad school, working—and, at the same time, episodically strug- gling with symptoms of illness. You were working in the field of mental health, too. Was the work environment supportive? Dr. frese: No, I haven’t been hospitalized since I got mar- ried. I think that has been central in my recovery: having a person who you trust to give you feedback and let me know when I need more medication. Karyn: What role do medications play in recovery? Dr. frese: It’s very individual. We need more research to identify who, among people with schizophrenia, will benefit most by continuous medication versus episodic, reduced doses, or no medication. Genetic research is hopeful, but we’re not there yet. It’s hard to advise any individual what to do without knowing their individual cir- cumstances, and even knowing, it can be very hard.
ectrum and Other Psychotic Disorders ndividual know where to seek assistance e hospital when suicidal thoughts occur? atient discussed the recent loss with staff y members? 356 ent able to verbalize feelings and behav- ated with each stage of the grieving pro- ecognize own position in the process? ession with and idealization of the lost sided? oward the lost object expressed appro- treatment, the patient will be able to differentiate between delusional thinking and reality. ent seeking interaction with others in an te manner? patient maintain reality orientation with ce of delusional thinking? ent able to concentrate and make deci- erning own self-care? patient set realistic goals for self? tient able to verbalize positive aspects past accomplishments, and future pros- uding a desire to live? atient identify areas of life situation that ollable? ent able to participate in usual religious and feel satisfaction and support from been successful in achieving the objec- . Evaluation of the nursing actions for d patient may be facilitated by gathering using the following types of questions: arm to the individual been avoided? dal ideations subsided?
Real People, Real Stories features interviews with patients and provides a model for effective therapeutic communication.
Author Dr. frese: I was 25 when I had my first episode. I was in the Marines and—I know I had seen the movie The Manchurian Candidate previously—and I began to think that the Vietnamese were using the same strategies from the movie to control us. When I let my commanding of- ficer know my theories, I was hospitalized involuntarily, and for the next 10 years I was in and out of hospitals— mostly involuntarily—taking various medications, living many different places, and not employed. Karyn: Were you getting any treatments or intervention that you thought were helpful to your recovery? Artist B /W 4/C Dr. frese: Well, at that time it was thought that schizophre- nia was not an illness from which one could recover. Even recently, I’ve heard some folks who have a family member with schizophrenia say, “There’s no way that anyone with this illness can get better.” But that’s starting to change, and now that the government, through SAMHSA (Sub- stance Abuse and Mental Health Services Administration) is backing the recovery model approach, I think healthcare will improve. I remember being told that my brain was going to progressively deteriorate and that I would never be able to function on my own. All in all, I probably spent about a year of my life in hospitalizations. Once the laws changed and I knew you had to be of imminent harm to yourself or others in order to be hospitalized involuntarily, I talked some of the health professionals out of admitting Townsend UF15_01 GW-CO X People with schizophrenia continue to be disenfranchised, misunderstood, and stigmatized. Even within healthcare, evidence has shown that some settings have been very hostile to people with severe mental illnesses. One way to begin combating stigmatization of people with mental illness is to get to know them personally. Dr. Fred Frese is a licensed psychologist and an internationally renowned speaker, writer, and advocate in the field of mental illness. Karyn: Could you share a little bit about your history with the illness of schizophrenia? 1. Patient must understand that you do not view the idea as real.
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other psychotic disorders has been identified. e include (on a gradient of psychopathology least to most severe): schizotypal personal- sorder, delusional disorder, brief psychotic der, substance-induced psychotic disorder, hotic disorder associated with another medi- ondition, catatonic disorder associated with her medical condition, schizophreniform dis- , schizoaffective disorder, and schizophrenia. ng care of the patient with schizophrenia is ac- lished using the six steps of the nursing process. ing assessment is based on knowledge of tomatology related to thought content and esses, perception, affect, volition, interper- functioning and relationship to the external d, and psychomotor behavior. toms of schizophrenia are categorized as posi- an excess or distortion of normal functions) or ve (a diminution or loss of normal functions). sychotic medications remain the mainstay of ment for psychotic disorders. Atypical antipsy- cs have become the first line of therapy and both positive and negative symptoms of schizo- nia. They have a more favorable side-effect pro- han the conventional (typical) antipsychotics. iduals with schizophrenia require long-term rated treatment with pharmacological and interventions. Some of these include indi- l psychotherapy, group therapy, behavior py, social skills training, milieu therapy, fam- erapy, and assertive community treatment. he majority of clients, the most effective treat- appears to be a combination of psychotropic cation and psychosocial therapy. e clinicians are choosing a course of therapy d on a model of recovery, somewhat like that h has been used for many years with prob- of addiction. The basic premise of a recovery el is empowerment of the consumer. The re- ■■ By the end of 2 weeks, patient will recognize and verbalize that false ideas occur at times of in- creased anxiety. Long-Term Goals ■■ By time of discharge from treatment, patient’s verbaliza- tions will reflect reality-based thinking with no evidence of delusional ideation. ■■ By time of discharge from Movie Connections list films that demonstrate conditions and behaviors you may not encounter in clinical. ent selecting and consuming foods suffi- gh in nutrients and calories to maintain d nutritional status? patient sleep without difficulty and wake sted? patient attend to personal hygiene and ? atic complaints subsided? Modalities nal Psychotherapy s documented the importance of close, ttachments in the prevention of depres- ver double the risk among those with uality of social relationships (Teo et al., this concept in mind, interpersonal psy- focuses on the client’s current interper- ns. Interpersonal psychotherapy with the erson proceeds through three phases. Text continued on page 428
UNIT 3 ■ Care of Patients With Psychiatric Disorders
TABLE 15–2 | CARE PLAN FOR THE PATIENT WITH SCHIZOPHRENIA—cont’d
Fig. # NURSING DIAGNOSIS: DIsTuRbED THOugHT PROCEssEs RELATED TO: Inability to trust, panic anxiety, possible hereditary or biochemical factors EVIDENCED BY: Delusional thinking; inability to concentrate; impaired volition; inability to problem solve, abstract, or conceptualize; extreme suspiciousness of others OuTCOME CRITERIa NuRsINg INTERVENTIONs RaTIONaLE Short-Term Goal
Document name
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Final Size (Width X Depth in Picas) 19p x 12p8
1. Convey acceptance of patient’s need for the false belief but indicate that you do not share the belief. 2. Do not argue or deny the belief.
2. Arguing with the patient or denying the belief serves no useful purpose, because delusional ideas are not eliminated by this approach, and the development of a trusting relationship may be impeded. 3. Discussions that focus on the false ideas are purposeless and useless and may even aggravate the psychosis.
Use “reasonable doubt” as a thera- peutic technique: “I understand that you believe this is true, but I person- ally find it hard to accept.”
3. Reinforce and focus on reality. Discourage long ruminations about the irrational thinking. Talk about real events and real people. 4. If patient is highly suspicious, the following interventions may be helpful: a. Use same staff as much as possible; be honest and keep all promises. b. Avoid physical contact; ask the pa- tient before touching to perform a procedure, such as taking a blood pressure. c. Avoid laughing, whispering, or talk- ing quietly where patient can see but cannot hear what is being said. d. Provide canned food with can opener or serve food family style.
4. To decrease patient’s suspiciousness:
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a. Familiar staff and honesty pro- motes trust.
b. Patients with suspicious ideation often perceive touch as threatening and may respond in an aggressive or defensive manner.
Therapeutic Communication Icon identifies helpful interventions and guidance on how to speak with your patients. Look for this icon in Care Plan sections. c. Patient may have ideas of refer- ence and believe he or she is being talked about.
d. Suspicious patients may believe they are being poisoned and re- fuse to eat food from an individu- ally prepared tray. e. Suspicious patients may believe they are being poisoned with their medication and attempt to discard the tablets or capsules. f. Competitive activities are very threatening to suspicious patients. g. Patients with suspicious ideation are prone to distrust and are hypervigi- lant of peoples’ behavior and com- munication. Approaches that are overly directive or cheerful may in- crease the patient’s suspiciousness.
e. Mouth checks may be necessary following medication administration to verify whether the patient is actually swallowing the pills. f. Provide activities that encourage a one-to-one relationship with the nurse or therapist. g. Maintain an assertive, matter-of- fact, yet genuine approach.
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LEARN STEP #2 Make the connections to key topics.
UN I T 3
16 Depressive Disorders
403
CHAPTER 16 ■ Depressive Disorders
Introduction Depression is likely the oldest and still one of the most frequently diagnosed psychiatric illnesses. Symptoms of depression have been described almost as far back as there is evidence of written documentation. An occasional bout with the “blues,” a feeling of sadness or downheartedness, is common among healthy people and is considered to be a normal response to everyday disappointments in life. These episodes are short lived as the individual adapts to the loss, change, or failure (real or perceived) that has been experienced. Pathological depression occurs when adaptation is ineffective and the symptoms are significant enough to impair functioning. Mood is a pervasive and sustained emotion that may have a major influence on a person’s perception of the world. Examples of mood include depression, joy, elation, anger, and anxiety. Affect is described as the external, observable emotional reaction associated with an experience. A flat affect describes someone who lacks emotional expression and it is often seen in severely depressed clients. This chapter focuses on the different manifes- tations of depressive illness and implications for nursing intervention. A historical perspective and epidemiology of depression are presented. Predis- posing factors that have been implicated in the etiol- ogy of depression provide a framework for studying the dynamics of the disorder. Similarities and dif- ferences between depressive disorders and grief are discussed. CORE CONCEPT Mood and Affect Depressive illnesses specific to individuals at various developmental stages are reviewed. An explanation of the symptomatology is presented as background knowledge for assessing the client with depression. Nursing care is described in the context of the six steps of the nursing process. Various medical treat- ment modalities are explored.
evident. Changes in appetite, sleep patterns, and cog - nition are common. Severe depression may be accom - panied by suicide ideation and/or attempts.
Care of Patients With Psychiatric Disorders
Historical Perspective Many ancient cultures (e.g., Babylonian, Egyptian, Hebrew) believed in the supernatural or divine ori- gin of mood disorders. The Old Testament states in the Book of Samuel that King Saul’s depression was inflicted by an “evil spirit” sent from God to “torment” him. A clearly nondivine point of view regarding depres- sion was held by the Greek medical community from the 5th century BC through the 3rd century AD and represented the thinking of Hippocrates, Celsus, and Galen, among others. They strongly rejected the idea of divine origin and considered the brain as the seat of all emotional states. Hippocrates believed that melancholia was caused by an excess of black bile, a heavily toxic substance produced in the spleen or intestine, which affected the brain. Melancholia is currently used to describe a severe form of major depressive disorder in which symptoms are exagger- ated and interest or pleasure in virtually all activities is lost. During the Renaissance, several new theories evolved. Depression was viewed by some as being the result of obstructed air circulation, excessive brood- ing, or helpless situations beyond the individual’s control. Depression was reflected in major literary works of the time, including Shakespeare’s King Lear, Macbeth , and Hamlet . Contemporary thinking has been substantially shaped by the works of Sigmund Freud, Emil Krae- pelin, and Adolf Meyer. Having evolved from these early 20th-century models, current thinking about mood disorders generally encompasses the intrapsy- chic, behavioral, and biological perspectives. These various perspectives support the notion of multiple causation in the development of mood disorders. Epidemiology Major depressive disorder (MDD) is one of the leading causes of disability in the United States. In addition to the disability posed by the disorder itself, recent research links depression to an increased risk for several other medical conditions, including coronary artery disease (another leading cause of death), especially in women younger than age 65 (Jiang et al., 2016). In 2019, 4.7% of adults age 18
CORE CONCEPTS Mood and Affect: Depression Professional Behavior: Nursing process in caring for patients with depressive disorders Safety Clinical Judgment
CHAPTER OUTLINE
Objectives Introduction Historical Perspective Epidemiology Types of Depressive Disorders Predisposing Factors Developmental Implications Application of the Nursing Process Treatment Modalities
Summary and Key Points Review Questions Clinical Judgment Questions
Psychotic Disorders
Implications for Evidence-Based Practice Test Your Clinical Reasoning and Clinical Judgment Skills Communication Exercises Movie Connections
15
KEY TERMS affect cognitive behavior therapy
mood postpartum depression premenstrual dysphoric disorder psychomotor retardation
Psychotic Disorders
15
depression dysthymia melancholia
OBJECTIVES After reading this chapter, the student will be able to: 1. Recount historical perspectives of depression. 2. Discuss the epidemiology of depression. 3. Describe various types of depressive disorders. 4. Identify predisposing factors in the devel- opment of depression. 5. Discuss implications of depression related to developmental stage. 6. Identify symptomatology associated with depression and use this information in patient assessment.
7. Formulate nursing diagnoses and goals of care for patients with depression. 8. Identify topics for patient and family teaching relevant to depression. 9. Describe appropriate nursing inter- ventions for behaviors associated with depression. 10. Describe relevant criteria for evaluating nursing care of patients with depression. 11. Discuss various modalities relevant to treatment of depression.
Psychotic Disorders
15
CORE CONCEPT Depression
Depression is an alteration in mood that is expressed by feelings of sadness, despair, and pessimism. In clinically significant depression, there is a loss of inter - est in usual activities, and somatic symptoms may be
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• Depressive Disorders • Bereaved Individual
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Recovery Models Chapter 10 Suicide Prevention Chapter 11 Neurocognitive Disorders Chapter 13 Bipolar and Related Disorders Chapter 17 Eating Disorders Chapter 21 Personality Disorders Chapter 22
APPLY STEP #3
Develop critical-thinking skills & prepare for the Next Gen NCLEX. ®
Real-world cases mirror the complex clinical challenges you will encounter in a variety of healthcare settings. Each case study begins with a patient photograph and a brief introduction to the scenario.
The Patient Chart displays tabs for History & Physical Assessment, Nurses’ Notes, Vital Signs, and Laboratory Results. As you progress through the case, the chart expands and populates with additional data.
Complex questions that mirror the format of the Next Gen NCLEX® require careful analysis, synthesis of the data, and multi-step thinking.
Psychotic Disorders
You answered 2 out of 6 questions correctly.
Immediate feedback with detailed rationales encourages you to consider what data is important and how to prioritize the information to ensure safe and effective nursing care.
Test-taking tips provide important context and strategies for how to consider the structure of each question type when answering.
ASSESS STEP #4 Improve comprehension & retention.
Comprehensive rationales explain why your responses are correct or incorrect. Page-specific references direct you to the relevant content in your text, while test-taking tips improve your test-taking skills.
High-quality questions , including more difficult question types like select-all-that-apply , assess your understanding and challenge you to think at a higher cognitive level. PLUS! Brand-new Next Gen NCLEX® stand-alone questions provide you with even more practice answering the new item types and help build your confidence.
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Crisis Intervention
Ethical and Legal Issues
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Contents in Brief
Chapter 18 Anxiety, Obsessive-Compulsive, and Related Disorders Chapter 19 Trauma- and Stressor-Related Disorders Chapter 20 Somatic Symptom and Dissociative Disorders
UNIT 1 Introduction to Psychiatric Mental Health Concepts
475
1
508
Mental Health and Mental Illness
2
Chapter 1
533
Biological Implications Ethical and Legal Issues
12
Chapter 2
Chapter 21 Eating Disorders
561
38
Chapter 3
Chapter 22 Personality Disorders
587
Psychopharmacology
59
Chapter 4
UNIT 4 Psychiatric Mental Health Nursing of Special Populations
UNIT 2 Psychiatric Mental Health Nursing Interventions
623
99
Chapter 23 Children and Adolescents
624
Relationship Development and Therapeutic Communication The Nursing Process in Psychiatric Mental Health Nursing Psychosocial Interventions and Spiritual Care
Chapter 5
100
Chapter 24 The Aging Individual
669
Chapter 6
Chapter 25 Survivors of Abuse or Neglect Chapter 26 Community Mental Health Nursing
700
125
Chapter 7
725
149
Chapter 27 The Bereaved Individual
756
Intervention in Groups
170
Chapter 8
Chapter 28 Military Families
775
Crisis Intervention
182
Chapter 9
Appendix A Mental Status Assessment
A-1
Chapter 10 The Recovery Model
205
Appendix B Glossary
A-5
Chapter 11 Suicide Prevention
219
Appendix C Answers to Review Questions
A-29
UNIT 3 Care of Patients With Psychiatric Disorders
Appendix D Examples of Answers to Communication Exercises
A-31
247
I-1
Index
Chapter 12 Caring for Patients With Mental
Online Chapters
Illness and Substance Use Disorders in General Practice Settings
248
Chapter 29 Concepts of Personality Development
Chapter 13 Neurocognitive Disorders
263
795
Chapter 14 Substance Use and Addiction Disorders Chapter 15 Schizophrenia Spectrum and Other Psychotic Disorders
Chapter 30 Complementary and Integrative Therapies
299
812
Chapter 31 Cultural Concepts Relevant to
362
Psychiatric Mental Health Nursing
835
Chapter 16 Depressive Disorders
402
Chapter 32 Issues Related to Human Sexuality and Gender Dysphoria
Chapter 17 Bipolar and Related Disorders
445
847
xiii
11 Suicide Prevention
CORE CONCEPTS Behaviors: Suicide Caring: Therapeutic relationship Safety: Suicide risk
CHAPTER OUTLINE
Objectives Introduction Historical Perspectives Epidemiology Risk Factors Predisposing Factors: Theories of Suicide
Application of the Nursing Process With the Suicidal Patient Summary and Key Points Review Questions Clinical Judgment Questions Communication Exercises
assessment, Suicide prevention Evidence-Based Practice: Suicide prevention Health Promotion: Suicide risk assessment Professional Behavior: Nursing process in the care of patients with suicidal ideation or behaviors Clinical Judgment
KEY TERMS collaborative safety plan suicide
suicide risk factors suicide warning signs
OBJECTIVES After reading this chapter, the student will be able to: 1. Discuss epidemiological statistics and risk factors related to suicide. 2. Describe predisposing factors implicated in the etiology of suicide. Introduction Suicide is not a diagnosis or a disorder; it is a behav- ior. Specifically, it is the act of taking one’s own life, and it derives from the Latin words for “one’s own killing.” Many religions hold that suicide is a sin, and it is strictly forbidden. Cultural norms and attitudes also influence an individual’s beliefs about suicide. Although some populations are considered at higher risk for suicide (such as American Indians and Alaska Natives; active and veteran military members; lesbian, gay, bisexual, or transgender individuals; and people in justice or child welfare settings), suicide touches the lives of all age-, ethnic, and racial groups in all parts of the country. A complex interaction of fac- tors, such as mental illness, substance abuse, painful
3. Differentiate between facts and myths regarding suicide. 4. Apply the nursing process to individuals exhibiting suicidal behavior.
losses, exposure to violence, and social isolation, are all influential in increasing these risks (Substance Abuse and Mental Health Services Administration [SAMHSA], 2020). In the past decade, many state legislatures have debated the acceptability of physician-assisted sui- cide. Although it is legal in all parts of the United States for an individual or the individual’s power of attorney to refuse life-preserving medical treatment, the majority of states have not legalized physician- assisted suicide. As of 2020, nine states (California, Colorado, Hawaii, Maine, Montana, New Jersey, Oregon, Washington, and Vermont) and Washing- ton, DC, have legalized physician-assisted suicide. New Mexico also adopted a similar law, but it was overturned on appeal in August 2015. Can suicide be
219
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UNIT 2 ■ Psychiatric Mental Health Nursing Interventions
a rational act? Most people in our society do not yet believe that it can. In the field of psychiatry, suicide is considered an irrational act associated with mental illness and most commonly, but not exclusively, with depression. How- ever, not everyone who dies by suicide has a mental illness. Individuals in non-psychiatric health-care settings and in the community may also be at risk. This chapter explores suicide from an epidemiolog- ical and etiological perspective. Care of the suicidal patient is presented in the context of the nursing process. Historical Perspectives In ancient Greece, individuals were said to have “com- mitted” suicide because it was an offense against the state, and individuals who did so were denied burial in community sites (Minois, 2001). In the culture of ancient Rome, individuals sometimes resorted to sui- cide to escape humiliation or abuse. In the Middle Ages, suicide was viewed as a selfish or criminal act (Minois, 2001). Individuals who “com- mitted suicide” were often denied cemetery burial and their property was confiscated and shared by the crown and the courts (MacDonald & Murphy, 1991). The issue of suicide changed during the Renaissance period. Although condemnation was still expected, the view became more philosophical, and intellectu- als could discuss the issue more freely. Most philosophers of the 17th and 18th centuries condemned suicide, but some writers recognized a connection between suicide and melancholy or other severe mental disturbances (Minois, 2001). Suicide was illegal in England until 1961, and only in 1993 was it decriminalized in Ireland. With the decriminalization of suicide, many have advanced the idea that the term committed suicide should be removed from our vocabulary because it is inaccu- rate and potentially maintains a stigmatizing attitude toward this population. Most religions consider suicide as a sin: Judaism, Christianity, Islam, Hinduism, and Buddhism all con- demn suicide. The Catholic Church still teaches that suicide is wrong, that it is in opposition to proper love of self and love of God, and that it wrongs oth- ers through the experience of loss and grief (Byron, 2016). But as Byron points out, some of the church’s condemnation may have been rooted in a “denial of the responsibility to understand the pain” that pro- duces such an act, and he stresses the importance of encouraging those who “are hurting to open up,”
which, it is hoped, will remove some of the taboos of discussing suicide within the church. Likewise, replacing the term committed suicide (which has per- sisted long since its decriminalization) may also help to reduce the stigma and taboo that has historically been associated with discussing suicide. Epidemiology In 2019, the most recent year for which statistics have been recorded, 47,511 people died by suicide in the United States (Centers for Disease Control and Pre- vention [CDC], 2021a). Most of those deaths were firearm suicides. These statistics have established sui- cide as the second-leading cause of death (behind unintentional injuries) among young Americans ages 10 to 24 (19.2% of deaths) and 25 to 44 (10.9%), the eighth-leading cause for those ages 45 to 64 (3.1% of deaths), and the 10th-leading cause of death overall (CDC, 2019a). (While suicide has been the 10th-leading cause of death for several years, provi- sional statistics for 2020 indicate suicide as the 11th- leading cause of death for a year where COVID-19 deaths became the third-leading cause of death over- all in the United States [Ahmad et al., 2021].) Many more people attempt suicide than succeed (about 12:1), and countless others seriously contemplate the act without carrying it out. With a steady incline in rates of suicide over the period from 2000 to 2018, suicide has become a major health-care problem in the United States today. Not only have the number of suicides been on the incline but the demographics have changed. Histor- ically, the highest rates of suicide were among the elderly. However, the current highest rates of suicide are among individuals ages 45 to 54 and the second- highest are those over 85 years of age (American Foundation for Suicide Prevention [AFSP], 2021). Historically, the suicide rate has been lower among military personnel than among the general popula- tion. However, in some time periods since the Iraq War began—including in 2010 and 2011—more soldiers died by suicide than died in combat (Nock et al., 2013). The Department of Defense reports that among all military populations, the 2018 rate of suicide was consistent over the last two years but rates from the active military component were statis- tically higher than the last five years (Lopez, 2019). See Chapter 28, “Military Families,” for further discussion. Research is being conducted to better under- stand the best methods for assessment of suicide
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CHAPTER 11 ■ Suicide Prevention
risk, what differentiates those with suicidal ideation from those who attempt, and evidence-based treat- ments and interventions. The federal government, through the Substance Abuse and Mental Health Services Administration (SAMHSA), has endorsed the “Zero Suicide” movement; a partnership of sev- eral national organizations dedicated to identifying evidence-based strategies for suicide prevention. Within the next several years, we may discover that
our understanding of and approaches to treatment will dramatically change. We are certainly begin- ning to recognize that, with the rise in suicide rates, our conventional interventions have not adequately addressed the complex needs of this population. Confusion exists over the reality of various notions regarding suicide. Some currently accepted facts and some myths relating to suicide are presented in Table 11–1.
TABLE 11–1 Facts and Myths About Suicide MYTHS FACTS
People who talk about suicide do not act on their ideas. Suicide happens without warning. You cannot stop suicidal people. They are fully intent on dying.
Eight out of 10 people who kill themselves have given definite clues and warnings about their suicidal intentions. Very subtle clues may be ignored or disregarded by others. Most suicidal people are very ambivalent about their feelings regarding living or dying. Most are “gambling with death” and see it as a cry for someone to save them. Suicidal ideation and risk fluctuate over time and may be time limited. If provided adequate support and resources, a suicidal person can go on to lead a normal life. However, multiple suicide attempts may reflect greater chronicity of suicidal ideation. Reassessment over time is important to identify current risks. Most suicides occur within about 3 months after the beginning of “improvement,” when the individual has the energy to carry out suicidal intentions. Suicide is not inherited. Many mental illnesses like depression, bipolar disorder, and substance abuse run in families and confer an increased risk, but suicidal behavior is not inevitable in these populations. However, suicide by a close family member does increase the risk of similar behav- ior in other family members. Although a majority of people who attempt suicide are extremely unhappy, or clinically depressed, they are not necessarily psychotic. They are merely unable at that point in time to see an alternative solution to what they consider an unbearable problem. All suicidal behavior must be approached with the gravity of the potential act in mind. Attention should be given to the possibility that the individual is issuing a cry for help.
Once people are suicidal, they are suicidal forever.
Improvement after severe depression means that the suicidal risk is over.
Suicide is inherited, or “runs in families.”
All suicidal individuals are mentally ill, and suicide is the act of a psychotic person.
Suicidal thoughts and attempts should be considered manipulative or attention-seeking behavior and should not be taken seriously. People usually take their own lives by taking an overdose of drugs. If individuals have attempted suicide, they will not do it again. Suicide always happens in an impulsive moment.
Gunshot wounds are the leading cause of death among suicide victims.
Between 50% and 80% of all people who ultimately kill themselves have a history of at least one previous attempt. People who are suicidal often contemplate, imagine, plan strategies, write notes, post things on the Web. The importance of in-depth exploration and assessment cannot be overstated. Each year, 30 to 35 children younger than age 12 take their own lives and not all are clinically depressed.
Young children (ages 5–12) cannot be suicidal.
Sources: Compiled from Fuller (2020); National Alliance on Mental Illness (NAMI) (2021); and The Samaritans (2021).
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UNIT 2 ■ Psychiatric Mental Health Nursing Interventions
Risk Factors Suicide risk factors are identified as factors that have statistically been correlated with a higher incidence of suicide. They should be differentiated from sui- cide warning signs, which are identified as factors suggesting a more immediate concern. Both are included as part of a comprehensive assessment of overall risk for suicide. Marital Status Widows and widowers, in some studies, have been identified as high risk, but a longitudinal study found that being single or widowed had no effect on sui- cide rates (Kposowa, 2000). However, the Kposowa study did find that divorced men were twice as likely as married men to die by suicide. For those who are divorced or widowed, the stresses associated with major life changes and loss are influential. Evidence has demonstrated that change in marital status increases risk for suicidal behavior, particularly in the first year after the change and par- ticularly among older people (Ro˘skar et al., 2011; Yamauchi et al., 2013). Again, it should be noted that demographics such as marital status, age, and sex may inform about populations that are statistically at higher risk, but none of these factors is predictive of immediate risk. A thorough assessment of variables, including risk factors, warning signs, and a host of other data, is essential to identifying individuals at acute risk for attempting suicide. Sex More women than men attempt suicide, but men succeed more often (about 70% of men who attempt suicide succeed, and 30% of women who attempt it succeed). This rate reflects the lethality of the means. Women tend to overdose on drugs; men use more lethal means, such as firearms. These differ- ences between men and women may also reflect dif- fering societal expectations; women are more likely than men to seek and accept help from friends or professionals. Age Suicide risk and age are, in general, positively cor- related, particularly with men. Although rates among women remain fairly constant throughout life, rates among men increase with age. The most recent sta- tistics, according to the AFSP (2021), revealed that in 2018, the highest rate of suicide occurred in the 45-to-64-year-old age-group (with the highest rates
among those 52 to 59 years of age, and men 3.56 times more often than women), and the second-highest rate was for those 85 or older. Although adolescents may statistically have a lower rate of suicide than some other age-groups, it is still important to note that it has been, over several years, the third-leading cause of death in this population, and in 2013 it jumped to the second-leading cause of death where it remained in 2019 (CDC, 2021b). Sev- eral factors put adolescents at risk for suicide, includ- ing impulsive and high-risk behaviors, untreated mood disorders (e.g., major depression and bipolar disorder), access to lethal means (e.g., firearms), and substance abuse. One study (Reyes et al., 2015) found a link between some modes of anger expres- sion in adolescents and suicide risk; in particular, hopelessness and hostility modes of anger expression were associated with an increase in suicidal tendency. Among children younger than 10 years of age, the statistics demonstrate a low number of suicides, and some have argued that younger children do not have the capacity to intentionally consider and follow through with a suicide attempt. Anecdotal evidence has shown that this is not always the case, with some therapists identifying 5- to 9-year-olds actively talking about suicide (Jobes, 2015). Research is beginning to emerge that supports real risk in young children (Duran & McGuinness, 2016). Bridge and associates (2015) studied a large sample of children ages 5 to 11 and found that an average of 33 children per year die by suicide within this age-group in the United States, predominately from suffocation and hanging. These researchers also noted that suicide was never coded as a cause of death for children under 5 years of age. When Whalen and associates (2015) studied children in the 3-to-7-year-old age-group, they found about 11% with suicidal ideation. Increased risk was correlated with male gender, psychiatric illness in their mothers, and psychiatric illness in the child. In young girls ages 10 to 14 years, the incidence of self- inflicted injury has risen 18.8% every year between 2008 and 2015, and self-inflicted injury is one of the strongest risk factors for suicide (Mercado et al., 2017). Duran and McGuinness (2016, p. 29) stress that the implications for nursing are clear; direct inquiry about suicide ideas is a “necessary com- ponent in healthcare encounters with children,” including those in primary care, emergency depart- ments, and with the school nurse. The American Association of Suicidology (2021) reports that although the overall number of suicides for 2019 (47,511) was less than it was in 2018 (48,344),
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