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UNIT 2 ■ Psychiatric Mental Health Nursing Interventions
(Chung et al., 2019). This higher risk may be a reflection of the severity of their mental illness. Other recent research supports that the increased risk of suicide in the period following discharge from psychiatric hospitalization is especially higher for those not connected to a system of care (Forte et al., 2019; Olfson et al., 2016). Suicide risk may increase during early treatment with antidepres- sants. One possible reason is that as energy returns to those taking antidepressants, they may have an increased ability to act out self-destructive wishes. Although suicide is often thought of as strictly related to depression, there is also a recognized risk of suicide among people with schizophrenia, bipolar disorders, personality disorders, eating dis- orders, anxiety disorders, and substance use dis- orders. A thorough suicide risk assessment should be conducted for anyone seeking mental health services. Other major physical conditions have also been identified as contributing to increased risk for sui- cide (Ahmedani et al., 2017), with three conditions (traumatic brain injury, sleep disorders, and HIV/ AIDS) conferring a twofold increase in risk. Severe insomnia is associated with increased suicide risk even in the absence of depression. Use of alcohol, and particularly a combination of alcohol and barbi- turates, increases the risk of suicide. Withdrawal from stimulants increases suicide risk as the person begins to “crash.” Psychosis, especially with command hallu- cinations (hearing voices telling one to harm or kill oneself), poses a higher risk as does having a chronic painful or disabling illness. Several studies have indicated a higher risk for suicide among lesbian, gay, bisexual, and transgen- der (LGBT) individuals (Cassels, 2011; Eisenberg & Resnick, 2006; King et al., 2008; Plöderl et al., 2013). The Trevor Project (2021), a national organization providing crisis intervention and suicide prevention services for young adults in the LGBTQ community, cites studies that found an 8.4% increase in suicide attempts among LGBTQ youth who come from fam- ilies who reject them, and an average of a 2.5 times greater risk of self-harming behavior for each episode of LGBTQ victimization, such as physical or verbal harassment or abuse. A report from the CDC (2016) identified that in a study of youths in grades 7 to 12, lesbian, gay, and bisexual youth were twice as likely to attempt suicide than their heterosexual peers (this study did not address the risk for transgender indi- viduals). Another study, however, found that trans- gender individuals are also a high-risk population
for suicide, with an alarming 41% lifetime prevalence (Stroumsa, 2014). Higher risk is also associated with a family history of suicide, especially in a same-gender parent and with individuals who have made previous suicide attempts. About one-half of individuals who kill them- selves have previously attempted suicide. Because roughly equal numbers die by suicide on their first attempt, all individuals with suicide ideation should be assessed carefully for risk factors and warning signs. Significant losses, including relational, social, work, or financial losses, have also been identified as risk factors (CDC, 2019b). In recent years, a number of suicides have been reported in the media among young people who are the victims of bullying. Zweig and Dank (2013) reported that 41% of youth are victims of physical bullying (most often boys), 17% are victims of cyber- bullying, and girls are more likely to be victims of psychological bullying. Clearly, bullying is a prevalent concern among youth. Cyberbullying has also been associated with increased risk of depression and suicidal behavior among young people. Researchers found that both perpetrators and victims of cyberbullying had more suicidal ideation, more incidents of self-harm, and more suicide behaviors than those who had not expe- rienced such forms of peer aggression (Bauman et al., 2013; John et al., 2018). Edgerton and Limber (2013), in a research brief on suicide and bullying, caution that although research does show that those who are bullied have high levels of suicidal thoughts and attempts, there is not enough research to identify a cause-and-effect relationship. Other risk factors such as mental health problems appear to play a larger role. Predisposing Factors: Theories of Suicide Psychological Theories Psychological theories focus primarily on cognitive, emotional, and behavioral factors that are associ- ated with risk for suicide. While suicidal behavior is most commonly associated with depression, several other emotions and behaviors have been identified as influential. Following is a description of several of these psychological factors. Anger Turned Inward Freud (1957) believed that suicide was a response to intense self-hatred. The anger is first directed toward a love object but is ultimately turned inward against the self.
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