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UNIT 2 ■ Psychiatric Mental Health Nursing Interventions
ideation (for both men and women and across age-groups). 2. Connectedness prevents suicide ideation from escalating in those at risk, but when pain and hope- lessness exceed one’s sense of connectedness to others, suicide ideation becomes active. 3. When strong, active suicide ideation is present, it leads to an attempt only if one has the capacity to make an attempt. Biological Theories Biological theories attempt to understand the bio- chemical and genetic influences in the risk for sui- cidal behavior. Current theories recognize that the complexity of suicide risk and behavior is likely a complex interaction of biological, psychological, interpersonal, and environmental factors. Genetics Twin studies have shown a much higher concor- dance rate for monozygotic twins than for dizy- gotic twins. Some studies with people who have attempted suicide have focused on the genotypic variations in the gene for tryptophan hydroxylase, with results indicating significant association to sui- cidality (Zhang et al., 2010). Tryptophan hydroxy- lase is an enzyme associated with the synthesis of serotonin, and diminished serotonin has implica- tions for both depression and suicidal behavior. Additional research has identified a genetic varia- tion in prefrontal cortex tissue that may be a bio- marker for suicide risk when vulnerable individuals are exposed to a significant stressor (Sudak, 2017). These findings suggest the potential for genetic predisposition toward suicidal behavior, but more research is needed. Neurochemical Factors Studies have revealed altered levels of serotonin, glutamate, gamma-aminobutyric acid (GABA), and dopamine, and increased levels of corticotropin- releasing hormone (CRH) (which triggers the release of cortisol) in individuals who died by suicide (Offord, 2020). These studies have supported the association of altered neurochemical levels with risk for suicide. However, a recent meta-analysis examining bio- logical factors found that they are, in general, weak predictors of a future suicide attempt or death by suicide (Chang et al., 2016). The only two biologi- cal factors that had statistical significance in this analysis were cytokines (anti-inflammatory response
chemicals) and low levels of fish oil nutrients (includ- ing omega-3 fatty acids). Application of the Nursing Process With the Suicidal Patient Many research studies are being conducted that explore suicide from different vantage points to iden- tify demographics, risk factors, predictors of risk for suicide attempts, and strategies for prevention. This research can help nurses become more aware of the phenomenon of suicide and understand the limita- tions of research in making a clinical judgment about a patient’s actual risks versus statistical risks. Influen- tial organizations across the nation are advancing the importance of improving the quality of care, docu- mentation, and reporting of details around sentinel events related to acts of or deaths by suicide. In addi- tion to government-endorsed national strategies for suicide prevention, The Joint Commission (2016) has advanced standards that include requiring orga- nizations to conduct risk assessments “identifying specific patient characteristics and environmental features that may increase or decrease the risk of suicide.” It is nurses practicing in general medical settings, including emergency departments and pri- mary care practices, who are frontline practitioners in the fight to prevent suicide, so these assessment skills are critical wherever nurses are practicing. The American Psychiatric Nurses Association (APNA, 2020; Puntil et al., 2013) has taken a leadership role in identifying psychiatric mental health nurse essen- tial competencies for assessment and management of individuals at risk for suicide. The CDC (2011) has advanced strategies for a uniform definition and reporting about acts of self-directed violence to improve data collection and ultimately improve our understanding and prevention of suicide. At the heart of this wealth of information is the necessity for accurate, comprehensive assessment that includes collaboration with the patient and other clinicians and is rooted in forming a therapeutic relationship of trust and open communication. Assessment When nurses assess a patient’s suicide ideation, it is important to identify and distinguish ideas (thoughts), plans (intentions), and attempts (behav- ior). Each of these assessment factors can provide information about a patient’s level of risk. When the patient has attempted self-injury, it is import- ant to distinguish between suicidal self-injury and
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