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CHAPTER 11 ■ Suicide Prevention
nonsuicidal self-injury . The latter injury is often used as a method to release emotions, but it may also be a way of communicating the severity of distress that the patient is experiencing (Nock et al., 2013). Dr. David Satcher, as Surgeon General of the United States (1998–2002), spoke of risk factors and protec- tive factors in his Call to Action to Prevent Suicide (U.S. Public Health Service, 1999). This report initiated a national movement toward research designed to bet- ter understand predictors of suicide risk and develop more evidence-based interventions. Current models have clarified risk factors as different from warning signs associated with a greater potential for suicide and suicidal behavior. Protective factors have been identified that are associated with reduced potential for suicide. Examples of protective factors are out- lined in Box 11–1. Figure 11–1 presents a model for differentiating low, high, and imminent suicide risks. The goal of such models is not to predict a suicide attempt but to assist in making a clinical judgment about the level of intervention needed to prevent an attempt. Further, while risk assessment is part of a com- prehensive psychosocial assessment and safety plan , there is good evidence that risk assessment scales, when used alone, have not had strong predictive value, and may provide a false sense of reassurance (Chan et al., 2016; Large et al., 2016). The importance of a comprehensive and collaborative approach cannot be overstated. BOX 11–1 Examples of Protective Factors Resilient temperament Social competency Skills in problem-solving, coping, and conflict resolution Perception of social support from adults and peers Positive expectations, optimism for the future; identifica- tion of future goals Connectedness to family, school, community Presence and involvement of caring adults (for adolescents) Integration in social networks Cultural and religious beliefs that discourage suicide and encourage preservation of life Access to quality social services and clinical health care for mental, physical, and substance use disorders Support through ongoing medical and mental health-care relationships Restricted access to highly lethal means of suicide
Demographics The following demographics should be noted when evaluating a patient for suicide risk. Although demo- graphics alone do not directly increase a person’s risk, they provide information as part of a compre- hensive assessment of proximal or potentiating risk factors. ■■ Age: Adolescents and the elderly have been gen- erally identified as high-risk groups, but recent statistics demonstrating the highest incidence in the 45-to-54-year-old age-group as well as increas- ing incidence among children suggests that nurses should assess for suicide risk in all age-groups. ■■ Sex: Males are at higher risk for death by suicide than females, but females attempt suicide more frequently. ■■ Ethnicity/race: The CDC reports that the “highest rates across the life span [are] occurring among non-Hispanic American Indian/Alaska Native and non-Hispanic White populations” (CDC, 2018). ■■ Marital status: Those with recent changes in mar- ital or relationship status (such as a breakup, divorce, or recently widowed individuals) may be associated with increased risk for depression and suicide. ■■ Socioeconomic influences: Financial strain and unemployment are identified as risk factors for suicide. ■■ Occupation: Health-care professionals (especially physicians), law enforcement officers, dentists, art- ists, mechanics, lawyers, and insurance agents have all been identified as occupational groups believed to incur greater risks for suicide. Potential con- tributing factors include occupations that involve high stress, isolation, lack of access to health-care resources, and repeated exposure to painful or vio- lent stimuli. The most recent data on suicide rates by occupation (Peterson et al., 2020) identified that highest rates were among construction work- ers, maintenance and repair workers, those in the arts and entertainment industry (including sports and the media), transportation workers, protective service workers, and health-care support staff (par- ticularly personal care aides and registered nurses). ■■ Religion: People with close religious affiliation may be at less risk for attempting suicide if they believe, for example, that suicide is an unforgivable sin or that suicide is strictly forbidden within the reli- gion. Conversely, people without close affiliations that impose restrictions about suicide may be at greater risk.
Source: Crosby et al. (2011).
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