- Name:Ben
- Age:47 years
- Sex:Male
- Name of informant: Police
- Reason for referral: the client’s wife who reported that Ben had taken an overdose of paracetamol, sertraline and diazepam and wanted to die
- Recent Treatment history: Patient has been brought to the Emergency Department once before in the last month due to a suicide attempt.
- Mental state impression: Ben was agitated, and confused and intoxicated.
- Crisis Triage Rating Scale: Patient has a high risk for suicide evidenced by the fact that this is his second failed attempt. His agitation also increases his risk for self-harm
- Current social situation: Ben has a wife, but their relationship is broken down.
Mental Health Assessment
- Appearance and Behavior: The client was brought to the emergency ward by police, was combative and uncooperative the patient also seemed confused and agitated
- Mood: Depressed
- Affect: Appropriate for mood
- Thought: Suicidal ideation, patient claims he wants to die. Perception, sensorium, cognition, insight and judgment could not be assessed due to the confused, intoxicated and agitated behavior of the patient.
Risk assessment
Ben requires assessment for suicide risk. The ‘SAD PERSONS’ scale would be most appropriate to gauge whether he is at high risk or not (Pedersen 2005, 88). This scale is an acronym for risk factors associated with suicide. They include Sex, Age, Previous attempts, Ethanol use, Rational-thinking loss, Social support deficit, Organized plan, No spouse and Sickness. From this scale, several risk factors for Ben are identified. Sex, more males than females commit suicide (around four times more) hence his risk is higher. (Preskorn, 2007). Older males are more likely to commit suicide than younger ones, at his age Ben falls in this category too. Most people who die from suicide do so on their second or first attempts. Due to Ben’s history of a previous attempt, he is at risk of attempting to kill himself again. Recent onset of ethanol or other sedative-hypnotic drug use increases the risk for suicide attempts and completion.(Freshwater 2005, 102-103), from his self-report, Ben indicates that he has access to sedative-hypnotics which were his drug of choice for suicide, he may attempt to use them again. Other factors that contribute to his increasing risk of suicide attempts and success are his social support deficit and absence of a spouse. (APA, 2003). These two go together in Ben’s situation since his support system seemed to be his wife and the breakdown of their relationship is an issue that has attributed to his feelings of guilt and remorse. In addition due to his unwillingness to be brought to the emergency ward, he is at risk of absconding and therefore security needs to be alerted about him and all staff need to know that he is under observation.
Medical history
No reports are available on medication, adverse drug effects, and current forensic issues or other
significant medical history.
Diagnosis: Suicidal behavior and ideation with co-morbid factor of depression.
This diagnosis is supported by the patient’s previous attempts at suicide, making the recent attempt the second one in a month. Previous suicide attempt is a director indicator for future suicide attempts and suicide completion (Freshwater 2005). In addition, the patient says he wants to die and has attempted to kill himself through an overdose of sertralline, diazepam and paracetamol. Indicators that Ben may be depressed include crying and exposing remorse over the broken relationship with his wife, which points to the fact that he may be feeling guilty about the breakup.
Background Discussion
Suicide is a public health problem that is persistent in industrialized countries with around 10% of the people committing suicide suffering from a psychiatric disorder, most of the times a mood disorder. (Mann, 2003, 181-189). Mann et al suggest that stress factors may trigger suicidal acts in vulnerable individuals. (Mann et al, 1999, 203-206). Vulnerability factors include pessimism and a previous history of suicide attempts. (Oquento et al, 2004, 223-227). By suggesting vulnerability, the consensus is that suicidal behaviour and depression are characteristics that can be inherited. This means that a client with family members who have been depressed or committed suicide is likely to commit suicide or attempt himself or herself. (Beyond blue, 2007).
Depression is a condition characterized by persisted sadness, anxiety or an empty mood, feelings of pessimism, guilt, helplessness, decreased energy and loss of interest in pleasurable activities, thoughts of death or suicide and suicide attempts. (National Institute of Mental Health, NHIM, 2000). Men are less likely to suffer from depression than women are, they are also likely to admit it and doctors usually do not suspect it in men. (NHIM, 2000). All these factors contribute to making diagnosis of depression in men difficult. Again, alcohol or drugs as in the case study above often mask men’s depression. Depression is a major predictor of suicidal behavior and many patients who kill themselves have suffered some form of mood disorder (Elder, Evans and Nizette, 2005, 819-828). Usually depression is brought about by mix of various factors; long-term events, recent events, personal risk factors (like people with borderline personality disorders) and family history all play a role (Beyond blue, 2007). Recent events and long-term ones can act as precipitating factors for both depression and suicidal behaviour; hence, the perception by most people that depression is caused by recent stressful events is misleading
Generally, there is interplay of biological, sociological and psychological factors that cause depression. The biological theory supports the use of antidepressant drugs to treat depression. This theory holds that the etiology of major depression is under activity of nerve cells that have the biogenic amines as their neurotransmitters (examples are serotonin and nor epinephrine). As stated above, the factors contributing to and leading to depression and suicide are interrelated and overlap, hence it is difficult to separate suicidal tendencies from depression.
Sane Australia reports that over 2000 Australians die from suicide every year. Sometimes self-harming actions such as cutting, overdosing may end up as suicide even when the individual did not mean to kill himself or herself. This further illustrates the relation of depression with suicide and suicide attempts since most patients who exhibit self-harm behavior are usually depressed.
Management
Nursing diagnosis
Self-destructive thoughts and behavior related to mental illness manifested by ingestion of a combination of drugs- sertraline, diazepam and paracetamol.
Impaired verbal communication related to confusion and intoxication manifested by difficulty in establishing rapport.
Ineffective coping related to emotional liability manifested by feelings of guilt indicated by remorse and crying over breakdown of relationship with wife (Beck, 2007, 23-30).
Social isolation related to anxiety as evidenced by uncommunicative behavior (Beck, 2007, 26-30).
Ineffective family coping related to Ben’s disease manifested by breakdown of relationship with wife.
Interventions
Self-destructive thoughts and behavior
Place Ben in an area where he can be observed, remove all potentially harmful items (drugs, weapons) from Ben’s environment. This decreases his risk of attempting suicide since things that would aid his suicide attempts are not within his reach. Since he is unwilling and uncooperative, involuntary admission will be necessary, as he requires hospitalization to ensure his safety. NSW MHA, 1990, Chapter 8)
Continual assessment for suicidal behavior and thoughts to protect him from self-harm. (Beck, 2007, 28). Observe record and report to other staff changes in mood, as these are indicators of suicidal behavior (Gary and Kavanagh, 1990, 121).
Determine the presence of suicidal ideation and plan and Ben’s willingness to seek help if ideation or impulses feel out of control. Separating suicidal thoughts and feelings can help Ben feel less out of control. This empowers Ben as he realizes that though he may have suicidal feelings he can make a choice not to act on them. (Pedersen, 2005, 89)
Establish a no-suicide contract with Ben on a 24-hour basis. This will help to make Ben fell more in control. (Gary and Kavanagh, 1990, 123).
Administer medication to Ben to ensure he calms down and is not a threat to himself or the staff. The medication, antidepressants (selective serotonin reuptake inhibitors-flouxetine) will also help to decrease suicide ideation. (Gliatto and Rai, 1999, 89-92)
Impaired verbal communication
Communicate in a straightforward and honest manner. This prevents Ben from being overwhelmed especially in his confused state. (Mental Health Matters, 2007). Orient Ben to his environment in terms of time, place, and person. Ben needs to know where he is so he can begin to comprehend the gravity of his condition and attempt at trying to get better.
Provide information and encourage conversation without cross-examining. Cross-examining will provoke distrust, confusion and disorientation. All these are likely to cause him to regress as far as verbal communication is concerned. (Gary and Kavanagh, 1990, 122)
Ineffective individual coping
Encourage Ben to talk about his guilt and frustration. Giving him a chance to event will reduce the stress that he may be feeling. Offer understanding, empathy and varied opportunities to discuss his condition it is necessary to guarantee that he will become better gradually if he complies with the treatment procedure. This will give him hope, will increase security, and comfort (Horgan, 2002,819-822)
Ben’s activities and responsibilities during hospitalization should be structured so that he can gradually regain a sense of control and direction. (Bentall, 2004, 58-62).
Encourage Ben to participate in physical activities and to be outdoors. These serve a diversionary role and will distract him from thoughts of guilt and suicide he may have. It is also an avenue for him to meet other people (Pederson, 2007, 90)
Social isolation
Plan social contacts with Ben. Social skills training and assertiveness training will be taught as he gets better and symptomatology reduces. (Gray and Kavanagh, 1990, 123). Social contacts are necessary even though Ben may not feel the desire to do so; they will serve as positive reinforcement for him especially when he is on outpatient treatment.
Encourage Ben to join a support group to reduce feelings of loneliness. Participation in a support group will help him realize he is not the only one dealing with suicidal behaviour. This will also increase his social contacts.
Encourage Ben’s wife to visit him and if possible to bring former friend along so that his social contacts can be further reinforced. This will increase his emotional supports, making treatment an easier process for him.
Ineffective family coping
Ben’s wife is also going through a trying time and will require encouragement to join a support group for families and friends of people who have suicidal ideation. This will enable her to ventilate and express herself with people who understand her situation.
Providing education for her on mental illness and her role in assisting Ben to get better will also help her to be less anxious about what is expected of her. She is a significant support for Ben and necessary if he is to form a healthy social network. (Stovall and Domino, 2003)
In all the management of Ben, his safety cannot be secured without the involvement of the NSW Mental Health Act. Ben’s suicide attempt puts him in an emergency and due to his combative and unwilling state; his admission will most likely be involuntary. The NSW MHA in chapter 8 allows for a patient at risk of harming himself to be hospitalized through involuntary admission; following the criteria outlined, he will be detained in hospital after being reviewed by psychiatrist. The psychiatrist or clinician will discharge him when he deems him fit for discharge; meanwhile he will be under treatment to ensure his safety.
The MHA also has provision for a medical certificate for examination of a person suffering from mental illness (MHA, 1990, schedule 2). This allows the clinician to assess him, hospitalize him, and put him on the necessary treatment to ensure his safety.
During Ben’s management, he will at some point be discharged and treated as an outpatient. This is catered for by empowering healthcare agencies with an appropriate treatment plan and capability of implementing it to have Ben under their care. A community counseling order is a document that will ensure Ben’s attempt of suicide are minimized by providing him with the necessary care at the healthcare agency. (Section 120, subsection 3)
If Ben breaks the community counseling order, the MHA allows the Director of the healthcare agency to give a written notice to the person (Ben) requiring them to attend the agency at a specified time for counseling, medication or both. The MHA by allowing police to be used to ensure attendance of an individual in accordance with the notice shows the importance of an inter-disciplinary approach in managing people with mental illness. (MHA 1990, sect 128, subsection 2a and 2b).
Legal consultation is advisable when dealing with suicidal patients especially when the patient may be unwilling to have his family contacted. In addition, for purposes of liability should Ben be successful in his attempts, legal advice will ensure the nurse stays within legal boundaries if the Mental Health Act.
Expected outcomes
- Ben will avoid ingestion of drugs in quantities sufficient to cause poisoning or intoxication within one days of admission into hospital. Ben will exhibit absence of self-destructive thoughts and behaviour indicated by decreased verbalization of wanting to die.
- Ben will be able to communicate normally with staff after 24 hours of admission. He will also be able to verbalize his feelings, thoughts and reasons for attempting suicide.
- Ben will identify effective and ineffective coping methods, he will begin to develop a support system and experience less depression indicated by decreasing incident of crying and self-harm.
- Ben will develop social interactions that are meaningful and begin to participate in recreational activities.
- Family communication will improve, with resumption of a working relationship between Ben and his estranged wife.
References
- Beck J (2001) the Nursing Process: Context of Psychiatric Nursing.
- Bental R. (2004) Madness explained: Psychosis and human nature, Penguin, London.
- Elder R. Evans K and Nizette D. (2005) Psychiatric and mental health Nursing. Mosby, Mann J (2003), Neurobiology of suicidal behaviour. Not Rev Neurosci 4 (10):819-828
- Freshwater D. 2006, Mental Health and Illness: Questions and answers for counselors and therapists. Whurr publishers, Chichester
- Gary F and Kavanagh CK. (1990) Psychiatric Mental Health Nursing, Lippincott publishers ISBN 0-377-54852-4
- Gliatto MF and Rai A.K, ‘Evaluation and Treatment of Patients with Suicidal Ideation, American Family Physician, 1999 vol 59 no 6
- Horgan D, 2002, Practical management of the suicidal patient, Australian Family Physician, 2002, 31 (9):819-822
- Mann J, Waternaux C, Haas G I, Malone KM (1999), Toward a clinical model of suicidal behaviour in psychiatric patients, America Journal of Psychiatry. 156 (2); 181-189.
- National Institute of Mental Health, (NIMH) Depression (2000).
- New South Wales Mental Health Act 1990, government printers Sydney.
- Preskorn S (2007) Outpatient management of depression: assessing the suicide risk.
- America Psychiatric Association: practice guideline for the assessment and treatment of patients with suicidal behaviours. America Journal of Psychiatry 160.(supply): 1-60, 2003.
- Sane Australia, Suicidal Behaviour and Self harm.
- Stovall J and Domino FJ (2003) Approaching the suicidal Patient, American Family Physician, 2003,vol 68 no 9
- Wise M.G. and Rundell S.R.(2002). The American Publishing Textbook of Consultation – Liaison Psychiatry: American Psychiatric Publishers Inc. ISBN 0880483938.