Suicide is one of the most pressing health issues in the country today, but it’s also one many people are reluctant to discuss openly. With September designated as National Suicide Prevention Month, this is a great opportunity to help shed the stigma around suicide.
According to the National Alliance on Mental Health (NAMI) one in five adults will experience a form of mental illness this year. According to the National Institute of Mental Health (NIMH), the 47,173 suicides in 2017 makes suicide the 10th leading cause of death in the nation. But the problem is even more pervasive than even those alarming numbers. NIMH reported that in 2017, 10.6 million adults aged 18 or older reported having serious thoughts about trying to kill themselves.
Those numbers are staggering and reveal a deep level of anguish among the people in this country. Many of those people do not get any kind of professional help and many don’t even tell another person they have had thoughts of harming themselves. That’s why it’s so important for others to recognize, and act on, signs of trouble.
How You Can Help
As a nurse, you have a level of interaction with so many different people every day, so noticing subtle signs is important. It’s essential to know the warning signs of someone in crisis.
Depending on your specialty and your typical workday, your nursing career might not bring people in obvious mental health crisis into your day. That doesn’t mean your patients aren’t struggling. Friends and family might also be hiding their serious despair, so knowing what to look for and how to listen and interpret is helpful.
Talking about feeling hopeless or having no purpose
Talking about feeling trapped or being in unbearable pain
Talking about being a burden to others
Increasing the use of alcohol or drugs
Acting anxious, agitated, or reckless
Sleeping too little or too much
Withdrawing or feeling isolated
Showing rage or talking about seeking revenge
Displaying extreme mood swings
If you notice something is worrisome, for instance a friend’s social media posts have started to mention that “the world would be better off without me” or a struggling colleague’s behavior with drugs or alcohol is increasingly reckless, it’s okay to ask about it.
It’s Okay to Say Something
Saying something in a nonjudgmental way is best and helping that person find a professional to talk to is going to be helpful. Call a crisis line for immediate help or bring them to the ER, especially if you think they are in imminent danger of hurting themselves. It’s also probably going to be awkward and may not be met with affection, but generally those behaviors are the way someone might ask for help without really asking for help.
In your workplace, see if you’re able to post crisis hotline numbers, so others can have immediate access to the information—either for themselves, their patients, or someone they are concerned about.
While the holiday season can be a lot of fun, it can also be a time that makes a lot of people become depressed. Whether it’s because they’ve lost family or friends, they’re experiencing rough times, or they are in the hospital and/or are ill, it can make many sad.
There’s a difference between regular sadness and depression, though. And it’s important to be able to recognize if your patients are experiencing depression. According to Sharon R. Kowalchuk, RN, DPN, Director of Nursing at Silver Hill Hospital (an academic affiliate of the Yale University School of Medicine, Department of Psychiatry), nurses can recognize symptoms of depression in their patients. “In any setting, patients may come to our attention with reports of loss of energy, anxiety, aches and pains, headache, insomnia, changes in appetite, or a significant weight loss or gain in a short period of time. These symptoms are not necessarily signs of depression, but they call for further exploration,” says Kowalchuk.
What are the specific signs that you can recognize as being those of depression? “It is easiest to recognize depression when the patient reports feeling sad, empty, hopeless, having difficulty enjoying usually pleasurable activities or sex. The more subtle signs may be irritability, restlessness, becoming more cranky than usual, having difficulty keeping up with everyday routines, or focusing on TV or reading. Expressing feelings of pessimism, guilt about one’s life, thinking a lot about losses or failures, believing things will not get better—these are more concerning symptoms,” explains Kowalchuk. As difficult as it might be, she says, “You will need to ask if they have thought about suicide.”
If you recognize these signs in patients, it’s important to get more information about any action they may have taken to prepare for suicide. “A key question is whether they have attempted suicide or began a suicide attempt that was interrupted by another person—or they stopped of their own volition,” says Kowalchuk. She adds that these questions are outlined in the Columbia-Suicide Severity Rating Scale (C-SSRS), a protocol that uses simple, plain language questions that anyone can ask to assess risk.
Depending on the level of risk or the particular setting, says Kowalchuk, the nurse caring for this patient may need to refer him or her to a mental health professional.
“Holidays are times that bring up life events, feelings of loss or loneliness, placing all of us at risk. The consequence of undetected depression is death by suicide,” she says. “According to the suicide experts at The Lighthouse Project, ‘Just ask, you can save a life.’”
Suicide is a rising epidemic in today’s contemporary society. According to the World Health Organization (WHO), globally nearly one million people die each year at their hands, by an act of suicide and more than thirty thousand people die annually in the United States alone. Since the risk for suicide is largely determined on a continuum, the severity of suicidality can vary with individual circumstances. Because of this realization, nurses play a pivotal role in suicide prevention because they often have the greatest number of opportunities to identify and recognize suicidal patients and tendencies in the health care arena.
Suicide Screening Strategies
While many hospitals are working diligently to comply with the Joint Commission in implementing suicide-screening questions, there is limited evidence available to guide suicide risk initiatives in the inpatient clinical setting. To help resolve this issue, researchers developed the Ask Suicide-Screening Questions to Everyone in Medical Settings tool (asQ’em), aimed to identify suicidality in the inpatient units and subspecialties. The asQ’em two-item screening tool is a unique instrument designed specifically for nurses to administer to medical-surgical patients at risk for suicidal tendencies and predispositions. Due to the straightforward nature of the asQ’em suicide-screening questionnaire, researchers have found it to be an efficacious method in properly recognizing suicidality in susceptible patients across the health care setting.
Applicability in the Clinical Setting
Although suicide risk assessments are an essential tool in the hospital setting, there is a growing body of evidence suggesting the underutilization of suicide screenings among medical-surgical patients. As a psychiatric-mental health nurse, I understand the importance of assessing patients for suicidality because it provides me with vital information on how to properly care for patients suffering from suicidal thoughts.
The asQ’em suicide-screening questionnaire is a tremendous tool that can be easily implemented in all inpatient units because it consists of two questions that determine if patients are at risk for suicide as a result of their present thoughts or past behaviors. Based on their answers, nurses can consequently determine if the patient exhibits enough significant emotional distress to ensure proper safety measures are in place before subsequent inpatient treatment and stabilization.
As a result of this realization, increased efforts must be made to ensure suicide-screening tools are readily available to not only uncover meaningful clinical data but also promote safe holistic nursing practices to preserve the health and well-being of suicidal patients nationwide.
With suicide rates rising and an alarming number of teens and young adults at serious risk for suicide, many health professionals are not fully prepared to recognize a patient’s psychiatric difficulties. A team of researchers at the National Institute of Mental Health (NIMH) recently came up with the ASQ Toolkit, a simple four-question survey for health professionals to help identify and get help for at-risk youth.
NIMH’s Division of Intramural Research Programs created the free Ask Suicide-Screening Questions (ASQ) Toolkit that can be used in various medical settings. According to the NIMH, the toolkit (available in many languages) is easy to use, making it effective in many settings including emergency departments, outpatient clinics, primary care offices, and inpatient medical/surgical units.
Before using the toolkit, organizations must have a plan in place to have a standard set of effective next steps for patients who do test with an outcome that indicates they are at risk. Whether that is a further evaluation with an on-site mental health counselor or another trained professional, the toolkit isn’t meant to be used without a follow-up plan.
No matter what their area of practice or setting, nurses and physicians can quickly assess patients by asking the four questions in the toolkit. If a patient answers yes to any of the questions, it’s a red flag for the medical professionals to consider the patient at risk for suicidal thoughts and behaviors. From there, the toolkit offers guidance on the next steps that will be most helpful for the patient and will also help them access the help they need.
Gaining this extra knowledge is essential skill to have no matter who your general patient population is. According to the World Health Organization, “Suicide accounted for 1.4% of all deaths worldwide, making it the 17th leading cause of death in 2015.” With such astounding facts, it’s imperative that nurses are able to have the tools to support them in identifying youth who might be at-risk. To help that, the toolkit even offers scripts like this nursing script for emergency room settings or this nursing script for inpatient medical/surgical settings.
The toolkit’s importance is highlighted in the rising numbers of youth who die by suicide. But underneath those shocking numbers are the hidden numbers of even greater numbers of people who are suffering with thoughts of suicide or even attempts at suicide. In fact, the American Foundation for Suicide Prevention estimates that for each person who dies from suicide (all ages), 25 more make a suicide attempt. Early intervention by healthcare professionals who can identify the risk and then have the resources to help the patient can be a turning point for the youth.
The ASQ Toolkit is only one resource for nurses to use in helping patients in a mental-health crisis or who are suffering from long-term suicidal ideation. With proper steps in place to help patients who do screen positive, it is also a potentially life-saving tool that healthcare setting and organizations might find worth investigating.
When Asian and Pacific Islander (API) patients visit medical facilities complaining of physical problems, they usually receive physical treatments. However, Shih-Yu (Sylvia) Lee, PhD, RNC, a postdoctoral fellow at Emory University in Atlanta, knows that asking these patients a few extra questions may mean the difference between curing a minor physical ailment and treating a major mental illness.
“[API patients] tend to express their feelings through physical complaints like a headache or upset stomach,” she explains. This practice is known in psychiatry as somatization.
ShihYu (Sylvia) Lee, PhD, RNC
Research suggests that health care providers’ failure to look at non-physical causes of ailments in Asian Americans and Pacific Islanders, combined with other cultural and linguistic barriers, may mean that this population is receiving inadequate mental health care. Lee encourages nurses to actively help eliminate these barriers by adopting a culturally competent approach to assessing API patients’ symptoms. Cultural sensitivity to these patients’ unique mental health needs is also a must for communicating treatment options to API individuals, who represent the fastest-growing minority population in the United States.
According to A Provider’s Handbook on Culturally Competent Care: Asian and Pacific Islander Population, 2nd Edition, published by Kaiser Permanente, little is known about the frequency of mental disorders in APIs. Because they represent a relatively small number of patients admitted to psychiatric hospitals compared with other racial and ethnic groups, this has led to the misconception that Asian Americans simply have fewer mental health problems than other Americans.
Gayle Tang, MSN, RN
However, the research data that is available contradicts this stereotype. The Centers for Disease Control and Prevention’s National Center for Health Statistics reports that API males and females between the ages of 15-24 consistently have the highest suicide rate of all ethnic groups in that age range. Elderly Asian Americans exhibit more instances of dementia than the general population, according to the National Asian American Pacific Islander Mental Health Association (NAAPIMHA). The association also reports higher than average suicide rates among some elderly Asian groups.
Many immigrants from Southeast Asian countries, particularly those from Vietnam, Laos and Cambodia, have survived traumatic refugee experiences. According to NAAPIMHA, 40% of these refugees suffer from depression, 35% from anxiety and 14% from post-traumatic stress disorder. And a study cited in Kaiser Permanente’s Provider’s Handbook reveals that while API patients are less likely to be admitted to psychiatric hospitals than their Caucasian counterparts, those who are admitted have a longer median length of stay than white patients.
These disturbing statistics suggest that Asian Americans and Pacific Islanders may not be receiving adequate mental health care early on and that by the time they do obtain treatment, their problems are more severe and harder to treat.
Behavior, Culture and Language
While mental illness is not an easy topic for most Americans to discuss, there is an especially strong stigma in the Asian American culture that discourages potential patients from seeking mental health services. “We tend to suppress our feelings,” says Lee, who is from Taiwan. “What happens in the family stays in the family.”
This is where the somatization comes in. Instead of seeking a mental health referral, many API patients will choose to see their primary care physician about a physical problem. Even if primary care providers are aware that their patient’s physical complaints may have an underlying emotional cause, lack of familiarity with Asian cultural norms can make it difficult for providers to determine whether a particular behavior is a common practice or a cause for concern.
For example, Lee says, in Chinese, Japanese and Korean cultures, women who have given birth take the post-partum healing period so seriously that they often remain at home on bed rest for up to a month after delivering their baby. Even if the newborn needs to be placed in the NICU, the mother might send other family members to visit the baby, while she continues to rest. If she were to visit the baby, her family may request a wheelchair for her to help conserve her energy. Nurses who are not familiar with this cultural practice may be unnecessarily alarmed that the mother is showing signs of post-partum depression.
If a nurse does have a concern about a patient’s behavior, Lee’s advice is to simply ask for more information. “You really need to talk to a family member,” she emphasizes.
Linda S. Beeber, PhD, APRN, BC, a professor of nursing at the University of North Carolina at Chapel Hill, agrees that nurses should look at each patient individually, even if they are Asian American nurses who share the patient’s ethnic background and are familiar with the culture. This is because familiarity could lead to labeling and making assumptions. “It could perpetuate biases. It is a step away from stereotyping,” says Beeber, who has studied depression in Korean, Chinese, Taiwanese and Native Hawaiian graduate students. “It does not take into account the powerful process of acculturation.”
In addition to barriers caused by cultural differences, there are often obvious language barriers that can prevent Asians and Pacific Islanders from receiving adequate mental health treatment. “New immigrants might not be able to speak English well,” says Lee.
Maggie Luo
According to the Kaiser Permanente Provider’s Handbook, about 38% of Asian Americans do not speak English fluently. The same holds true for a very large proportion of APIs over 65 years of age. And unlike most Hispanic subgroups, who all speak Spanish, API subgroups encompass a wide range of different languages, from Chinese, Japanese and Vietnamese to Tagalog, Hindi and Hmong.
While nurses are not expected to provide interpretive services, patients will rely on nurses to find well-trained translators to help communicate with them. Lee advises nurses to get to know the network of translators in their geographic area and to only recommend the professionals who have proper training. “In addition to linguistic training, they need to know the medical terms,” she says, citing an instance where a patient misunderstood a diagnosis because one of the medical terms was not communicated effectively.
Gayle Tang, MSN, RN, director of national linguistic and cultural programs at Kaiser Permanente in San Francisco, believes that linguistic competence is an important component of a health care facility’s ability to provide culturally competent care. This goes beyond simply providing translation services, she adds. “Language and culture are interchangeable,” Tang argues. “[If you can’t] speak the right words, in the right tones and with the right expressions, you’re not linguistically competent.”
Communication for Compliance
Once it has been determined that an Asian American or Pacific Islander patient is in need of mental health care, the next challenge for the nurse to overcome is often recommending treatment in a way that encourages the patient to complete his or her therapy successfully. Typically, a care provider would gather data on the symptoms of the problem, determine the cause, recommend a treatment and assume that the patient accepts the counsel.
However, an API patient might have a different explanation for the problem, based on his/her cultural beliefs. According to Tang, some patients may feel that their problem is primarily a spiritual one, or is a consequence of past behavior. If the recommended therapy does not address what the patient believes is causing the problem, the patient may choose to forego treatment.
Raising Awareness: Resources for Patients and FamiliesThere are a number of support groups, education programs and other consumer-focused resources available nationwide to help Asian and Pacific Islander patients, families and communities become better educated about the mental health system. By referring patients to these resources, nurses can help remove some of the cultural stigma associated with treatment. • The National Alliance for the Mentally Ill (NAMI) is an organization dedicated to providing support for mental health consumers and their families. “[NAMI] has local grassroots support groups in every state,” says Maggie Luo, whose Chinese American Mental Health Outreach Project (CAMHOP) is an initiative of the NAMI New Jersey chapter. NAMI’s national Web site is www.nami.org. • The National Asian American Pacific Islander Mental Health Association (NAAPIMHA) is committed to enhancing appropriate and accurate research data, identifying best practices for treating the API population, increasing mental health care training, and engaging consumers and their families. The consumer section of its Web site, www.naapimha.org, offers resources such as fact sheets on depression, bipolar disorder and schizophrenia in English, Chinese, Korean, Vietnamese, Khmer and Hmong.• “Healing the Spirit: Treating Depression Among the Asian Elderly” is a 19-minute educational video produced by the Asian Pacific Fund in partnership with the Stanford Geriatric Education Center (SGEC) and the American Association of Retired Persons (AARP). An excellent resource for both health care professionals and health consumers, the video discusses the symptoms of depression, its effects and treatment options. The project leader is an Asian American nurse, Melen McBride, PhD, RN, associate director of curriculum, technology and research at SGEC. To order the video, which costs $30, contact her at (650) 494-3986 or [email protected].• The National Asian Women’s Health Organization (NAWHO) is partnering with several community organizations on an outreach campaign called Empowering Avenues for Community Action in Mental Health: The National Collaborative for Asian American Women’s Health. The campaign’s mission is to “lower rates of depression and suicide in Asian-American women aged 18-34; remove stigma surrounding mental health issues through education and outreach; build the mental health information and referral capacity of community-based organizations; and empower Asian American women to serve as leaders and advocates for mental health.” More information about this initiative is available at www.nawho.org/mentalhealth.html.
Tang recommends using one of two culturally sensitive communication methods to increase the chances of successful treatment: the Kleinman model or the LEARN model. These methods can help nurses determine their patient’s level of acculturation and minimize the use of broad cultural stereotypes and prejudicial biases.
The Kleinman model, developed by noted psychiatrist Arthur Kleinman, is a general tool for cross-cultural communication. According to Tang, this model involves asking patients a series of questions about their complaint. “[It helps] assess a patient’s beliefs about their condition,” she says.
What do you call your problem? What name does it have? Why has it happened to you? Why now? are examples of questions Tang may ask. She would also ask patients what they believe will help make the problem go away. Using this model helps nurses understand whether or not they are seeing an issue in the same way their patient sees it.
The LEARN model, published in 1983 by E.A. Berlin and W.C. Fowkes, Jr., is geared toward letting the patient lead the discussion of his/her symptoms. It is an acronym for listen, explain, acknowledge, recommend and negotiate.
“It is an easy-to-remember model that reminds nurses to not only explain a situation but to also take time to understand how their patient sees a problem,” says Tang. “The nurse will listen to how the patient sees their own problem, then the nurse will explain his or her own perception of the problem. At that point the nurse acknowledges the differences and similarities between the two viewpoints while being nonjudgmental. The nurse would then recommend treatment or behavior change and then try to negotiate the best way to get the patient to follow through.”
Encouragement is a good way to successfully negotiate a treatment plan. “Find out what the patient is doing to help himself,” Beeber suggests. Even if a nurse has to advise a patient to stop using his current remedy in favor of a more medically effective option, the nurse can still use negotiation techniques to encourage the patient to try the recommended treatment.
For example, if a patient is treating her ailment with a traditional remedy such as a blend of herbal plants, Tang recommends saying something along the lines of: “We would like you to stop taking the herbal remedy for two weeks [and use the medicine that the doctor prescribed for you], just to make sure we know what is working and what is not working.” The patient is probably more likely to take the prescribed medicine if this approach is used–as opposed to the nurse saying, “That’s not going to work. There’s no scientific basis for [the herbal remedy].”
Even if patients accept a specific treatment regimen, they may not know how to follow it once they get home. “Ask for a return demonstration to help ensure that the information was communicated successfully,” says Tang.
Patient Advocacy
If an API patient needs to be referred to an outpatient or inpatient psychiatric care facility, it is once again important for the nurse to be a strong encourager. “[Patients] need assurance that this is the right thing to do,” says Maggie Luo, program coordinator for the Chinese American Mental Health Outreach Project (CAMHOP) in New Jersey. This may mean encouraging family members to encourage the patient. Luo suggests that nurses identify the relative who may have the most influence in the family and try to win that person’s support for the referral.
She also recommends using the term “mental health consumer” instead of “mentally ill” when referring to patients. This simple title change may help reduce the level of stigma associated with the referral.
Being a patient advocate also means proactively locating other supportive health care providers. “Try to help patients find a physician who knows about their culture,” says Lee. “You could actively make the referral for the patient, or you could just follow up with the other physician.”
Tang agrees that nurses should take a proactive approach to making sure the patient’s cultural and linguistic needs are met. “Every single nurse needs to make sure the system is in place,” she urges. “Make sure there are no gaps. Take that extra step. Make sure the interpreter is pre-scheduled for the next visit and the referral is made.”
