- Email: [email protected]
Suicide myths and health care provider bias
SUICIDE MYTHS AND HEALTH CARE PROVIDERBIAS by Marshelle
Thobaben,
RN,C,
PHN, MS, FNP
elieve suicide is not an r clients
to alleviate
y are these providers ents
for
their
not more dili-
suicidal
ideation
ne reason is providers
c
nts w
This article discusses several suicide myths and the truth behind them in an attempt to provoke health care providers to evaluate their biases and seek ways to put them aside when caring for elderly suicidal patients.
MYTH: sUICI . ‘d e IS not United
a serious
problem
in the
States.
Suicide is the ninth leading cause of death in the United States.’ Approximately 10,000 clients older than age 60 kill themselves each year, accounting for about 25% of the total number of suicides in this country,’ Every day in the United States, 17 elderly persons commit suicide.3
MYTHS: If 1’ t
c len s are determined to kill themselves, no one can stop them. If clients really want to kill themselves, health care professionals do not have the right to stop them. The United States has long embraced individual liberty and the freedom to make personal choices as fundamental values. However, the right of clients to take their own lives has met with controversy. Most health care providers
JUNE
1997,
VOL.
2 NO.
3
believe suicide is not a rational choice for clients. A few health care providers believe suicide, in certain circumstances, is an acceptable way for clients to relieve their anguish. Most clients are ambivalent about death, even until the last minute. Most suicidal clients do not want to die, they simply want their pain to stop. Their impulse to kill themselves, however overpowering, does not last forever. Such patients often gamble others will save them.
MYTHS: cl’lents
who commit suicide have not sought medical help before their suicide attempt. Suicides happen without warning. Suicidal clients want to die and believe there is no turning back. Elderly clients who are suicidal are unlikely to seek psychiatric treatment from the mental health care system because of the stigma associated with mental illness. They are more likely to see their primary care providers. A recent study reported that 75% of the geriatric patients who completed suicide had seen their primary care physician during the previous month.” In another study, 80% of suicidal older adults had visited a physician I week before their suicide.2 Research shows that suicidal clients often
HOME
CARE
PROVIDER
109
BEYOND seek medical help within months of their deaths. They often present with physical symptoms and seek medical treatment for their physical ailments. Clients who seek counseling often are disappointed when they do not have immediate results, which adds to their feelings of despair and hopelessness.
MYTH:
If clients
try to kill themselves,
they must
be crazy. Clients who commit suicide usually have no history of mental illness, nor are they psychotic or delusional. Major depression is present in 50% of all suicidal clients, and those suffering from major depressive disorder are at 25 times greater risk for suicide than the general population. Ten percent of clients with schizophrenia commit suicide, clients who are alcoholic comprise 4% to 6%. Most clients who commit suicide are in good physical health, contrary to the belief held by some health care providers that the terminally ill are more apt to kill themselves. In fact, only 2% to 4% of terminally ill clients take their lives. The elderly population is at increased risk for suicide and depression. White males have four times the risk of suicide than the nation as a whoIe.5 Risk factors for older clients include a higher prevalence of alcohol abuse, depression, and social isolation; this group also has greater access to highly lethal methods. Unlike younger clients who attempt suicide, elders make fewer attempts per completed suicide. Often they visit a health care provider before their suicide and have more physical illnesses.6 Clients contemplating suicide often are so distressed they are unable to objectively see options they may have. They feel isolated and believe no one can help them.
MYTH: themselves
Asking clients if they are planning will lead to suicide attempts.
to kill
Clients already have the idea of killing themselves. Health care providers may feel uncomfortable asking clients if they are suicidal because providers believe it will alienate or humiliate clients. Although suicide is the ninth leading cause of death in the United States, the subject is taboo. The fact is that asking clients directly about their suicidal ideation, without acting shocked or disapproving, gives them permission to discuss how they feel. The inquiry indicates to the clients that the health care provider takes them seriously and is willing to share their anguish. Broaching the subject gives clients the opportunity to relieve some of their pent-up, painful feelings and may prevent them from needing to escalate their “cry for help” by suicidal gestures or attempts. Asking about suicide allows
1 lo
HOME
CARE PROVIDER
PHYSICAL
health care providers an opportunity clients attempt suicide.
to intervene
MYTH:
suicide
ly commit
Clients
who talk about
rarely
CARE
before
actual-
it.
Most clients who are suicidal talk about their suicidal intentions. They may not state directly they are suicidal but give clues of their intention to kill themselves. Home care providers need to be aware of the clues that clients give that indicate they are suicidal, such as statements like, “I can’t see my way out” or “Pretty soon you won’t have to worry about me.” Suicidal clients need professional interventions. The home care provider should assess clients’ suicidal risk. Do they have a plan? Is it lethal? Can they carry it out? Are they alone? Do they have a support system? Have they suffered losses? Are they abusing substances? Do they have mental (depression) or physical illnesses? Have they attempted suicide in the past? Home care providers need to notify the clients’ physicians and their own supervisors of potential suicidal situations and may need to call 9- 1 - 1 in an emergency. They should stay with clients who are actively suicidal until help arrives,
MYTHS:
A f ai.I e d suicide attempt as manipulative behavior. Clients who attempts will always have thoughts of who improve after a suicidal crisis are another attempt.
should be treated have suicidal suicide. Clients not at risk for
Clients who have failed suicide attempts are not manipulative, more likely they are giving evidence of their ambivalence toward killing themselves. Clients usually make suicide attempts during crises or stressful periods and are suicidal only for a limited period. When clients are extremely depressed and decide death is the only alternative, their behavior often improves because they are no longer conflicted about dying. This period is when they are apt to have the energy to kill themselves. Clients also may have the energy to kill themselves if they begin to feel better but are confronted once again with their problems and anguish. If clients receive the help they need to better deal with their problems and increase their coping abilities, their suicidal ideation will lessen. However, it can take months for clients to consistently feel better and not be suicidal. SUMMARY Suicide has been a taboo subject surrounded The processes that give clients the impetus
by myths. to kill them-
JUNE 1997, VOL. 2 NO. 3
BEYOND
PHYSICAL
CARE
selves are at least as complex and difficult as those by which they continue to live. Clients may have suicidal ideation because of precipitating factors, such as the death of or separation from a loved one. More typically they have a history of long periods of depressive episodes or feelings of hopelessness and helplessness and have lost their ability to cope with their lives.
Prac
1996;9:8-17.
3. Osgood
N. Perspectives
AARP Perspectives 4. Miller
MD.
[cited
Jl
h+://sun 2. McIntyre suicide:
USA suicide:
1994
of Suicidology
official
[cited
final data.
1997
March
March
York
cide 6
and
treating
February
Center
in the United
Prevention
[revised
for Injury
depression
In the elderly
States. February
Centers
of sui-
at hp://wwwhea/h 1. himi
and
Control.
for Disease
2 1 , 19971
www.cdc.gov/ncipc/dvp/suifacts.
i6.htmi
Ib.mil/er/mh The epidemiology
Available
Prevention
persons.
1 1(2):7,9.
at www.medscape.com/
us/nysdoh/consumer/pcliienf/chop
National
older
1996;
of Health.
19961.
among
and Aging
/997/vOZ.n03/mh
State Department
[posted
cide
Promotion
2 11. Available
Medscope/Menialhe.. 5. New
Home care providers may feel uncomfortable talking with clients about suicidal ideation and believe the myths associated with suicide. They need to be sensitive to clients’ suicidal threats. Health care providers need to be comfortable discussing suicide with their clients and be aware of their own biases preventing them from dealing effectively with suicidal clients. By recognizing potentially suicidal clients and offering them the help they need, home care providers can reduce the risk of clients committing suicide and indeed may save clients’ lives.
Association
Recognizing
1997
siaie.ny.
1 McIntosh
from the field: suicide
in Health
Violence:
Control
Available
sui-
and at htfp://
htmi
American
231.
Available
at
i iusb.edu.-jmcinfos/Suicide~~a~s.himi lG,
Oreck
assessment
P, Camarillo and
MA,
intervention.
and 3.5”
Valente Home
diskette
SM.
Depression
Health
Care
and
Manage
iBook Code #29122)
T
he I997
Physicians
GenRx,
Drug Reference,
gives
unbiased
information
resource:
drug
full FDA prescribing
uses; international data,
NDC
color
ID section
is the drug
you
brand
numbers, and
reference
Mosby’s more
information:
names;
single
unlabeled
800=426-4545
cost comparative
See why
of choice.
Order TolbFree
comprehsive,
than any other
bioequivalency more!
Complefe
ratings Physicians
plus GenRx
v hA
Y
11830WestlineIndustrial Drive * St. Louis, MO 63146 PGR42
JUNE 1997, VOL. 2 NO. 3
HOME
CARE PROVIDER
111
Thobaben,
RN,C,
PHN, MS, FNP
elieve suicide is not an r clients
to alleviate
y are these providers ents
for
their
not more dili-
suicidal
ideation
ne reason is providers
c
nts w
This article discusses several suicide myths and the truth behind them in an attempt to provoke health care providers to evaluate their biases and seek ways to put them aside when caring for elderly suicidal patients.
MYTH: sUICI . ‘d e IS not United
a serious
problem
in the
States.
Suicide is the ninth leading cause of death in the United States.’ Approximately 10,000 clients older than age 60 kill themselves each year, accounting for about 25% of the total number of suicides in this country,’ Every day in the United States, 17 elderly persons commit suicide.3
MYTHS: If 1’ t
c len s are determined to kill themselves, no one can stop them. If clients really want to kill themselves, health care professionals do not have the right to stop them. The United States has long embraced individual liberty and the freedom to make personal choices as fundamental values. However, the right of clients to take their own lives has met with controversy. Most health care providers
JUNE
1997,
VOL.
2 NO.
3
believe suicide is not a rational choice for clients. A few health care providers believe suicide, in certain circumstances, is an acceptable way for clients to relieve their anguish. Most clients are ambivalent about death, even until the last minute. Most suicidal clients do not want to die, they simply want their pain to stop. Their impulse to kill themselves, however overpowering, does not last forever. Such patients often gamble others will save them.
MYTHS: cl’lents
who commit suicide have not sought medical help before their suicide attempt. Suicides happen without warning. Suicidal clients want to die and believe there is no turning back. Elderly clients who are suicidal are unlikely to seek psychiatric treatment from the mental health care system because of the stigma associated with mental illness. They are more likely to see their primary care providers. A recent study reported that 75% of the geriatric patients who completed suicide had seen their primary care physician during the previous month.” In another study, 80% of suicidal older adults had visited a physician I week before their suicide.2 Research shows that suicidal clients often
HOME
CARE
PROVIDER
109
BEYOND seek medical help within months of their deaths. They often present with physical symptoms and seek medical treatment for their physical ailments. Clients who seek counseling often are disappointed when they do not have immediate results, which adds to their feelings of despair and hopelessness.
MYTH:
If clients
try to kill themselves,
they must
be crazy. Clients who commit suicide usually have no history of mental illness, nor are they psychotic or delusional. Major depression is present in 50% of all suicidal clients, and those suffering from major depressive disorder are at 25 times greater risk for suicide than the general population. Ten percent of clients with schizophrenia commit suicide, clients who are alcoholic comprise 4% to 6%. Most clients who commit suicide are in good physical health, contrary to the belief held by some health care providers that the terminally ill are more apt to kill themselves. In fact, only 2% to 4% of terminally ill clients take their lives. The elderly population is at increased risk for suicide and depression. White males have four times the risk of suicide than the nation as a whoIe.5 Risk factors for older clients include a higher prevalence of alcohol abuse, depression, and social isolation; this group also has greater access to highly lethal methods. Unlike younger clients who attempt suicide, elders make fewer attempts per completed suicide. Often they visit a health care provider before their suicide and have more physical illnesses.6 Clients contemplating suicide often are so distressed they are unable to objectively see options they may have. They feel isolated and believe no one can help them.
MYTH: themselves
Asking clients if they are planning will lead to suicide attempts.
to kill
Clients already have the idea of killing themselves. Health care providers may feel uncomfortable asking clients if they are suicidal because providers believe it will alienate or humiliate clients. Although suicide is the ninth leading cause of death in the United States, the subject is taboo. The fact is that asking clients directly about their suicidal ideation, without acting shocked or disapproving, gives them permission to discuss how they feel. The inquiry indicates to the clients that the health care provider takes them seriously and is willing to share their anguish. Broaching the subject gives clients the opportunity to relieve some of their pent-up, painful feelings and may prevent them from needing to escalate their “cry for help” by suicidal gestures or attempts. Asking about suicide allows
1 lo
HOME
CARE PROVIDER
PHYSICAL
health care providers an opportunity clients attempt suicide.
to intervene
MYTH:
suicide
ly commit
Clients
who talk about
rarely
CARE
before
actual-
it.
Most clients who are suicidal talk about their suicidal intentions. They may not state directly they are suicidal but give clues of their intention to kill themselves. Home care providers need to be aware of the clues that clients give that indicate they are suicidal, such as statements like, “I can’t see my way out” or “Pretty soon you won’t have to worry about me.” Suicidal clients need professional interventions. The home care provider should assess clients’ suicidal risk. Do they have a plan? Is it lethal? Can they carry it out? Are they alone? Do they have a support system? Have they suffered losses? Are they abusing substances? Do they have mental (depression) or physical illnesses? Have they attempted suicide in the past? Home care providers need to notify the clients’ physicians and their own supervisors of potential suicidal situations and may need to call 9- 1 - 1 in an emergency. They should stay with clients who are actively suicidal until help arrives,
MYTHS:
A f ai.I e d suicide attempt as manipulative behavior. Clients who attempts will always have thoughts of who improve after a suicidal crisis are another attempt.
should be treated have suicidal suicide. Clients not at risk for
Clients who have failed suicide attempts are not manipulative, more likely they are giving evidence of their ambivalence toward killing themselves. Clients usually make suicide attempts during crises or stressful periods and are suicidal only for a limited period. When clients are extremely depressed and decide death is the only alternative, their behavior often improves because they are no longer conflicted about dying. This period is when they are apt to have the energy to kill themselves. Clients also may have the energy to kill themselves if they begin to feel better but are confronted once again with their problems and anguish. If clients receive the help they need to better deal with their problems and increase their coping abilities, their suicidal ideation will lessen. However, it can take months for clients to consistently feel better and not be suicidal. SUMMARY Suicide has been a taboo subject surrounded The processes that give clients the impetus
by myths. to kill them-
JUNE 1997, VOL. 2 NO. 3
BEYOND
PHYSICAL
CARE
selves are at least as complex and difficult as those by which they continue to live. Clients may have suicidal ideation because of precipitating factors, such as the death of or separation from a loved one. More typically they have a history of long periods of depressive episodes or feelings of hopelessness and helplessness and have lost their ability to cope with their lives.
Prac
1996;9:8-17.
3. Osgood
N. Perspectives
AARP Perspectives 4. Miller
MD.
[cited
Jl
h+://sun 2. McIntyre suicide:
USA suicide:
1994
of Suicidology
official
[cited
final data.
1997
March
March
York
cide 6
and
treating
February
Center
in the United
Prevention
[revised
for Injury
depression
In the elderly
States. February
Centers
of sui-
at hp://wwwhea/h 1. himi
and
Control.
for Disease
2 1 , 19971
www.cdc.gov/ncipc/dvp/suifacts.
i6.htmi
Ib.mil/er/mh The epidemiology
Available
Prevention
persons.
1 1(2):7,9.
at www.medscape.com/
us/nysdoh/consumer/pcliienf/chop
National
older
1996;
of Health.
19961.
among
and Aging
/997/vOZ.n03/mh
State Department
[posted
cide
Promotion
2 11. Available
Medscope/Menialhe.. 5. New
Home care providers may feel uncomfortable talking with clients about suicidal ideation and believe the myths associated with suicide. They need to be sensitive to clients’ suicidal threats. Health care providers need to be comfortable discussing suicide with their clients and be aware of their own biases preventing them from dealing effectively with suicidal clients. By recognizing potentially suicidal clients and offering them the help they need, home care providers can reduce the risk of clients committing suicide and indeed may save clients’ lives.
Association
Recognizing
1997
siaie.ny.
1 McIntosh
from the field: suicide
in Health
Violence:
Control
Available
sui-
and at htfp://
htmi
American
231.
Available
at
i iusb.edu.-jmcinfos/Suicide~~a~s.himi lG,
Oreck
assessment
P, Camarillo and
MA,
intervention.
and 3.5”
Valente Home
diskette
SM.
Depression
Health
Care
and
Manage
iBook Code #29122)
T
he I997
Physicians
GenRx,
Drug Reference,
gives
unbiased
information
resource:
drug
full FDA prescribing
uses; international data,
NDC
color
ID section
is the drug
you
brand
numbers, and
reference
Mosby’s more
information:
names;
single
unlabeled
800=426-4545
cost comparative
See why
of choice.
Order TolbFree
comprehsive,
than any other
bioequivalency more!
Complefe
ratings Physicians
plus GenRx
v hA
Y
11830WestlineIndustrial Drive * St. Louis, MO 63146 PGR42
JUNE 1997, VOL. 2 NO. 3
HOME
CARE PROVIDER
111