Introduction and Background of Suicidal Behavior
Numerous studies have been conducted to better understand the concept of suicidal behavior. Suicidal behavior consists of three different classifications, such as; suicide-related ideation, suicide-related communication, and suicide-related behavior. Suicide-related ideation is when an individual is having thoughts and urges to commit suicide, suicide related communication consists of suicide threats and plans, and suicide-related behavior consists of self-harm, suicide attempts, and suicide (Sun, 2011, p. 459). Throughout the research, there continues to be a disconnect, some saying the disconnect comes from poor insight on mental health and a society. This can become an issue when it comes to identifying, diagnosing, and treating individuals struggling with the many types of suicidal behavior.
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Suicidal behaviors have been identified world-wide, especially in adolescents and young adults. Per the World Health Organization, one person in every forty seconds commits suicide. Suicidal behaviors effect many different types of geographical regions, more specifically, suicide attempts can be four to forty times more frequent in different regions. In recent years, research studies have shown suicide skyrocketing to an astronomical 60% growth rate (Marcolan, 2018).
By identifying the defining attributes leading to suicidal behaviors in an individual, it will make it easier to intervene and treat the patient’s symptomology. Sun (2011) identified external hazards, internal crisis, the absence of coping devices, the absence of significant others, suicidal intent, and a lethal act being the primary attributes to the development of suicidal behaviors. External hazards are events that happen in an individual’s life that causes significant distress. Internal crisis is the “internal emotional disruption that occurs due to the threat from an external event, the effects of which are often referred to as symptoms (Sun, 2011, p. 460).” Coping devices are skills that an individual utilizes to help with difficult emotions. If an individual is not able to utilize a positive coping device, it may lead to negative coping devices, such as self-harm. Significant others supply support and reassurance to individuals during their lifetime. A marital partner, parent, relative, friend, or neighbor can be considered a significant other and has been shown that they can help an individual with suicidal behaviors cope with life stressors (Sun, 2011). Suicidal intent is when an individual is having thoughts about death and dying with serious thoughts of following through with a lethal act.
The significance and implication of this research to nursing is to form a better understanding the concept of suicidal behavior. As a child and adolescent psychiatric nurse, I help treat patients struggling with suicidal behaviors. My job is to assess my patient’s symptomology, teach my patient and families about their disease process, and medicate accordingly. I have found it challenging at times to distinguish the appropriate interventions due to the lack of development and understanding of psychiatric disorders. Nearly 90% of suicide attempts are completed by individuals with a psychiatric disorder, and of that approximately one half to two-thirds have been diagnosed with depression. Many others also experience depressive symptoms without reporting them (Peters, E., Balbuena, L., Marwaha, S., Baetz, M., & Bowen, R., 2015). If healthcare professionals are able to identify the suicidal behavior, it may help decrease the growing number of deaths by suicide world-wide.
Review of Literature
The terms and keywords that were used to search for the articles related to the concept of suicidal behaviors are as followed: “suicidal behavior,” “suicidal behavior in adolescents,” “concept analysis of suicidal behavior, “suicidal ideation,” and “suicide and adolescent suicidal behavior.” The search engines that were utilized were CINAHL, PubMed, and Google Scholar. Literature was also identified in the reference sections of the associated literature for additional information and most up to date research on suicidal behavior. The following is a summary of each article reviewed and how they relate to the concept of suicidal behavior.
A study utilizing longitudinal data from the 2000 Adult Psychiatric Morbidity Survey, which surveyed 2,406 individuals between the ages of 16-74 years of age, was reviewed to identify its relationship to the concept of suicidal behavior to impulsivity and mood instability. The study looked into identifying the correlation of mood instability and impulsivity as trait predictors of suicidal thoughts. Peter et al. (2016 p. 436) hypothesized that “impulsivity and mood instability would separately predict suicidal ideation, but only mood instability would remain significant when both variables were entered into the same regression.”
An individual that is impulsive is described as someone who acts quickly without thinking about the consequences and without fully planning out the act before acting. These individuals are at high risk of following through with a suicide attempt due to the connection of impulsive behaviors with serotonin levels and impulsivity effecting the limbic system, which is the decision-making process area of the brain. Also, mood instability is identified as a fluctuating mood over a period of time and has been seen to be highly related to impulsivity. Over the course of 18 months two waves of the study were conducted.
The measuring tool for the study was the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, which looked at the traits of impulsivity and mood instability. Individuals were asked to answer a question of ‘do you have a lot of sudden mood changes’ in a ‘yes’ or ‘no’ response to determine mood instability. To determine impulsivity the individuals were asked to answer the question ‘have you often done things impulsively’ in a ‘yes’ or ‘no’ response. In identifying recent suicidal ideation, the individuals were asked to answer the question of ‘have you ever thought of taking your life, even though you would not actually do it’ in a ‘yes’ or ‘no’ answer as well (Peter et al., 2016). There were many controls within this study to better understand the concept. The areas of control were: (1) baseline depression measured by the CIS-R with a depression score ranging from 0-4; (2) living arrangements which had three levels: Married/ cohabiting, single, and widowed/divorced/ separated; and (3) employment status which had three categories: Employed, unemployed, and economically inactive. The study also identified that an individual is at high risk of suicidal thoughts if they are unemployed and single. Peter et al. (2016) analyzed the data using a logistic regression model to assess the populations baseline impulsivity and mood instability in relation to being predictors of future suicidal thoughts.
The primary finding in this study was that after mood instability is controlled, impulsivity predicting suicidal ideation becomes a non-significant finding. In fact, after conducting an additional study looking at depression severity, it appears that mood instability is a better predictor to future suicidal ideation than impulsivity. If therapy works more toward focusing on mood instability alongside impulsivity, it may be beneficial in treating the patient dealing with suicidal ideation. The study’s findings are beneficial in the continuation of identifying the different causes of suicidal behavior due to it showing that mood instability is an indicator of suicidal ideation. Studies have shown mood stabilizing medications are beneficial in treating mood instability, which in turn could help decrease the number of individuals struggling with depression and suicidal behaviors.
A concept analysis of suicidal behavior was conducted to help better understand the concept. Sun (2011) believed that if suicidal behavior is better understood, public health nurses will better identify suicide behaviors and will be able to implement appropriate interventions to prevent the individual from following through with a suicide attempt. This concept analysis focused on clarifying the different concepts of deliberate self-harm, suicidal behavior, and self-mutilation to help decrease the amount of suicides world-wide. The method that was used in this concept analysis was the Walker and Avant’s 8-step method of concept analysis. The research sources were from a systematic search of Medline, CINAHL, ProQuest Nursing & Allied Health Sources, and the references listed on the related journal articles (Sun, 2011). There was an eight-step process which included (1) selecting the concept, (2) determining the aims of the analysis, (3) identifying all uses of the concept, (4) determining the defining attributes, (5) identifying a model case, (6) identifying contrary cases, (7) identifying antecedents and consequences, and (8) defining empirical referents (Sun, 2011). The data was compared and contrasted in relation to the concept of suicidal behavior.
After reviewing the literature related to the concept of suicidal behavior, Sun (2011), identified suicidal behavior to be associated with several different factors. The analysis showed that an individual requires a strong support system and positive coping mechanisms to be successful in dealing with internal or external crises. If an individual lacks positive coping mechanisms and support systems, studies show that the individual is as great risk of suicidal behaviors or suicide. If an individual cannot bear painful events and are vulnerable, the consequences could be a failed suicide or death. If the individual fails to complete their suicide attempt, the consequences could be life long and could include both medical and psychological consequences. The findings suggest that it is vital for health care professionals to be able to identify the difference between suicidal behavior, self-mutilation, and deliberate self-harm, and to also be able to have an understanding of the attributes, antecedents, and consequences of suicidal behavior to better treat and implement prevention measures for the at-risk population.
Another study was conducted exploring the correlation of race/ethnicity, gender, and sexual orientation to bullying and vulnerability leading to suicidal ideation among United States adolescents. Studies suggests the lesbian, gay, bisexual population is at higher risk for suicide and suicidal behaviors than heterosexuals (Mueller, A., James, W., Abrutyn, S., & Levin, M., 2015). 75,344 individuals, 5,541 identifying as lesbian, gay, or bisexual, were analyzed in a pool of data between 2009 through 2011 from the Youth Risk Behavior Surveys. There were 5 variables that were focused on in this study; (1) suicide ideation, (2) being bullied, (3) sexual orientation, race/ ethnicity, and gender, and (4) control variables: year of administration, jurisdiction, region, and age of respondent (Muller et al., 2015). There were a range of questions that were asked to help identify the different criteria for the study and the use of a binary logistic regression analytic plan was used for all of the analyses.
The study suggests that White heterosexual adolescents were at less risk of being bullied than their White and Hispanic gay and bisexual male peers, White lesbian and bisexual female peers, and their Hispanic bisexual female peers. The youths that are at highest risk for suicidal behaviors are the youths that are being bullied and the study suggests that no matter the gender, sexual orientation, or race of the child. Overall, 21.81% of the sample of youths reported being bullied at some point in their lives (Muller et al., 2015). The study also suggests the idea that lack of social support or the stigma associated to social events could be a large risk factor with the increase in suicidal ideation in youths who are in the lesbian, gay, bisexual community. With a better understanding of the negative implications of bullying in relation to the increase in suicidal behaviors, especially in the lesbian, gay, bisexual community, practitioners may be able to implement additional education within the school to help combat the high rate of bullying, with the overall goal to decrease the number of youths with suicidal behaviors (Muller et al., 2015).
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The final study that was analyzed was a study based on the interpersonal theory of suicide and adolescent suicidal behavior. 1,196 Israeli Jewish and Arab high school students, mean age being 15.91 years, with 945 males and 226 females, involved in this study were asked to complete a questionnaire asking them to measure how they saw themselves in relation to feeling as though they are a burden, feelings of thwarted belongingness, risky health behaviors, self-injury unrelated to suicide, suicidal ideation, and a history of suicide attempts (Barzilay et al., 2015). Thwarted belongingness is the feelings of loneliness or the feelings of isolation. There were two hypotheses, the first was that the feelings of being a burden and the feelings of loneliness or isolation is related to suicidal ideation. The next is that self-harm or acquired capability will increase the number of suicidal ideation and suicide attempts (Barzilay et al., 2015).
There were multiple scales used to assess the different questionnaires. The scales to monitor the psychiatric symptoms were the Beck Depression Inventory, the Zung Self-Rating Anxiety Scale, and the Strengths and Difficulties questionnaire, and to measure suicidal behavior, the five-item Paykel Suicide Scale was utilized. “The SEYLE study reported high to very high internal reliability for all scales: Cronbach’s alpha .91 for the BDI-II, .78 for the Z-SAS, .72 for the SDQ. The Cronbach’s alpha in the study was .85. Suicidal ideation was measured for current ideation, which was over the past two-weeks, and suicide attempts which would be over the lifetime (Barzilay et al., 2015, p. 69).” In regard to peer and parental feelings of thwarted belongingness was assessed by the Global School-based Student Health Surveys and the Peer Problems Scale of SDQ. The scale used a 3- or 4-point scale and the Cronbach’s alpha in the study was .69. For the parental belongingness, it was assessed with 7 items from the GSHS, which discussed how supportive the parent was and how bonded the parent and child were. The scoring was on a 3-or 5-point scale and the Cronbach’s alpha in the study was .81. The perceived burdensomeness was assessed using the Impact Supplement of the SDQ and 5 different items were measured. They were scored on a 3- or 5-point scale and the Cronbach’s alpha was .81. Finally, in regard to the health risk behaviors, the GSHS items were utilized using 8 different categories related to bodily harm to assess the risk. The higher the score, the more indicated they were for health risk behaviors. They used a 0-3 rating scale to measure and the Cronbach’s alpha was .79 (Barzilay et al., 2015).
With the utilization of SPSS v. 18 and a significance level of .05, all statistical analyses were performed. The hypotheses were correct that were stated previously. The results showed that how the individual sees themselves in relation to feeling as though they are a burden and the feelings of not belonging were predictors of suicidal behaviors and ideation. Within the results, it appears that depression played a big role in the feelings of not belonging, isolating, and being a burden, ultimately leading to suicidal ideation. If the individual has health risk behaviors and participate in direct non-suicidal self-injurious behaviors, such as cutting, they are at an even greater risk of attempting suicide. This study assists practitioners with the understating of how to identify adolescents at risk for suicidal behavior and to help identify interventions to assist with the prevention of suicidal behaviors.
Applications of Middle-Range Theory
The middle range theory of Social Support can be applied to the concept of suicidal behaviors. This theory was first introduced in the 1970’s by Cassel and is based off Bowlby’s theory of attachment. The main theme of this literature analysis was to examine the different causes of the development of suicidal behaviors. By being able to identify the different causes of the development of suicidal behavior, practitioners will be able to identify additional interventions to help decrease the number of suicides. As seen throughout the literature analysis, positive social support systems are vital in being able to cope with stressful life situations, ultimately decreasing the number of suicide attempts. The middle range theory of Social Support believes that social support impacts an individual’s health status, health behavior, and the use of health services. The theory has four theoretical constructs that include instrumental, appraisal, informational, and emotional support. When in need of assistance in life, people normally reach out to individuals close to them, such as best friends, coworkers, and neighbors. Best friends, coworkers, and neighbors are considered to be instrumental support. Appraisal support is helpful in assisting an individual with constructive feedback, affirmation, and social comparison. When times get difficult in one’s life and they need assistance in solving problems, they reach out for informational support to receive advice they can use to address the issue. Through sharing life experiences and forming new connections with someone through empathy, love, trust, and caring, an individual is able to find emotional support.
Five critical assessment questions for nurses to help determine effective emotional, information and instrumental social support interventions are; (1) who helps you get the day to day things you need in your life; (2) if you had an emergency, who would you call on for help; (3) who would lend you money to or keep or ask to keep your children if you needed it; (5) who gives you advice that is useful; (6) who understands your private worries and feelings (Peterson & Bredow, 2017). By asking these identifying questions, nurses and other practitioners will be able to assist in the identification of risk factors for the onset of suicidal behaviors. If the risk factors are able to be found, nurses and other practitioners can suggest additional support systems such as respite, support group meetings, and family therapy if needed. This will build more self-awareness and self-compassion to form a stronger sense of self appreciation and wellbeing.
Further nursing research is needed related to the concept of suicidal behavior. Suicidal behavior continues to be a significant issue not only in the United States, but world-wide as well. Due to the ever-growing number of suicides, it is important to continue delving into the concept of suicidal behavior to form better interventions for healthcare providers to help predict suicidal behaviors before they turn into a completed suicide attempt. With approximately 90% of individuals committing suicide having some sort of a mental illness, it is important to identify the signs and symptoms of mental health disorders upon assessment of an individual. Per Barzilay et al. (2015, p. 73), “further research could help to validate the findings of the current study by using prospective design on other populations and settings.” Muller et al. (2015) believed that further research needs to be conducted to be able to create safer school environments of the lesbian, gay, bisexual communities. They also suggest lesbian, gay, bisexual education and issues to be addressed in the school’s curriculum to help develop and discuss respect for all individuals. Due to the lack to studies on suicidal behavior, much is still needed to know in regard to the causes and interventions needed to combat the crisis. By conducting additional studies, more data will be collected to better support the understanding of the different therapeutic approaches needed to intervene before the behavior strikes.
In the first study, mood instability and impulsivity were looked at as trait predictors of suicidal thoughts. The study showed that mood instability was a main indicator of suicidal ideation. Studies show that mood instability can be treated effectively by mood stabilizing medications, which could decrease the number of individuals that are struggling with depressive symptoms and suicidal behaviors. Next, the concept of suicidal behavior was analyzed. Within the findings of this study, it showed that it is vital for healthcare professionals to be able to identify the different concepts: (1) suicidal behavior; (2) self-mutilation; (3) deliberate self-harm. By having a better understanding of these concepts, they will be able to determine the high-risk individuals to develop, or have already developed, suicidal behaviors. The study also suggested the importance of understanding attributes, antecedents, and consequences of suicidal behavior. By doing so, healthcare professionals will be able to develop a better understanding of appropriate interventions for each concept for better patient-centered care. The third study seek out additional data supporting the idea that bullying increases the risk of the development of suicidal behaviors and ideation. The study supports the fact that overall youths bullied overall are put at highest risk for suicide. The study also suggests that the lesbian, gay, bisexual communities being at high risk as well for suicidal behaviors. As practitioners, it is important to have a better understanding of the negative implications of bullying in relation to the increase in suicidal behaviors. Additional education within the school and health care setting is needed to help combat the high rate of bullying, with the overall goal to decrease the number of youths with suicidal behaviors. The final study that was analyzed on the interpersonal theory of suicide and adolescent suicidal behavior. The two hypotheses that were analyzed were as followed; (1) the feelings of being a burden and feelings of loneliness/ isolation is related to suicidal ideation and (2) self-harm or acquired capability will increase the number of suicidal ideation and suicidal attempts, both were proven to be correct. There were multiple instruments used and looked at within this study. The use, population, reliability, validity, and Cronbach’s alpha scores were identified.
The middle range theory of Social Support was looked at in relation to the concept of suicidal behavior. Social support was identified in each of the literatures that were analyzed, as being important to the decrease in suicidal behaviors. Various types of questionnaires, interviews, and scales can be utilized within the concept of suicidal behavior in relation to the middle range theory of Social Support. By developing social support systems, whether it be a close friend, sibling, or neighbor, stress will be easier to cope with because the individual can go to them for support when needed. Nurses and other practitioners can also be utilized as a support system. They are able to help set up support groups, refer to family therapy, and can just be a listening ear for the patient to tell their story.
The concept of suicidal behavior is relevant not only in psychiatric nursing but throughout the nursing practice. Several cases have been identified in the primary care setting, way before a suicide attempt, leading to a potential emergency department visit. If practitioners are able to ask the appropriate identifying questions to identify suicidal behavior, they would be able to find the correct intervention for the patient. Whether it be medications, such as mood stabilizers to stabilize the mood and decrease the individual’s impulsivity, or to refer to counseling with DBT or CBT. There is a chance of changing the patient’s course of action and behavior. Thus, in turn, could help lower the rate of suicide world-wide. For now, the importance of open-ended questions, the identification of support systems, education of the importance of coping mechanisms, and education on bullying should be addressed during youth.
- Barzilay, S., Feldman, D., Snir, A., Apter, A., Carli, V., Hoven, C. W., … Wasserman, D. (2015). The interpersonal theory of suicide and adolescent suicidal behavior. Journal of Affective Disorders, 183, 68–74. https://doi-org.ezproxy.csusm.edu/10.1016/j.jad.2015.04.047
- Marcolan, J. F. (2018). For a public policy of surveillance of suicidal behavior. Revista Brasileira de Enfermagem, 71, 2343–2347. https://doi-org.ezproxy.csusm.edu/10.1590/0034-7167-2018-0256
- Mueller, A. S., James, W., Abrutyn, S., & Levin, M. L. (2015). RESEARCH AND PRACTICE. Suicide Ideation and Bullying Among US Adolescents: Examining the Intersections of Sexual Orientation, Gender, and Race/Ethnicity. American Journal of Public Health, 105(5), 980–985. https://doi-org.ezproxy.csusm.edu/10.2105/AJPH.2014.302391
- Oquendo, M. A., & Baca-Garcia, E. (2014). Suicidal behavior disorder as a diagnostic entity in the DSM-5 classification system: advantages outweigh limitations. World psychiatry: official journal of the World Psychiatric Association (WPA), 13(2), 128-30.
- Peters, E. M., Balbuena, L., Marwaha, S., Baetz, M., & Bowen, R. (2016). Mood instability and impulsivity as trait predictors of suicidal thoughts. Psychology & Psychotherapy: Theory, Research & Practice, 89(4), 435–444. https://doi-org.ezproxy.csusm.edu/10.1111/papt.12088
- Peterson, S. J., & Bredow, T. S. (2017). Middle range theories: Application to nursing research and practice.
- Sun, F.K. (2011). A concept analysis of suicidal behavior. Public Health Nursing, 28(5), 458-468.
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