Running head: CLC HEALTH ISSUE ANALYSIS: SUICIDE 1

CLC Health Issue Analysis: Suicide

Leora Bain, Maribel Frias, Leanda Jackson, & Lata Thomas

Grand Canyon University: NUR 508

July 1, 2018
CLC HEALTH ISSUE ANALYSIS: SUICIDE 2

CLC Health Issue Analysis: Suicide

Suicide is defined as an act of self-inflicted injurious behavior, resulting in death (CDC,

2017). This has a lasting effect on family, friends, and communities (National Institute of Mental

Health [NIMH], n.d.). As this discussion will demonstrate, increasing rates of suicide occur

within all socioeconomic statuses, genders, ages, and ethnicities (WHO, 2014). However, in

most instances, it fails to be the focus of public health concerns. While many studies have

information regarding suicide and how it can be prevented, the taboo and stigma surrounding

suicide continues. Due to this, people frequently fail to ask for help or are left alone. In the

events when individuals do ask for help, services required most often arrive too late.

In addition to the mainstream suicide discussion, this document will also explore the

ethics of Physician-assisted Death (PAD) or Physician-assisted Suicide. Physician-assisted

death, is the practice of physicians providing medications intended to end life for terminally ill

patients. These patients, who must be competent and of sound mind, make the choice to

consume the medication at a time they have chosen, ultimately resulting in death (Quill, 2018).

The acts associated with PAD, lead to death at the will of an individual, which allows for further

discussion on this topic as it relates to suicide. Ethical dilemmas posed by this practice are

contradictory to the responsibilities stated within the nursing code of ethics.

The overall discussion regarding suicide, will provide a history of the problem in the

United States (US) and globally. It will further include US funding initiatives, and how the US

compares to other countries with universal health care, as well as, exploration of the scope of the

problem, population disparities, past and present initiatives, public and private programs, ethics,

and religious and cultural considerations of the problem. Finally, this document will conclude

with how the nursing profession impacts this global health problem both now and in the future.
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Health and Socioeconomic Determinants

Although suicide is often linked with several risk and protective factors, as an individual

action, it fails to have a specific reason. Suicide can take place as a reaction to several biological,

psychological, interpersonal, environmental, and societal pressures interrelated with one another.

This happens most often over time rather than impulsively (Stone, Bartholow, Crosby, Davis,

and Wilkins, 2017).

Individuals experience pressures from society which could include loss of a job, financial

or work stress, being a victim of violence, having a poor support system, and feeling helpless. To

some, what is perceived as normal can place others at risk for suicide. The biological and

psychological factors that play a role may include depression, hopelessness, lack of self-worth,

and the inability to appreciate themselves. On various occasions, individuals fail to ask for help

due to feelings of shame and having difficulty realizing they have a mental illness. Other

circumstances that can place a person at risk for suicide may include having a family member

who committed suicide, mental illness, substance abuse, having certain health conditions, and a

history of previous suicidal attempts (World Health Organization [WHO], 2014).

At times, those who want help live in communities devoid of health care and medical

aide, leaving them unable to attain much needed psychological attention and medication. Instead,

there is access to unsafe media portrayal of suicide and availability of attaining lethal means.

While not all people who are depressed or have other risk factors attempt suicide, it is important

to have resources available to assist people going through difficult times, and seek to prevent the

causes associated with suicidal ideation.

In some cases, protective factors may help to prevent individuals from committing

suicide. Environmental protective factors include, having access to effective treatment and health
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care, having a supportive community, and access to social institutions. Personal protective

factors include having strong family support, being able to connect with other individuals,

having good self-esteem, possessing problem solving and coping skills, and strong religious and

cultural beliefs which discourage suicide (Suicide Prevention Resource Center [SPRC], n.d.).

Brief History of Public and Private Initiatives

Many remember the 1950’s as a decade of great conflict and economic growth, but few

knew the high rate of suicide. Suicide was major issue that prompted the United States (US) to

provide funding for the first suicide prevention program, opening the Public Health Service in

Los Angeles, California in 1958. As suicide continued to be a problem affecting communities,

additional centers were created. In 1966, the Center for Studies of Suicide Prevention (later the

Suicide Research Unit) was created at NIMH within the National Institutes of Health (NIH). This

was followed by the creation of national nonprofit organizations dedicated to the cause of suicide

prevention (Office of the Surgeon General, 2012).

In 1987, the American Foundation for Suicide Prevention (AFSP) was created by a group

of individuals witnessing a disturbing increase of suicide deaths over the previous forty years.

Prior to the AFSP, a non-profit organization devoted to recognizing and preventing suicide

through education, research and advocacy failed to exist. AFSP created a society that focuses on

mental health by providing funding for scientific studies, educating the public regarding mental

health issues and how to prevent suicide. In addition, the AFSP supports policies which pertain

to suicide prevention and mental health issues, as well as providing support to people affected by

suicide (AFSP, 2018).

Outcome Indicators Developed

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The NIMH summoned a mission in 1970 to discuss the status of suicide prevention in the

US, the findings were presented in the 1973 “Suicide Prevention in the 70s” report with

initiatives and directions to aid the problem. The Centers for Disease Control and Prevention

(CDC) created a violence prevention unit that brought public attention to a disturbing increase in

youth suicide rates. In response, the Secretary of the U.S. Department of Health and Human

Services (DHHS) established a task force on youth suicide. In 1989, DHHS analyzed the data

and published recommendations (Office of the Surgeon General, 2012 para 2).

In 2005, the U.S. Substance Abuse and Mental Health Services Administration

(SAMHSA) and the Mental Health Association of New York City (MHA-NYC) created Lifeline.

Lifeline works in suicide prevention by providing education, advocacy, and services. The

Lifeline chat is an online chat platform available 24-hours a day, seven days a week to assist

people in distress and with suicidal ideation (NIMH, 2017). A different way help may be attained

is by calling 1-800-273-TALK (1-800-273-8255). This information is available in multiple

bridges throughout the U.S. (Draper, 2017). Thanks to many public figures, this information is

advertised.

Status Based on Measured Outcomes

Suicide is a major concern of premature death and public health issues having a

prolonged negative impact on individuals, families, and communities. In 1950, there were 13.2

deaths by suicide per 100,000 residents in the United States. In 2015, the suicide death rate

remained at 13.3 per 100,000 residents in the United States (Statista, 2018 para 1). The reasons

individuals commit suicide are complicated and attributed to a variety of issues. As a

community, along with the resources provided by various organizations, the aim to prevent

suicide can be achieved by reducing risk factors and promoting protective factors.
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Global Scope and Depth

Suicide is a phenomenon affecting all regions of the world, as well as each section of

society. Every 40 seconds a precious life is lost to suicide, claiming nearly 80,000 lives per year.

While suicide occurs in every age group, in 2015 it was the second leading cause of death among

15-29-year-olds. Although there is an established connection between suicide and mental health

disorders in high income countries, many suicides take place in a moment of crisis when the

individual is unable to cope with life stresses. In 2015, suicides in low and middle-income

countries constituted about 78% of suicides. Common methods for suicide include ingestion of

pesticides, hanging, and firearms. Other methods are also used which differ by population group.

In many countries there is a stigma connected to suicide, leading to many failing to seek help and

becoming victims (WHO, 2018).

International and United States Ranking

Globally the crude rate of suicide in 2016 was 10.6 per 100,000 people. WHO (2016) has

grouped the world into six regions to estimate suicide rates in different countries. In 2016, the

crude rate for both sexes per 100,000 people in the WHO regions are: Europe at 15.4, Southeast

Asia 13.2, Western Pacific 10.2, America 9.8, Africa 7.4 and Eastern Mediterranean 3.9. Among

European countries, Lithuania has the fifth highest suicide rate worldwide. Kazakhstan has the

10th highest, and Turkmenistan has the 14th highest suicide rate (WHO, 2018).

According to WHO, the adjusted death rates for 2017 ranked the US 47 out of the 183

countries studied, making the number 12.7 per 100,000 (World Health Rankings, n.d.). The CDC

(2016), Leading Causes of Death Reports, states that suicide claimed the lives of 45,000 people,

making it the tenth leading cause of death in the US. It also states, suicide was the second leading

cause of death among populations aged 10-34, and the fourth leading cause among populations
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35-54. In addition, from 1999-2016, the suicide rate in the US increased by 28% from 10.5 to

13.4 per 100,000 (NIMH, 2018). The cost of suicide in the US accounts for $69 billion annually

(American Foundation of Suicide Prevention [AFSP], 2018).

Disparities

As previously stated, suicide is a worldwide problem. As such, it does not discriminate

between age, race, gender and socioeconomic status. In addition to worldwide suicide rates being

the second most common cause of death among 15-29-year-olds, the rates are higher among

people over age 70. Completion of suicide is more common among men than women across the

globe. However, in high income countries, the suicide rate among men is three times that of

women (WHO, 2014). National studies have shown that suicidal behavior, especially suicide

methods, varies between countries depending upon its availability. A report in the WHO bulletin

states hanging was the common method of suicide used in most countries, with a rate of 90% in

men and 80% in women as noticed in Europe. In the US, firearms were the common method

used, while in Asian countries poisoning with pesticide was a major concern, and in Canada and

the United Kingdom women used poisoning with drugs as the common method. (WHO, 2011).

In the US, the global statistics are transferable. In addition, in 2016 the highest suicide

rate was in middle aged white men, accounting for seven out of 10 suicides. Among the different

races and ethnic groups Caucasians had the highest rate of suicide, followed by American

Indians and Alaskan Natives. Asians, Pacific Islanders and African Americans had a much lower

rate (AFSP, 2018).

Contributing factors of suicide are complex and encompassing mental disorders such as

depression, alcohol abuse disorders, and inability to deal with life stresses (i.e. financial

problems, chronic pain/illness, and problems in relationships). In addition, people who have
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experienced loss, disaster, conflict, violence, or abuse along with a sense of isolation, tend to

have suicidal behaviors. Lastly, there are high incidences of suicide among vulnerable groups

such as refugees, migrants, those within the LGBTQ community, and prisoners (WHO, 2018).

Prevention Efforts

World Suicide Prevention Day is observed on the 10th of September each year, and is

organized by the International Association of Suicide Prevention and co- sponsored by WHO. It

provides an occasion for joint efforts to raise awareness about suicide and its prevention in all

parts of the world. According to the WHO Mental Health Action Plan of 2013-2020, the global

target of all WHO member states, is to decrease suicide rates by approximately 10% in all

countries by 2020. The 2008, WHO Mental Health Gap Action Program focuses on suicide

prevention and gives evidence-based technical direction to promote services in different

countries (WHO, 2014).

Within the US, there are many national organizations and federal agencies offering

valuable resources, information, funding, and training. The NIMH conducts research on suicide

and its prevention, and has a website providing information and resources. The National Center

for Injury Prevention and Control (NCIPC) provides valuable resources and statistics on suicide,

its risks, and prevention. NCIPC’s revised national policy for preventing suicide emphasizes the

role of every citizen in protecting their friends, family and colleagues from suicide. Non-profit

organizations like Suicide Awareness Voices of Education (SAVE), American Association of

Suicidology (AAS) and AFSP, help prevent suicide by funding research and promoting public

awareness, and educational programs and resources for professionals (SAMHSA, n.d.).

Funding for Past and Present Initiatives

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As a public resource, SAMHSA provides grants for initiatives in suicide prevention

across the nation. In 2014, they announced 14.5 million dollars would be awarded to eight

programs. Six of the eight programs were state run, the other two consisted of the Choctaw

Nation, and the University of Central Florida (SAMHSA, 2017).

The Action Alliance for Suicide Prevention (AASP, 2018) is a partnership, “bringing

together senior leaders from public and private sectors to collectively advance our nation’s

suicide prevention efforts” (min 0.52). Since this is a public-private partnership, they receive

funding from both public and private sectors including. Funding comes from organizations such

as SAMHSA, NFL, Johnson & Johnson, Facebook, CDC, The Joint Commission, Vietnam

Veterans of America, Saddleback Church, and many more (AASP, 2018).

Past and Present Quality Initiatives

According to a document published by the Office of the Surgeon General, suicide

prevention centers did not exist prior to 1958. From 1958-1966, there was one center in Los

Angeles, California. In 1966 the NIMH established a center for studies of suicide prevention.

During the time from 1966 to the mid-1990s, several non-profit organizations formed. NIMH

created a task force for suicide prevention, the CDC began to increase awareness, and DHHS

created a task force for at risk youth. The movement picked up momentum when in the mid-

1990s, family survivors began to push for national strategies resulting in two Congressional

Resolutions. Overall, from 1958-1991, there were 13 notable movements addressing suicide,

with a large growth noted from 1991-2011 and the formation of 38 notable movements during

that time. (Office of the Surgeon General; National Action Alliance for Suicide Prevention; US

Department of Health and Human Services [OSG, NAASP, & DHHS], 2012).
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The AASP has developed an initiative called Zero Suicide, and set a goal to reduce

suicide 20% by 2025 utilizing three priorities. The first priority is increasing awareness and

action within healthcare systems (AASP, 2018). The second, is increasing awareness within each

community, and the third addresses “changing the conversation” (AASP, 2018, min 3:33). This

initiative is likely the largest of its kind. However, there is a number of programs run and/or

supported by DHHS and SAMHSA, within each state and community.

Impact of Insurance Coverage

The impact of insurance coverage on mental health can sometimes be a driving force in

receiving mental healthcare. In some cases, however, it can be a very large deterrent depending

on insurance coverage, deductibles, and premiums. For this section the author contacted Priority

Health, a large supplier of health insurance through the private sector, as well as via Priority

Health Medicaid, and the Market Place. In a phone interview, a customer service representative

confirmed that all private sections of insurance provided has mental health coverage for

inpatient, outpatient, and substance abuse. Participants are subject to pay the deductible before

insurance coverage is applied. Those with Priority Health Medicaid may receive outpatient

counseling. However, if any inpatient hospitalization is necessary, it must be managed through

the local DHHS via the local community mental health department. Without DHHS certification

that hospitalization is necessary, the participant will not receive inpatient treatment. Mental

health coverage through the Marketplace is determined by whether the participant is purchasing

health insurance coverage via the private or public health sector within Priority Health.

(Customer Representative, personal communication, June 8, 2018).

The impact insurance coverage has on access to treatment is notable. As mentioned,

participants receiving Medicaid may have access to inpatient mental health treatment, but only if
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a DHHS worker deems it necessary. The pitfall here is that many who need inpatient

hospitalization are denied services while others who abuse the system are almost always

approved. The author experienced this as an employee at one of the largest freestanding mental

health hospitals in the country, Pine Rest Christian Mental Health Services. There are many

patients that know exactly what to say to receive services. This number increases especially

among the homeless population in the winter. Some might believe the homeless individual to be

suicidal. However, upon admission and receiving a meal and warm bed, the patient’s lack of

attendance in group therapy, personal therapy, and dedication to their care reveals the true nature

of their intentions. During this time, many who need services, are unable to receive them due to

lack of mental health beds.

In addition, while those with private insurance may have coverage, often the lack of

ability to pay the deductible is a deterrent to receiving care. Since financial stress is a

contributing factor for contemplation of suicide, the added stress on a patient is clearly unhelpful

(Foster, 2011). To truly address the growing problem with suicide and mental health problems,

there is a great need for improvement to accessing services both financially as well as bed

availability.

Outcome Comparison

The crude rate of suicide per 100,000 people in the US in 2016 was 15.3, in comparison

with the global average of 10.6 (WHO, 2018). Since the data compares rates per 100,000 people,

it is fair to generalize these numbers across populations regardless of size. Taking this into

account, the country with the lowest rate of suicide is Antigua and Barbuda (A&B) with 0.5

(WHO, 2018). In comparing the US and A&B, it is worth mentioning that A&B does have free

universal health care (WHO-AIMS, 2009). The WHO-AIMS (2009) report details the mental
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health services available in A&B. This includes free access to any medications needed to treat

mental health disorders. In addition, those in need of mental health services can access healthcare

through community services, hospitals, primary care offices, and community residential

facilities.

In comparison to other countries, the mental health services in A&B is sparse. There is no

mental health policy or plan in the country, and only four percent of the total cost of healthcare is

spent on mental health (WHO-AIMS, 2009). One might even call the mental health system there

primitive as the definition of a person suffering with mental illness is “any epileptic, idiot,

imbecile, feeble-minded person; and a moral defective person” (WHO-AIMS, 2009, p. 15). If

medical professionals are to come to a complete understanding of the low suicide rates in A&B,

more exploration is necessary. Access is affected by many things with the two notable factors

being availability of services and financial barriers. Given the scant resources available, there are

variables potentially affecting the low suicide rates, which could be unrelated to universal

healthcare.

Discussion of Physician Assisted Death

Physician-assisted death (PAD) was initially legalized in Oregon, in 1995. More recently,

Washington passed legislation on the practice in 2008. This was followed by Vermont in 2013,

California in 2015, Colorado in 2016, Washington DC in 2017, and lastly Hawaii in 2018. As

controversial as this topic proves, there are continual attempts to challenge the legalization of

PAD. However, since there are so few states holding legislation in this area, data is scarce. Most

studies are conducted based on Oregon’s data since this was the initial state of legalization.

Globally, PAD is an accepted practice. In the Netherlands, PAD and euthanasia have been in
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practice for over thirty years (Quill, 2018). This section will further explore the ethical dilemmas

posed by this practice.

Ethical Considerations

When discussing nursing ethics, there are four main principals to consider: non-

maleficence, beneficence, autonomy, and justice. Autonomy is respecting the individual desires

of the patient, despite disagreement and supports the concept of informed consent (Virtual

Campus for Public Health [VCPH], 2018). In applying the principle of autonomy to this

population, the nurse is ensuring appropriate information and education is provided. In this way,

patients are equipped with tools and resources to make a decision. An additional ethical principal

applied to this population, is Deontological ethics.

In applying deontology, ethics are concerned with what one does, not the consequence of

their action (Shakil, 2018). It is a situation where a potentially immoral act is done to achieve a

good outcome. For example, if one was to shoot an intruder, they would be protecting their

family. In this case, shooting the intruder was the immoral act being done to ensure good. In

relation to PAD, the nursing code of conduct states, to do no harm. It further speaks of moral

obligation to follow rules and principals and provides a guide for nurses related to what should

be done and what should be sought (Nursing World, 2015). A nurse faced with addressing PAD,

may feel conflicted because of their duty to do no harm, and PAD is providing the means for a

patient to inflict self-harm to end their life.

In an effort to address and remove this disparity, utilitarian ethics can be applied.

Utilitarianism is an opposing theory to deontological ethics. The utilitarian aims for the greatest

happiness or best consequence and has a justification for any action taken in meeting that goal

(Shakil, 2018). Consequentialism considers the end consequence of the action even when the act
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is not morally good (Shakil, 2018). In this case, the greatest number of people includes the

patient and family. Is the family supportive of their loved one's decision? If not, is there a way

they could be supported as their family member seeks to complete suicide? Utilitarianism would

be applied to address providing support to the family so they are prepared to provide support to

the patient.

Application of ANA Code of Ethics for Nurses

The ANA Code of Ethics for nurses with interpretative statements, sets the foundation for

the nursing profession and provides assistance for making decisions with ethical issues. Of the

nine provisions, four of them can be appropriately applied to the ethical issues surrounding PAD.

Provision 4 provides the nurse with the authority, accountability and responsibility for practicing

nursing. It further extends to nurses, authority to make decisions, and is consistent with the

obligation of health promotion and providing optimal care to patients. In applying the 6th

provision to practice, nurses may act alone, or in collaboration with others to maintain an ethical

environment in the workplace. This environment must assist in providing safe and quality

healthcare. In provision 8, the nurse is collaborating with health professionals and the

community to reduce health disparities, promote health diplomacy, and protect human rights.

Finally, provision 9 integrates social justice into nursing care and health care policy, and

instructs the nurse to articulate values and maintain integrity of the profession (Nursing World,

2015).

Cultural Influences on Suicide

The influence of culture on mental health and suicidal thoughts plays a significant role in

how patients receive and process their emotions. This demonstrates the importance of

understanding cultural influences when treating and preventing suicidal ideations and mental
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health disorders. However, as we have seen in previous sections, suicide is no respecter of

persons, cultures, religions, age, or socioeconomic status. Researchers argue that conversation

regarding cross-cultural differences, is not helpful in overall understanding of the issues. With

the vast number of cultures globally, even the most solid understanding of diversity will not

prove helpful in the few moments or hours a clinician has, to assess risk in patients. In addition,

within the US alone, there are subcultures within the larger American culture wherein each has

its own set of risk and protective factors. Attempting to understand each one is not possible in

this short section. Therefore, the new perspective on this lies in understanding “psychological

universals, omniculturism, and intersectionality” (Atilola & Ayinde, 2015, p. 459).

For complete satisfaction of this section however, there will be a brief discussion

regarding universal risk and protective factors. According to the Institute of Medicine Board on

Neuroscience and Behavioral Health (IOM-BNBH, 2001) “countries with low suicide rates tend

to be predominantly Catholic or Muslim, are typically relatively youthful, have strong social

control networks, more extended family ties, and explicit proscription of suicide” (p. 8). In

contrast, “high suicide rate countries have higher rates of depressive disorder, high levels of

alcohol consumption, often apart from rituals or food intake, a greater relative proportion of an

older population, more social isolation, more cognitive rigidity and inflexibility” (IOM-BNBH,

2001, p. 8). By understanding what universals are present rather than the vast differences, there

can be more successful implementation of interventions that will impact larger populations. This

also proves to be more efficient in assisting clinicians to assess risk.

Religious Influences on Suicide

The influence of religion on suicidality can be a double-edged sword. In the author’s

experience within mental health, there were two major ways patients with suicidal thoughts were
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affected by religion. The first was that religion was a protective factor and prevented the patient

from carrying out their suicidal thoughts. The second was that patients often experienced and

lack of connection with their peers of the same religious sect. This section will take a brief look

at the research behind these phenomena.

Martinez (2014) provides the most comprehensive overview of religious views toward

suicide, this author could find. According to this resource, the Catholic Church views suicide as a

mortal sin while the Judeo-Christian strongly discourages the act. For these, religion can be a

protective factor, on the other hand it could also be the factor that discourages treatment. In some

parts of Japan, suicide can be an honorable act depending upon the situation and method of

suicide. Islam tends to quote a section of the Quran which states “do not destroy yourselves.”

(Martinez, 2014).

Impact of Religion

Being part of a religion or being spiritual is a principal value to people around the world.

More than 80% of people in the United States are religious or spiritual (Rasic, Belik, Elias, Katz,

Enns, 2008). For those religions whom consider suicide a mortal sin, those active within such

organizations are less likely to commit suicide. Religion is a form of social connection and

provides individuals with a sense of belonging. Most people that commit suicide suffer with a

lack of connection to others. Studies have shown that people with mental illness use religious

beliefs to cope with stress (Rasic, Et. Al., 2008). In addition, religion can also be considered a

form of meditation and communication with God or a higher power.

For some individuals, their spirituality increases the likelihood that they will seek help

from their religious institution. This is sometimes seen as a way to clean the mind and soul from

evil thoughts. During this time, whether through prayer or conversing with someone representing
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the religion, the individual may realize what is causing their stress. In these situations,

individuals may also realize better solutions and that death is irreversible. Frequently, those

belonging to a religious institution experience enhanced mental health by being social, which

reduces stress and depression. Therefore, the possibility of committing suicide may be decreased

through the impact of one’s religion.

Political Influences

Due to economic influences of a community, politics may sometimes contribute to an

increase in suicide rates. Studies confirm that during economic recession, loss of jobs, homes and

financial stability, may also lead to an increase in suicide (Stone et. al., 2017). While local and

presidential elections may prove to be a period of increased stress for the nation, there is no

research indicating elections have any influence on suicide.

It is important for politicians to understand suicide is the second preventable cause of

death worldwide. Advocating on behalf of the community represented, politicians should

advocate for funding to educate the public regarding mental health and suicide. In 2018, US

funding provided for mental health services such as substance abuse and public awareness was

decreased (Health and Human Services [HHS], 2017).

Since firearms have been shown to cause the greatest number of suicide deaths, it is

important for public policy to focus on possible interventions (Kposowa, 2013). It is well known

that the second amendment of the United States constitution states, citizens have the “right to

bear arms.” While many people believe having a gun at home helps to protect against burglars

and trespassers, research indicates 52% of suicide was executed with a firearm (ProCon.org,

2018). It is for this reason; public policy should focus on reasonable interventions to protect

those suffering with mental health disorders.

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Impact of Nursing on Suicide

In finalizing this discussion on suicide, it is important to discuss the impact Advanced

Practice Registered Nurses (APRNs), and other professionals have in addressing this issue. The

nursing profession past and present are considered the frontline in health care. Nurses are

afforded the opportunity to be the first to provide interventions for suicide prevention and

education (Bolster, Holliday, Oneal, & Shaw, 2015). According to Bolster et. al. (2015), it was

found that most whom have completed suicide had contact with a healthcare professional within

the previous month. WHO reports suicide is a preventable health concern. In addition, they

report suicide assessment and education on identifying suicidal behaviors, has the potential to

prevent the act of suicide.

Over the years suicide assessment has been taken more seriously. Previously, there has

been a lot of discomfort related to suicide assessment. Studies have shown when nurses and other

health care professionals were properly trained in addressing suicide education and prevention,

learners are more comfortable in providing interventions (Bolster, et al., 2015). Currently there

are several tools and resources available for use in clinical or community settings which may

assist in identifying suicide risk. Over the years, resources have evolved to become more

inclusive as risk populations are identified through data (Healthy People, 2018). For example,

according to the CDC, over the past decade, bullying has become more of a cause for suicide in

youth. The CDC provides resources which aid in identifying bullying behavior and assessing

suicidal ideations in at risk individuals (CDC, 2014).

Influencing Health Policy Related to Suicide

Under federal rules from the Health Insurance Portability and Accountability Act

(HIPPA) of 2006, insures are not allowed to deny coverage related to depression. Some
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insurances deny claims for injuries related to suicide or attempted suicide, despite laws stating

denial is not allowed. Denial of coverage is made possible by source of injury exclusions,

described as injuries caused by activities such as risky recreational activities, often applied to

self-inflicted injuries (Andrews, 2014). These exclusions appear to be a loop hole in laws

leading to denial of claims. Nurses can advocate for policy which removes source of injury

exclusions or modifies them to include some form of coverage for cost associated with suicide or

attempted suicide.

Another way nurses may influence policy is to develop model policies involving suicide

prevention and addressing suicidal behaviors within educational institutions (SPRC, 2016). This

can be done on a local level by identifying challenges within the community so model policies

are directly related to populations which it will serve. APRNs can also participate and become

actively involved in research efforts to obtain data which may be used to create evidence-based

practices.

As a member of nursing organizations, one is afforded several opportunities to participate

in health policy influence. The American Psychiatric Nurses Association (APNA) is a nursing

association specific to mental health. APNA collaborates with consumer groups to promote

advances based on evidence for those with mental illness and substance abuse issues. The APNA

also provides opportunity for members to be involved on committees and task forces addressing

issues related to mental health. A main resource related to taking action, is ongoing stakeholder

education. This is an opportunity to educate on the responsibility to adequately address issues

related to mental health (APNA, 2018).

Nursing Influence on Suicide Prevention

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Nurses are in a unique position to assist in curbing suicide rates in our country, due to

their hands-on approach to patient care and the ability to create therapeutic connections with

patients. The high suicide rate in the US make it a possibility that future suicide victims will be

patients on different units and clinics in a non-psychiatric setting. Knowing the warning signs of

suicide and where to get help may decrease the incidence of suicide. Identifying key patient cues

becomes crucial. This begins with understanding that suicidal behaviors are not an illness, but a

complex set of behaviors ranging from ideas or thoughts and eventually leading to actions.

Identified cues should be recorded and included in each patient’s health care plan (Suicide

Prevention, 2008).

The APNA has put forth essential competencies for psychiatric registered nurses to

provide evidence based care. Nurses play a vital role in systems and patient level interventions.

Forming systems level interventions includes assessing and maintaining environmental safety,

developing protocol, policies, and practices consistent with zero suicide. In addition, it includes

participating in training programs. Patient level interventions include assessing suicidal risk,

providing suicide specific psychotherapeutic interventions, monitoring and supervising at risk

patients and evaluating intervention outcomes. These essential competencies will help nurses to

provide expert care leading to reduction of suicide mortality rates (APNA, 2018).

Summary

Suicide is a major public health problem, occurring when people die by directing

violence at themselves with the intent of taking their own lives. It’s a complex phenomenon

which occurs in all demographic groups and needs to be openly discussed in communities, to

remove the stigma and taboo associated with feelings of suicide. According to the World Health

Organization (WHO), suicide is the second leading cause of death among 15-29 years old’s
CLC HEALTH ISSUE ANALYSIS: SUICIDE 21

(2017). Public awareness and methods to support social change are vital suicide prevention

strategies. Culture, religion and politics have a major influence on the community hence

religious leaders, politicians and health care providers need to educate their communities on

preventive, protective and problem-solving strategies to decrease the occurrence of suicide.

The focus on suicide prevention in the US has been a recent phenomenon, with the first

center for suicide being initiated only 60 years ago. Since that time, the primary focus on

prevention and treatment of suicide has rested mainly within the public health/mental health

sector. Recent initiatives show increased interest of private donors, as well as, an increase in

quality initiatives for screening by acute care givers. While there may continue to be issues

regarding access to mental health care, those within the acute setting have the advantage of

advocating for each patient at risk of suicide.

Nurses being a major work force in the health care industry, play an important role in

prevention of suicide by influencing policy making and by providing direct patient care.

Utilizing the ethical principles of deontology, utilitarianism, consequentialism, autonomy and

justice nurses may be able to reconcile their personal objections with physician-assisted suicide.

In addressing this major public health problem, it is imperative that health care professionals

become aware of the scope of issue, risk factors, and early signs of distress which could lead to

better diagnosis and reception of services

CLC HEALTH ISSUE ANALYSIS: SUICIDE 22

References

American Foundation for Suicide Prevention (2018). About AFSP. Retrieved from

https://afsp.org/about-afsp

American Foundation for Suicide Prevention (2018). Suicide Statistics. Retrieved from

https://afsp.org/about-suicide/suicide-statistics/

American Psychiatric Nurses Association. (2018). Get involved. Retrieved from

https://www.apna.org/i4a/pages/index.cfm?pageid=4985

American Psychiatric Nurses Association. (2018). Psychiatric-Mental Health Nurse Essential

Competencies for Assessment and Management of Individuals at Risk for Suicide.

Retrieved from https://www.apna.org/i4a/pages/index.cfm?pageid=5684

Andrews, M. (2014). Some Insurance Plans Don’t Cover Medical Costs Related to Suicide

Despite Federal Rules. Retrieved from https://www.washingtonpost.com/national/health-

science/some-insurance-plans-dont-cover-medical-costs-related-to-suicide-despite-

federal-rules/2014/02/24/b584856e-98b8-11e3-b931-

0204122c514b_story.html?noredirect=on&utm_term=.9dc96c9cc53c

Atilola, O., & Ayinde, O. (2015, July 24). A cultural look on suicide: The Yoruba as a

paradigmatic example. Mental Health, Religion, & Culture, 18(6), 456-469.

https://doi.org/10.1080/13674676.2015.1077212

Bolster, C., Holliday, C., Oneal, G., Shaw, M., (2015) Suicide Assessment and Nurses: What

Does the Evidence Show? OJIN: The Online Journal of Issues in Nursing Vol. 20, No. 1,

Manuscript 2. DOI: 10.3912/OJIN.Vol20No01Man02

Centers for Disease Control and Prevention. (2014). Violence Prevention. Retrieved from

https://www.cdc.gov/violenceprevention/pdf/bullying-suicide-translation-final-a.pdf
CLC HEALTH ISSUE ANALYSIS: SUICIDE 23

Centers for Disease Control and Prevention (2017). Violence Prevention. Retrieved from

https://www.cdc.gov/violenceprevention/suicide/definitions.html

Curtin, S., Warner, M., & Hedegaard, H., (2016). Increase in suicide in the United States. Center

for Disease Control and Prevention. Retrieved from

https://www.cdc.gov/nchs/products/databriefs/db241.htm

Draper, J., (2017). Suicide prevention on bridges. The National suicide prevention lifeline

position. National Suicide Prevention Lifeline. Retrieved from

https://suicidepreventionlifeline.org/wp-content/uploads/2017/04/Suicide-Bridges-

National-Suicide-Prevention-Lifeline-Position-2017-FINAL.pdf

Foster, T. (2011, January 1). Adverse life events proximal to adult suicide: A synthesis of

findings from psychological autopsy studies. International Academy for Suicide

Research, 15(1), 1-15. https://doi.org/10.1080/13811118.2011.540213

Health and Human Services. (2017). HHS FY 2018 budget in Brief – SAMHSA. U.S

Department of Health and Human Services. Retrieved from

https://www.hhs.gov/about/budget/fy2018/budget-in-brief/samhsa/index.html

Institute of Medicine (US) Board on Neuroscience and Behavioral Health. (2001). Risk factors

for suicide: Summary of a workshop. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK223750/pdf/Bookshelf_NBK223750.pdf

Kposowa,A. (2013). Association of suicide rates, gun ownership, conservatism and individual

suicide risk. Soc Psychiatry Psychiatr Epidemiol (48), 1467–1479 doi:10.1007/s00127-

013-0664-4

Martinez, A. (2014). Attitudes toward suicide, depression treatment varies widely across culture.

Retrieved from https://sundial.csun.edu/2014/09/dysfunctional-is-what-we-say-it-is/

CLC HEALTH ISSUE ANALYSIS: SUICIDE 24

National Institute of Mental Health (NIMH), 2017. Suicide prevention. Retrieved from

https://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml

National Institute of Mental Health. (n.d.). Suicide in America: Frequently Asked Questions.

Retrieved from https://www.nimh.nih.gov/health/publications/suicide-faq/index.shtml

Suicide. (n.d.). Retrieved from

https://www.nimh.nih.gov/health/statistics/suicide.shtml#part_154969

Nursing World. (2015). Code of Ethics for Nurses with Interpretive Statements. Retrieved from

https://www.nursingworld.org/coe-view-only

Office of the Surgeon General (2012). National strategy for suicide prevention: Goals and

objectives for action: A Report of the U.S. Surgeon General and of the National Action

Alliance for Suicide Prevention. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK109918/

Office of the Surgeon General; National Action Alliance for Suicide Prevention; US Department

of Health and Human Services. (2012, September). Appendix C Brief History of Suicide

Prevention in the United States. National Milestones In Suicide Prevention. Retrieved

from https://www.ncbi.nlm.nih.gov/books/NBK109918/

ProCon.org. (2018). Gun Control ProCon.org. Retrieved from http://gun-control.procon.org/

Quill, T., Sussman, B. (2018). Hastings Center Bioethics Briefings: Physician Assisted Suicide.

Retrieved from https://www.thehastingscenter.org/briefingbook/physician-assisted-

death/#

Rasic, D.T., Belik, S., Elias, B., Katz, L. Enns, M., Sareen, J., (2009). Spirituality, religion and

suicidal behavior in a nationally representative sample. Journal of Affective Disorders.

CLC HEALTH ISSUE ANALYSIS: SUICIDE 25

(114), 32-40. doi:10.1016/j.jad.2008.08.007 Retrieved from https://doi-

org.lopes.idm.oclc.org/10.1016/j.jad.2008.08.007

Shakil, A. (2018). Seven Pillars Institute: Kantian Duty Based (Deontological) Ethics. Retrieved

from https://sevenpillarsinstitute.org/ethics-101/kantian-duty-based-deontological-ethics/

Statista (2018). The statistics portal. Retrieved from

https://www.statista.com/statistics/187465/death-rate-from-suicide-in-the-us-since-1950/

Stone, D.M., Holland, K.M., Bartholow, B., Crosby, A.E., Davis, S., and Wilkins, N. (2017).

Preventing suicide: A technical package of policies, programs, and practices. National

Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdf

Substance Abuse and Mental Health Services Administration. (2017). HHS awards $14.5 million

in grants for suicide prevention programs. Retrieved from

https://www.samhsa.gov/newsroom/press-announcements/201709120400

Substance Abuse and Mental Health Services Administration and the Mental Health

Association of New York City (n.d.). Retrieved from

https://suicidepreventionlifeline.org/about/

Substance Abuse and Mental Health Services Administration. (n.d.). About us. Retrieved from

https://www.samhsa.gov/about-us

Suicide Prevention: Every Nurse's Responsibility. (2008, March 10). Retrieved from

https://www.nurse.com/blog/2008/03/10/suicide-prevention-every-nurses responsibility/

Suicide Prevention Resource Center. (n.d.). Retrieved from

http://www.sprc.org/about-suicide/risk-protective-factors
CLC HEALTH ISSUE ANALYSIS: SUICIDE 26

The Action Alliance for Suicide Prevention. (2018, March 20). Promotional video [Video file].

Retrieved from https://www.youtube.com/watch?v=QE-eAKmkF7U&feature=youtu.be

U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). (n.d.). National

Organizations and Federal Agencies. Retrieved from http://www.sprc.org/organizations/

national-federal

Virtual Campus for Public Health. (2018). Basic Principals. Retrieved from

https://cursos.campusvirtualsp.org/mod/tab/view.php?id=23168

World Health Organization. (2009). WHO-AIMS report on the mental health system in Antigua

and Barbuda. Retrieved from

http://www.who.int/mental_health/who_aims_report_antigua_barbuda.pdf

World Health Organization. (2011, March 04). Methods of suicide: International suicide patterns

derived from the WHO mortality database. Retrieved from

http://www.who.int/bulletin/volumes/86/9/07-043489/en/

World Health Organization (2014). Preventing suicide: A global imperative. Retrieved from

http://apps.who.int/iris/bitstream/handle/10665/131056/9789241564878_eng.pdf;jsession

id=045631ADF1C49A0FDFE2F657B4F60945?sequence=8

World Health Organization. (2014, October 03). First WHO report on suicide prevention.

Retrieved from http://www.who.int/mediacentre/news/releases/2014/suicide-prevention

report/en/

World Health Organization. (2016). GHO | By category | Suicide rates, crude - Data by WHO

region. Retrieved from

http://apps.who.int/gho/data/view.main.MHSUICIDEREGv?lang=en
CLC HEALTH ISSUE ANALYSIS: SUICIDE 27

World Health Organization. (2018, May 29). Data and resources. Retrieved from

http://www.euro.who.int/en/health-topics/noncommunicable-diseases/mental-health/data

and-resources

World Health Organization. (2018, May 08). Preventing suicide: A resource for media

professionals - update 2017. Retrieved from http://www.who.int/mental_health/suicide

prevention/resource_booklet_2017/en/

World Health Organization. (2018). Suicide. Retrieved from http://www.who.int/news

room/fact-sheets/detail/suicide

World Health Organization. (2018). Global health observatory data: Suicide rates per 100,000

population [Online]. Retrieved from

http://www.who.int/gho/mental_health/suicide_rates_crude/en/

World Health Rankings. (n.d.). Suicide Death Rate Per 100,000 Age Standardized. Retrieved

from http://www.worldlifeexpectancy.com/cause-of-death/suicide/by-country/