Do they indicate major depression? If so, is it stage 1, 2, or 3?
Verbalizing feelings of depression can be a significant symptom, but diagnosis of depression requires that several criteria be met and for specific periods of time.
As a psychiatric clinical nurse specialist working in long-term care, I often get urgent requests to see someone who staff members say has voiced suicidal ideation. When I see such patients, they often deny that they have threatened to harm themselves. They tell me they said, “I wish I would die” or “I’d be better off dead,” but would never kill themselves.
These are depressive statements, a symptom of depression as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), published by the American Psychiatric Association. Major depression—symptom No. 9 in DSM-5—includes the following criteria: 1) recurrent thoughts of death, 2) repeated suicidal ideation that lacks a specific plan, and 3) a suicide attempt or specific plan for committing suicide.
Stage 1 or beyond?
We must distinguish between the three criteria listed above. When people are depressed, they often feel helpless to change the situation or hopeless—that things will not change. It is not necessarily abnormal for a person to feel that things would be better if he or she died.
At this stage, supportive listening is helpful. A referral for mental evaluation of depression can be submitted. Determining the reason for someone expressing recurrent thoughts of death is important. What losses has the person suffered? Is he or she in chronic pain? What makes the patient feel he or she would be better off dead? Counseling and medication can be started. Perhaps pain should be more actively treated. While thoughts of death are not abnormal, an attempt to end one’s own life is.
The second evidence of major depression—recurrent suicidal ideation without a specific plan—is a more serious situation that needs more intervention. The patient is now perhaps contemplating suicide because his or her statements are no longer just expressing a wish to die but are a sign that a deepening of depressed mood is occurring.
The patient may make more active or provocative comments, such as, “I won't be here next week” or “They'll miss me when I’m gone.” At this point, more questioning is needed. “Do you have a plan?” “Where and how would you do it?” “Do you have access to any weapons?” “Is there a culture of suicide in your family?” Patients with a parent or sibling who committed suicide might regard self-destruction as a solution to their own problems. Some societal groups have what is called a “culture of honor.” Depression, they think, is a sign of weakness, so suicide may be regarded as an honorable way to avoid the shame. How old is the patient? Caucasian males over age 85 have the highest suicide rate. Has the person attempted suicide in the past?
If the patient denies that he or she has made statements that suggest active intent to commit suicide or is unwilling to continue counseling, intervention is needed. Assess the effectiveness of medication. Ask family members and friends to remove guns or other weapons from the person’s setting. Sometimes in such situations, a “contract” is suggested. Persuading a patient to tell staff members if he or she is thinking of self-harm and has devised a way to do it may create cognitive dissonance between a desire to harm him- or herself and to be a “good patient.” Although the contract is not binding, it may be helpful. If the patient is very depressed and has several risk factors, such as a family history or a past suicide attempt, inpatient or partial hospital care should be considered.
The last stage—suicidal ideation with a plan—is a crisis situation. You must stay with the patient until he or she is in a safe, supervised setting. The more exact the plan, the higher the risk. “I'm going to jump off the Eads Bridge at 4 p.m. Saturday” is likely more thought out than “I’ll take a handful of pills.”
If the patient won’t go voluntarily to a psychiatric unit, involuntary admission is required. Weapons must be removed. This includes call-light buzzers, the cords of which could be used for hanging. To avoid suicide by drowning, trips to the bathroom should be supervised. The sooner the patient is in a secure setting the better.
Completed suicides in long-term-care settings are rare. Many times, I have received a consult about patients with dementia who are threatening to harm themselves and have forgotten they said it by the time I see them. Many, because of cognitive deficits, don’t have the capacity to plan and carry out their threats. To send such patients to an ED, where they sit for long hours before returning to their residence, is a waste of resources and is traumatic.
If a patient with quadriplegia says he is going to jump off a bridge, we must assess how realistic the plan is—even though unlikely. We must not, however, underestimate the creativity some patients have. One patient in long-term care stuffed toilet and tissue paper down his throat continuously in an attempt to block his airway. He was discovered in time.
Many patients tell me they were angry and didn’t mean what they said. “It's just an expression,” they say. Some see making suicidal threats as a way to “get attention.” I explain to them that such statements are taken seriously in long-term-care settings and coach them on how to express their feelings appropriately. For example, saying “I’m upset that I had to wait 20 minutes to go to the bathroom” is a better way to voice frustration than “I’ll kill myself if I have to wait again.”
I also receive medication assessment requests from psychotherapists who tell me the patient is very depressed. When I see the patients, they are eating well, sleeping, and attending activities; they have interests and deny thoughts of death. When given the Patient Health Questionnaire-9 (PHQ-9) test, they score below 4.
Verbalizing feelings of depression can be a significant symptom, but diagnosis of depression requires that several criteria be met and for specific periods of time. “I’m depressed” can mean many things, including I’m bored, lonely, or in need of a friend. A thorough assessment and support may be all that such patients need to feel better and avoid making provocative statements that lead to unneeded medication and treatment. RNL
Michael C. LaFerney, PhD, RN, PMHCNS-BC, is a psychiatric clinical nurse specialist at Arbour SeniorCare in Haverhill, Massachusetts, USA.