New Insights on Suicide Care from a Nursing Perspective

Research Paper Title

Suicide care from the nursing perspective: A meta-synthesis of qualitative studies.


To explore nurses’ experiences of suicide care and to identify and synthesize the most suitable interventions for the care of people with suicidal behaviour from a nursing perspective. A qualitative meta-synthesis.


Comprehensive search of five electronic databases for qualitative studies published between January 2015 and June 2019.

The PRISMA statement was used for reporting the different phases of the literature search and the Critical Appraisal Skills Programme (CASP) qualitative research checklist was used as an appraisal framework. Data synthesis was conducted using Sandelowski and Barroso’s method.


Seventeen articles met the inclusion criteria. The data analysis revealed 13 subcategories from which four main categories emerged: ‘Understanding suicidal behaviour as a consequence of suffering’, ‘Nurses’ personal distress in suicide care’, ‘The presence of the nurse as the axis of suicide care’ and, ‘Improving nurses’ relational competences for a better therapeutic environment’.


Further training of nurses on the therapeutic relationship, particularly in non-mental health care work settings, and monitoring of the emotional impact on nurses in relation to suicide is required to promote more effective prevention and care.


This review provides new insights on how suicide is interpreted, the associated emotions, the way suicide is approached and proposals for improving clinical practice from the point of view of nurses. The results demonstrate that the nurse-patient relationship, ongoing assessment, and the promotion of a sense of security and hope are critical in nursing care for patients who exhibit suicidal behaviour. Consequently, to promote an effective nursing care of suicide, nurses should be provided with further training on the therapeutic relationship. Thus, health institutions do not only provide the time and space to conduct an adequate therapeutic relationship, but also, through their managers, they should supervise and address the emotional impact that is generated in nurses caring for patients who exhibit suicidal behaviour.


Clua-Garcia, R., Casanova-Garrigos, G. & Moreno-Poyato, A.R. (2021) Suicide care from the nursing perspective: A meta-synthesis of qualitative studies. Journal of Advanced Nursing. doi: 10.1111/jan.14789. Online ahead of print.

What are the Correlates of Suicidal Ideation & Behaviours Among Former Military Personnel Not Enrolled in the Veterans Health Administration?

Research Paper Title

Correlates of Suicidal Ideation and Behaviours Among Former Military Personnel Not Enrolled in the Veterans Health Administration.


The current study sought to explore suicidal concomitants, both demographic and psychological, among former military personal.


The sample included 645 veterans who are at increased risk for suicide but have not yet pursued Veterans Health Administration (VHA) services.


Descriptive statistics revealed that these veterans are primarily young Caucasian males who served in the US Army.

In terms of psychological characteristics, the current sample reported clinically significant levels of depression, post-traumatic stress, and insomnia.

Furthermore, respondents acknowledged use of various substances and high levels of perceived burdensomeness and thwarted belongingness.


The demographic and psychological makeup of the researchers sample was somewhat similar to that of VHA-connected veterans except that their sample was slightly more educated and reported less physical pain.


Raines, A.M., Allan, N.P., Franklin, C.L., Huet, A. Constans, J.I. & Stecker, T. (2020) Correlates of Suicidal Ideation and Behaviors Among Former Military Personnel Not Enrolled in the Veterans Health Administration. Archives of Suicide Research. 24(4), pp.517-533. doi: 10.1080/13811118.2019.1660286. Epub 2019 Dec 2.

Book: Reasons to Stay Alive

Book Title:

Reasons to Stay Alive.

Author(s): Matt Haig.

Year: 2015.

Edition: First (1st).

Publisher: Canongate Books Ltd.

Type(s): Hardcover, Paperback, Audiobook, and Kindle.


Aged 24, Matt Haig’s world caved in. He could see no way to go on living. This is the true story of how he came through crisis, triumphed over an illness that almost destroyed him and learned to live again.

A moving, funny and joyous exploration of how to live better, love better and feel more alive, Reasons to Stay Alive is more than a memoir. It is a book about making the most of your time on earth.

“I wrote this book because the oldest clichés remain the truest. Time heals. The bottom of the valley never provides the clearest view. The tunnel does have light at the end of it, even if we haven’t been able to see it . . . Words, just sometimes, really can set you free.”

Book: Suicide Prevention Handbook

Book Title:

Suicide Prevention Handbook: A Mental Health Guide For Saving Lives.

Author(s): Ben Oakley.

Year: 2020.

Edition: First (1st).

Publisher: Independently Published.

Type(s): Paperback and Kindle.


The book includes our detailed four-step guide for suicide prevention:

  • Warning Signs include social signs, personal signs and planning signs.
  • Risk Factors include isolation and social inequality, violence or abuse, self-harm and mental health disorders.
  • Intervention includes social intervention, personal intervention including exactly what to say to start a mental health conversation and how to seek help.
  • Coping Strategies include distraction, grounding and relaxation.

With real-world examples and concrete ways of how to help yourself or another.

Many mental health advocates and organisations recommend you talk about mental health but they don’t tell you how to get the conversation started. This book provides you with Conversation Starters, Direct Questions, Indirect Questions, Example Lists, Guidance and ways to move a conversation from negative emotions to positive ones.

Along with the extensive four-step suicide prevention handbook, there is a guide to writing your own suicide prevention life plan with tips on creating priorities, goals, action plans and how to write it.

You’ll also find a list of UK mental health organisations, what not to say, myths debunked and a series of essays about the misconception of man.

Supreme Movement is a mental health awareness social enterprise in the United Kingdom whose mission is to raise awareness of mental health issues, specifically suicide and self-harm among males.

Ben Oakley is an established non-fiction author, researcher, mental health advocate and founder of Supreme Movement.

Book: Critical Suicidology

Book Title:

Critical Suicidology: Transforming Suicide Research and Prevention for the 21st Century.

Author(s): Jennifer White, Ian Marsh, Michael J. Kral, and Jonathan Morris (Editors).

Year: 2015.

Edition: First (1st).

Publisher: UBC Press.

Type(s): Paperback and EPUB.


This book is a must-read for practitioners, policy makers, and researchers working in mental health services, psychology, counselling, social work, psychiatry, medicine, philosophy, sociology, suicidology, feminism, anthropology, critical disability studies, and cultural studies.

Book: Ferment – A Memoir of Mental Illness, Redemption, and Winemaking in the Mosel

Book Title:

Ferment – A Memoir of Mental Illness, Redemption, and Winemaking in the Mosel.

Author(s): Patrick Dobson.

Year: 2020.

Edition: First (1st).

Publisher: Skyhorse Publishing.

Type(s): Hardcover and Kindle.


A deeply moving account of one man’s return to the German town where he first pursued a career in winemaking, and his attempt to reckon with the mental illness, alcoholism, and enduring relationships that defined the most formative chapter of his life.

After an attempted suicide by hanging – with his son in the next room – author Patrick Dobson checks into a mental hospital, clueless, reeling from bone-crushing depression and tortuous, racing thoughts. A long overdue diagnosis of manic depression offers relief but brings his confused and eventful past into question.

To make sense of his suicide attempt and deal with his past, he returns to Germany where, three decades earlier, he arrived as twenty-two-year-old – lost, drunk, and in the throes of untreated mental illness – in search of a new life and with dreams of becoming a winemaker. The sublime Mosel vineyards and the ancient city of Trier changed his life forever.

Ferment charts his days in Trier’s vineyards and cellars, and the enduring friendships that would define his life. A winemaker and his wife become like parents to him. In their son, he finds a brother, whose death years later sends Dobson into a suicidal tailspin. His friends, once apprentices like himself, become leaders in their fields: an art historian and church-restoration expert, an art- and architectural-glass craftsman, a painter and photographer, and a theologian/journalist. The relationships he builds with them become hallmarks of a life well-lived.

In Ferment, Dobson reconnects with the people who stood by him through his dissolution and eventual recovery. In these relationships, he seeks who he was and how his time in Germany changed him. He peers into his memory to understand how manic depression and alcoholism affected who he was then and how his time in Germany made him who he’s become.

World Suicide Prevention Day


World Suicide Prevention Day (WSPD) is an awareness day observed on 10 September every year, in order to provide worldwide commitment and action to prevent suicides, with various activities around the world since 2003.

The International Association for Suicide Prevention (IASP) collaborates with the World Health Organisation (WHO) and the World Federation for Mental Health (WFMH) to host World Suicide Prevention Day.

In 2011 an estimated 40 countries held awareness events to mark the occasion. According to WHO’s Mental health Atlas released in 2014, no low-income country reported having a national suicide prevention strategy, while less than 10% of lower-middle income countries, and almost a third of upper-middle and high-income countries had.

On its first event in 2003, the 1999 WHO’s global suicide prevention initiative is mentioned with regards to the main strategy for its implementation, requiring:

  1. “The organisation of global, regional and national multi-sectoral activities to increase awareness about suicidal behaviours and how to effectively prevent them.”
  2. “The strengthening of countries’s capabilities to develop and evaluate national policies and plans for suicide prevention.”

As of recent WHO releases, challenges represented by social stigma, the taboo to openly discuss suicide, and low availability of data are still to date obstacles leading to poor data quality for both suicide and suicide attempts: “given the sensitivity of suicide – and the illegality of suicidal behaviour in some countries – it is likely that under-reporting and misclassification are greater problems for suicide than for most other causes of death.”


An estimated one million people per year die by suicide or about one person in 10,000 (1.4% of all deaths), or “a death every 40 seconds or about 3,000 every day”. As of 2004 the number of people who die by suicide is expected to reach 1.5 million per year by 2020.

On average, three male suicides are reported for every female one, consistently across different age groups and in almost every country in the world. “Conversely, rates of suicide attempts tend to be 2-3 times higher in women than in men, although the gender gap has narrowed in recent years.” More people die from suicide than from murder and war; it is the 13th leading cause of death worldwide. According to the WHO there are twenty people who have a suicide attempt for every one that is fatal, at a rate approximately one every three seconds. Suicide is the “most common cause of death for people aged 15 – 24.”

According to the WHO, suicide accounts for nearly half of all violent deaths in the world. Brian Mishara, IASP president, noted that, “more people kill themselves than die in all wars, terrorist acts and interpersonal violence combined.” As of 2008, the WHO refers the widest number of suicides occur in the age group 15 – 29, while the lowest in the 80+ although representing as well the one with the highest rate (per 100,000) of all age groups, with 27.8 suicides and 60.1 for females and males respectively. In 2015 the reported global age-standardised rate is 10.7 per 100,000.

Social norms play a significant role in the development of suicidal behaviours. Late 19th century’s sociological studies recorded first ever observations on suicide: with statistics of the time at hand, sociologists mentioned the effects of industrialisation as in relations between new urbanised communities and vulnerability to self-destructive behaviour, suggesting social pressures have effects on suicide. Today, differences in suicidal behaviour among different countries can be significant.


  • 2003 – Suicide Can Be Prevented!.
  • 2004 – Saving Lives, Restoring Hope.
  • 2005 – Prevention of Suicide is Everybody’s Business.
  • 2006 – With Understanding New Hope.
  • 2007 – Suicide prevention across the Life Span.
  • 2008 – Think Globally, Plan Nationally, Act Locally.
  • 2009 – Suicide Prevention in Different Cultures.
  • 2010 – Families, Community Systems and Suicide.
  • 2011 – Preventing Suicide in Multicultural Societies.
  • 2012 – Suicide Prevention across the Globe: Strengthening Protective Factors and Instilling Hope.
  • 2013 – Stigma: A Major Barrier to Suicide Prevention.
  • 2014 – Light a candle near a Window.
  • 2015 – Preventing Suicide: Reaching Out and Saving Lives.
  • 2016 – Connect, Communicate, Care.
  • 2017 – Take a Minute, Change a Life.
  • 2018 – Working Together to Prevent Suicide.
  • 2019 – Working Together to Prevent Suicide.
  • 2020 – Working Together to Prevent Suicide.


Suicide prevention’s priorities, as declared on the 2012 World Suicide Prevention Day event, are stated below:

  • We need to continue to research suicide and non-fatal suicidal behaviour, addressing both risk and protective factors.
  • We need to develop and implement awareness campaigns, with the aim of increasing awareness of suicidal behaviours in the community, incorporating evidence on both risk and protective factors.
  • We need to target our efforts not only to reduce risk factors but also to strengthen protective factor, especially in childhood and adolescence.
  • We need to train health care professionals to better understand evidence-based risk and protective factors associated with suicidal behaviour.
  • We need to combine primary, secondary and tertiary prevention.
  • We need to increase use of and adherence to treatments shown to be effective in treating diverse conditions; and to prioritise research into effectiveness of treatments aimed at reducing self-harm and suicide risk.
  • We need to increase the availability of mental health resources and to reduce barriers to accessing care.
  • We need to disseminate research evidence about suicide prevention to policy makers at international, national and local levels.
  • We need to reduce stigma and promote mental health literacy among the general population and health care professionals.
  • We need to reach people who do not seek help, and hence do not receive treatment when they are in need of it.
  • We need to ensure sustained funding for suicide research and prevention.
  • We need to influence governments to develop suicide prevention strategies for all countries and to support the implementation of those strategies that have been demonstrated to save lives.


Suicide has a number of complex and interrelated and underlying contributing factors … that can contribute to the feelings of pain and hopelessness. Having access to means to kill oneself – most typically firearms, medicines and poisons – is also a risk factor.

The main suicide triggers are:

  • Poverty;
  • Unemployment;
  • The loss of a loved one;
  • Arguments; and
  • Legal or work-related problems.

Suicide results from many complex sociocultural factors and is more likely to occur during periods of socioeconomic, family and individual crisis (e.g. loss of a loved one, unemployment, sexual orientation, difficulties with developing one’s identity, disassociation from one’s community or other social/belief group, and honour).

In richer countries, three times as many men die of suicide than women do, but in low- and middle-income countries the male-to-female ratio is much lower at 1.5 men to each woman.

In the United States, for example, males are four times more likely to die from suicide than are females. However, females are more likely to attempt suicide than are males.

The disparity in suicide rates has been partly explained by the use of more lethal means and the experience of more aggression and higher intent to die in men than women.

Physical and especially mental health disabling issues such as depression, are among the most common of the long list of complex and interrelated factors, ranging from financial problems to the experience of abuse, aggression, exploitation and mistreatment, that can contribute to the feelings of pain and hopelessness underling suicide. Usually substances and alcohol abuse also play a role.

Prevention strategies generally emphasise public awareness towards social stigma and suicidal behaviours.

Cultural and Religious Attitudes

In much of the world, suicide is stigmatised and condemned for religious or cultural reasons.

In some countries, suicidal behaviour is a criminal offence punishable by law. Suicide is therefore often a secretive act surrounded by taboo, and may be unrecognised, misclassified or deliberately hidden in official records of death.

Stigma, particularly surrounding mental disorders and suicide, means many people thinking of taking their own life or who have attempted suicide are not seeking help and are therefore not getting the help they need.

The prevention of suicide has not been adequately addressed due to a lack of awareness of suicide as a major public health problem and the taboo in many societies to openly discuss it.

Raising community awareness and breaking down the taboo is important for countries to make progress in preventing suicide.


Developing a Behavioural Health Readiness & Suicide Risk Reduction Review for Military Personnel

Research Paper Title

Development of the US Army’s Suicide Prevention Leadership Tool: The Behavioural Health Readiness and Suicide Risk Reduction Review (R4).


Although numerous efforts have aimed to reduce suicides in the US Army, completion rates have remained elevated.

Army leaders play an important role in supporting soldiers at risk of suicide, but existing suicide-prevention tools tailored to leaders are limited and not empirically validated.

The purpose of this article is to describe the process used to develop the Behavioral Health Readiness and Suicide Risk Reduction Review (R4) tools for Army leaders that are currently undergoing empirical validation with two US Army divisions.


Consistent with a Secretary of the Army directive, approximately 76 interviews and focus groups were conducted with Army leaders and subject matter experts (SMEs) to obtain feedback regarding existing practices for suicide risk management, leader tools, and institutional considerations.

In addition, reviews of the empirical literature regarding predictors of suicide and best practices for the development of practice guidelines were conducted. Qualitative feedback, empirical predictors of suicide, and design considerations were integrated to develop the R4 tools.

A second series of 11 interviews and focus groups with Army leaders and SMEs was also conducted to validate the design and obtain feedback regarding the R4 tools.


Leaders described preferences for:

  • Tool processes (e.g. incorporating engaged leadership, including multiple risk identification methods);
  • Formatting (e.g. one page);
  • Organisation (e.g. low-intermediate-high risk scoring system);
  • Content (e.g. excluding other considerations related to vehicle safety, including readiness implications); and
  • Implementation (e.g. accounting for leadership judgement, tailoring process to specific leadership echelons, consideration of institutional barriers).

Evidence-based predictors of suicide risk and practice guideline considerations (e.g. design) were integrated with leadership feedback to develop the R4 tools that were tailored to specific leadership echelons.

Leaders provided positive feedback regarding the R4 tools and described the importance of accounting for potential institutional barriers to implementation. This feedback was addressed by including recommendations regarding the implementation of standardized support meetings between different echelons of leadership.


The R4 development process entailed the simultaneous integration of leadership feedback with evidence-based predictors of suicide risk and design considerations.

Thus, the development of these tools builds upon previous Army leadership tools by specifically tailoring elements of those tools to accommodate leader preferences, accounting for potential implementation barriers (e.g. institutional factors), and empirically evaluating the implementation of those tools.

Future studies should consider utilising a similar process to develop empirically based resources that are more likely to be incorporated into the routine practice of leaders supporting soldiers at risk of suicide, very often located at the company level and below.


Curley, J.M., Penix, E.A., Srinivasan, J., Sarmiento, D.S., McFarling, L.H., Newman, J.B. & Wheeler, L.A. (2020) Development of the U.S. Army’s Suicide Prevention Leadership Tool: The Behavioral Health Readiness and Suicide Risk Reduction Review (R4). Military Medicine. 185(5-6), pp.e668-e677. doi: 10.1093/milmed/usz380.

Suicide Screening and Prevention

Reseach Paper Title

Suicide Screening and Prevention.


Suicide is a major public health problem not only in the United States (US) but in many western nations as well.

In the US, it is the 10th leading cause of death, accounting for nearly 44,000 deaths each year. Suicide is also the seventh leading cause of years of potential loss of life, surpassing liver disease, diabetes, and HIV.

Each year, nearly half a million individuals present to the emergency departments in the US following attempted suicide.

Data indicate that nearly 1 out of every 7 young adults admits to having some type of suicidal ideation at some point in their lives and at least 5% have made a suicide attempt.

Suicide has repercussions way beyond the affected individual. It costs the US healthcare system over $70 billion, and untold billions of dollars are lost by the families who are affected, in terms of loss of earning.

Suicides are at an all-time high and affect both genders. Men are nearly 3.5 times more likely than women to commit suicide, and on average 123 people kill themselves every day.

The World Health Organisation (WHO) has predicted that in the next 2 years, depression will be the leading cause of disability globally. Depression is not only a North American phenomenon but is now being diagnosed in almost every nation. The annual prevalence of major depressive disorders in North America is 4.5%, but this is a gross underestimate because many individuals do not seek medical help. Depression is a serious medical disorder and associated with a high risk of suicide. Data reveals that more than 90% of individuals with a major depressive disorder do see a healthcare provider within the first 12 months of the episode and at least 45% of suicide victims have had some contact with a primary health care provider within the 4 weeks of suicide.

This indicates that if their healthcare providers are more vigilant and alert, suicide could be prevented in these individuals. These grim statistics have led to a National Strategy for Suicide Prevention in the US.

Considering that many individuals who commit suicide have a mental health disorder and have visited their primary caregiver, the focus now is on health care providers to become aware of the factors that increase the risk of suicide and to refer these individuals to mental health professionals for some type of intervention.

The current United States Preventive Services Task Force (USPSTF) recommendations are that primary caregivers should screen adolescents and adults for depression only when there are appropriate systems in place to ensure adequate diagnosis, treatment, and follow-up.


Many factors have been identified in individuals who commit suicides or have attempted suicide. These factors include the following:

  • Advanced age.
  • Availability of a firearm.
  • Chronic illness.
  • A family history of suicides.
  • Financial difficulties.
  • Negative life experiences.
  • Loss of job.
  • Marital status divorced.
  • Medications.
  • Mental illnesses such as depression, anxiety, post-traumatic stress disorder (PTSD).
  • Pain that is continuous.
  • A physical illness that has led to disability.
  • Race: white.
  • Gender: Male.
  • Social media.
  • Stress.
  • A sense of no purpose in life.

Other Risk Factors for Suicide

Over the years, several other factors have been identified that increases the risk of suicide and they include:

  • Major childhood adverse events, for example, sexual abuse.
  • Discriminated for being gay, lesbian, transgender or bisexual.
  • Having access to lethal means.
  • A long history of being bullied.
  • Chronic sleep problems.

In Males and Older Individuals

  • Loss of job or unemployment.
  • Low income.
  • Neurosis.
  • Social isolation.
  • Spousal loss, bereavement.
  • Affective disease.
  • Functional impairment.
  • Physical illness.

Military Personnel

  • Traumatic brain injury.
  • PTSD.
  • Other mental health issues.

The most important thing to understand is that having just one risk factor has very limited predictive value. Millions of Americans have one of these factors at any one point in time, but very few attempt suicide and even fewer die as a result. One has to look at the entire clinical picture to increase the predictive values of these risk factors.


Which type of mental health disorder is associated with an increased risk of suicide?

Accumulated data reveal that many types of mental health disorders have been associated with an increased risk of suicide and they include the following:

  • Major depression.
  • Schizophrenia.
  • Substance abuse.
  • Alcoholism.
  • Post-traumatic stress disorder.
  • Bipolar disorder.
  • Personality disorders.
  • Emotional stress.
  • Medications and Suicides.

You can read further @


O’Rourke, M.C., Jamil, R.T. & Siddiqui, W. (2020) Suicide Screening and Prevention. Treasure Islan, Florida: StatPearls Publishing.

Factors Affecting the Usefulness of the Acquired Capability for Suicide Scale among US Military & Veterans

Research Paper Title

Use of the acquired capability for suicide scale (ACSS) among United States military and Veteran samples: A systematic review.


Military personnel and Veterans are at increased risk for suicide.

Theoretical and conceptual arguments have suggested that elevated levels of acquired capability (AC) could be an explanatory factor accounting for this increased risk.

However, empirical research utilising the Acquired Capability for Suicide Scale (ACSS) in military populations has yielded mixed findings.


To better ascertain what factors are associated with AC, and whether methodological limitations may be contributing to mixed findings, a systematic review was conducted.


A total of 31 articles utilised the ACSS to examine factors associated with AC, including combat history, in US military personnel and Veterans.

Nearly all studies (96.8%) were rated high risk of bias.

Use of the ACSS varied, with seven different iterations utilised.

Nearly all studies examined correlations between the ACSS and sample characteristics, mental health and clinical factors, Interpersonal Theory of Suicide constructs, and/or suicide-specific variables.

Results of higher-level analyses, dominated by cross-sectional designs, often contradicted correlational findings, with inconsistent findings across studies.


Included studies were non-representative of all US military and Veteran populations and may only generalise to these populations.

Due to the high risk of bias, inconsistent use of the ACSS, lack of sample heterogeneity, and variability in factors examined, interpretation of current ACSS empirical data is cautioned.

Suggestions for future research, contextualised by these limitations, are discussed.


Kramer, E.B., Gaeddert, L.A., Jackson, C.L., Harnke, B. & Nazem, S. (2020) Use of the acquired capability for suicide scale (ACSS) among United States military and Veteran samples: A systematic review. Journal of Affective Disorders. 267, pp.229-242. doi: 10.1016/j.jad.2020.01.153. Epub 2020 Jan 29.