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Washington Suicide Prevention Training

Introduction   

Defined as a harmful act to end one’s own life, suicide is a mental health emergency (25). In 2021, suicide claimed over 48,000 lives in the United States alone. That is approximately 130 individuals daily, and one life every 11 minutes (8). It is reported that in 2021, 12.3 million American adults considered suicide while 3.5 million made a plan, and 1.7 million made an attempt. Of those that complete suicide, 46% had a known or diagnosed mental disorder (23). In comparing this data to other medical conditions, suicide was the 11th cause of death in the United States as reflected in the chart below (5) [See figure 1]. 

Figure 1: Leading Causes of Death in the U.S. in 2021 (5) 

In the United States, Wyoming, Montana, and Alaska all have the highest rates of suicide, over 30 per 100,000 deaths, while New York and New Jersey have the lowest, 7.9 and 7.1 per 100,000 deaths respectively (7). Washington state ranks 27th on this list with 1,229 deaths or 15.3 in the year 2021 (7). Age wise, those 85 years and older had the highest rate of suicide in 2021 at a rate of 22.4 per 100,000. Chart 2 reflects suicide rates among Americans aged 10 to 85+ (7) [See figure 2]. Race and gender must also be considered when discussing suicide. Chart 3 discusses suicide rates based on race [See figure 3], while Chart 4 discusses rates by gender [See figure 4]. 

Figure 2: Suicide Rates by Age in the U.S. (7) 

Figure 3: Suicide Rates by Race in the U.S. (7) 
 

Figure 4: Suicide Rate by Gender in the U.S. (7) 

Suicide is a leading cause of death on a global level with more deaths than human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome (AIDS), breast cancer, war, homicide, or malaria. The World Health Organization reports that an estimated 703,000 individuals die from suicide each year, approximately one in every 100 individuals. However, this number could be higher due to the COVID-19 pandemic and risk factors that were exacerbated during the pandemic: isolation, anxiety, loss of job, and financial stress (40).  

Low and middle income countries see higher rates of suicide at approximately 77%. Within the past 45 years, the global suicide rate has increased 60%. For those ages 15 to 29, suicide is the fourth leading cause of death—behind road death, tuberculosis, and interpersonal violence—with it being the third leading cause of death in females and the fourth in males (40).  

Terminology 

Using proper definitions to clearly understand what is being discussed is important when discussing suicide. Providers may use certain words or phrases and mean different things. By having clear definitions that are universally used, providers can understand what other providers are conveying and continue care in an appropriate manner. Below is a list of commonly used terms when referring to suicide.  

Table 1: Commonly Used Terms When Referring to Suicide (11, 21, 29) 

Suicide Assessment 

Healthcare providers perform a variety of assessments on their patients: cardiac assessment, respiratory assessments, neurological assessments, etc. Just as those assessments help providers decide what treatment needs to be done, the suicide assessment is utilized to evaluate a variety of factors that can increase an individual’s risk for suicide.  

The latest guidelines from the American Psychiatric Association have clear goals of the suicide assessment: (17) 

• Identify any psychiatric signs and symptoms 
• Assess past suicidal behavior 
• Review any available past treatment  
• Determine if there is a family history of suicide or mental illness in the family 
• Identify the patient’s current psychosocial situation and the cause of the current crisis 
• Recognize strengths or coping skills and any opportunities for improvement that the patient has 

With the suicide assessment, there are five areas of questions that the American Psychiatric Association discusses with examples as to what is being looked for in each area (17). These areas can be found below:  

Table 2: American Psychiatric Association Suicide Assessment (17) 

The Interview: Gathering Information 

Conducted in a private place, the suicide assessment is an interview of the patient. Providers must ensure that they ask the right questions based on information provided to them by the patient or those that are accompanying the patient. Empathy, compassion, and trust must be integrated in these interviews. Below is a list of questions that can be used during the interview process. It is important to follow your facility’s specific policies and procedures regarding the suicide assessment and use the proper screening tools. Some common screening tools utilized in healthcare will be discussed later.  

Table 3: Suicide Assessment Interview Questions (17)  

It is important to keep in mind that the answers to these questions are self-reported, so patients may not be honest for any reason. Providers should pair answers given during the interview with objective data they collect through observation and past medical records. Family, friends, and partners can be a source of information; however, providers should consider collecting information with these individuals separately.  

Columbia-Suicide Severity Rating Scale: 

Also known as the Columbia Protocol, the Columbia-Suicide Severity Rating Scale was created by Columbia University, University of Pittsburgh, and University of Pennsylvania to be used during a 2007 National Institute of Mental Health study to decrease the suicide risk in adolescents with depression. The Centers for Disease Control and Prevention began using this protocol and recommending it be used in data collection in 2011. The next year, the Food and Drug Administration stated the Columbia Protocol was the standard for measuring and assessing suicidal behaviors and ideation in clinical trials (33).  

The Columbia Protocol is used to assist providers and laypersons in determining if an individual is at risk for suicide. These questions are worded in plain language to ensure this scale can be administered by anyone, regardless of profession. This scale questions individuals about the following information: (33) 

• If and when they have had any suicidal ideation or thoughts 
• Any action they have taken to prepare for suicide and when they have done so 
• If they have attempted suicide or started a suicide attempt that they interrupted or someone else did  

The image below [See figure 5] is the six-question Columbia Protocol that can be used by anyone in assessing suicide risk. The far-right column is color coded based on severity if they answer “yes” to the question. Yellow is low-risk, orange is medium-risk, and red is high-risk. The answers the individual gives will guide the interventions needed. If the individual answers “yes” to questions two or three, behavioral healthcare should be sought out. If the individual answers “yes” to questions four, five, or six immediate help is needed. Those asking the questions should call the suicide and crisis lifeline, 911, or take the individual to the nearest emergency department. The individual should not be left alone until an evaluation has been done (33).   

Figure 5: Columbia-Suicide Severity Rating Scale (Columbia Protocol) (33) 

Suicide Assessment Five-step Evaluation and Triage: 

The Suicide Assessment Five-step Evaluation and Triage consists of five questions that identifies risk and protective factors, risk levels and interventions, suicide inquiry, and documentation of treatment plans. This tool was created by Douglas Jacobs, MD, the physician who assisted in creating the suicide assessment published by the American Psychiatric Association (31). The five questions include: 

1. Identify risk factors with attention to those that can be modified. 
2. Identify protective factors and those that can be enhanced. 
3. Complete a suicide inquiry by asking about thoughts, plans, intent, and behavior. 
4. Determine risk level and any interventions that are appropriate for the risk level and attempt to reduce risk. 
5. Document as appropriate to include risk and rationale, interventions, and any follow-up that is needed. 

The Suicide Assessment Five-step Evaluation and Triage can be combined with the Columbia Suicide-Severity Rating Scale (C-SSRS) to expand on the benefits of both tools (34).  

Questions one through six from the C-SSRS all have an option for “yes” or “no,” If question two is a no, questions three through five can be skipped. After the C-SSRS questions have been asked, further assessment can be directed to precipitating events, clinical status presentation/statements, past treatment history, and any other relevant information. Providers also want to assess for access to lethal means by asking specifically about the presence of firearms in the home or how easy it would be to obtain a firearm (34).  

The next step is to identify protective factors the individual has. These can be internal or external factors that the individual has that can provide support. Internal factors can consist of fear of death, or reasons for living while external factors can consist of responsibility to family or friends, supportive social network, or interacting and engaging at work and/or school (34). 

Step three is the C-SSRS Suicidal Ideation Intensity screening questions that consists of thoughts, plans, and suicidal intent. Questions focus on frequency of thoughts, duration of how long the individual has had these thoughts, controlling the thoughts, if there is anything that the individual can do to deter the thoughts, and the reason for the suicidal ideation (34). 

Ask Suicide-Screening Questions 

The Ask Suicide-Screening Questions consists of the Suicide Risk Screening Tool that can be administered in the emergency department, inpatient medical unit, outpatient, primary care, or specialty provider offices as well as schools and juvenile detention centers. All questions are “yes” or “no” with additional open-ended questions if the individual answers “yes” (24) [See figure 6].  

Figure 6: Ask Suicide-Screening (24)

The answers provided will guide treatment/interventions. If the individual answers “no” to questions one through four, no intervention is needed. If they answer “yes” to any of the questions, question five must be asked since the individual is said to have a positive screen. If question five has a “yes” response, an imminent risk is identified, or they are an acute positive screen. The patient needs a safety or full mental health evaluation before they are able to leave. Immediate interventions that must be considered are keeping the patient in eyesight at all times, removing items that could be used to harm/kill self or others, notify the provider that is responsible for the individual’s care (24). 

You may wonder what to do if the individual answers “yes” to any of questions one through four but does not answer “yes” to question five. This means the individual is a non-acute positive screen and there is a potential risk identified. A brief suicide screen must be done in order to determine if a full mental health evaluation needs to be completed. The individual is not allowed to leave until they have been assessed for safety, and the provider must be notified (24).  

Depending on where the individual is when asking these questions, there are some additional questions that need to be asked regarding safety and safety plans. The links below will take you to the safety screening tools based on the location of the individual being assessed (24).  

Emergency Department Suicide Safety Assessment 

Inpatient Medical Unit 

Outpatient, Primary Care Provider, Specialty Provider Office 

Patient Health Questionnaire 

Since depression is often a risk factor for suicide, the Patient Health Questionnaire (PHQ-9) is used to measure, screen, monitor, and diagnose depression severity. This screening utilizes diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders 4th edition and rates the frequency of the individual’s symptoms. Question nine focuses on the presence and duration of suicidal thoughts while a non-scored question assigns and screens how much depression is affecting the individual’s activities of daily life and function. The minimum score is five while the maximum is 27. Anything greater than 20 has a provisional diagnosis of major/severe depression with a treatment recommendation of antidepressants and psychotherapy (27) [See figure 7] 

Figure 7: Patient Health Questionnaire (PHQ-9) Results Interpretation (27) 

The screening answer options include: not at all = 0, several days = 1, more than half the days = 2, and nearly every day = 3. The questions are as follows: (27) 

• Little pleasure or interest in doing things 
• Feeling hopeless, depressed, or down 
• Difficulty sleeping, staying asleep, or sleeping too much 
• Having too little energy or feeling tired 
• Overeating or a poor appetite 
• Feeling bad about yourself, or that your family sees you as a failure or that you have let them down 
• Having difficulty concentrating on things, like reading a book or watching a movie/television 
• Either being too fidgety or restless or moving/speaking slowly that you and/or others notice 
• Thoughts that you would be better off dead or thoughts of hurting yourself 
• Non-scored question: If you selected any of the above problems, how difficult have those problems made it for you to complete work, get along with family, friends, or manage things at home? (Answers options include: not difficult at all, somewhat difficult, very difficult, extremely difficult). 

Suicide Risk, Protectives Factors, and Warning Signs  

Risk factors for suicide can appear in a variety of ways: individual, relationships, community, society. These are factors that increase an individual’s risk for suicide through different means. For example, stay at home orders and quarantining during the initial phases of the COVID-19 pandemic led to isolation, which is a risk factor of suicide. Combining this with other risk factors increases the chance of an individual taking action to end their life (6).  

Table 4: Criteria for Low and High Suicide Risks (3, 4) 

Gender 

Per research, men are four times as likely to die as a result of suicide as opposed to women. This is regardless of religion, marital status, or race. However, women are three times as likely to have thoughts of suicide and/or attempt suicide than men. Research deducts that this is because the differences in attempt methods between women and men (3). Studies show that 30% of transgender youth in the United States have attempted suicide in their lifetime while 40% of adults who identify as transgender have attempted (15).  

Age 

Suicide rates increase with age. Individuals who have not gone through puberty are very unlikely to attempt or die by suicide as opposed to those that have gone through puberty. Age 45 is when suicide rates are the highest among men while it is highest in women after 55. Those over the age of 65 or who are considered elderly are less likely to attempt suicide, but they are more successful when they make an attempt. As we pointed out earlier, suicide is increasing among the young population: it is the third leading cause of death among individuals aged 15-24 (3).  

Marital Status 

Individuals who are married and have children have a lesser likelihood than their single counterparts. Those that are single or never married have a risk two times higher than those that are married (8). Divorce suicide rates in men are three times more than women. Some individuals may attempt or die by suicide on the anniversary of a loved one’s death (3). 

Sexual Orientation 

Homosexual and heterosexual individuals have differences in suicide rates. Those that identify as homosexual, regardless of marital status, do have higher rates of suicide (3).  

Race/Ethnicity 

Caucasian individuals, regardless of gender, are three times more likely to die by suicide as opposed to African Americans. Young Alaskan Natives or Native Americans have higher than the national average rates of death by suicide (22). Moving on to immigrants, the rates are much higher than citizens of the United States (40).  

Religion 

Many religions have negative views on suicide. Despite that, religious groups such as Protestants and Jews have higher rates of suicide than Muslim and Catholics combined. It is important to note that religion alone is not an accurate indicator of suicide, but the inclusion and societal integration and beliefs are better predictive factors (3).  

Occupation 

Increases in socioeconomic status increase the risk of suicide in any individual. It is noted that being employed is one protective factor, and while true, there are some occupations that increase the risk. Lawyers, healthcare providers, mechanics, artists, and insurance agents are classified as high-risk occupations. On the other hand, unemployment brings an increased risk of suicide in comparison to those that are employed. Providers should be aware that suicide risk increases during economic depressions and decreases during economic booms (3). 

Physical Health 

Good physical health is vital to good mental health and wellbeing as poor physical health contributes to at least half of all suicides. Thirty percent of those who died by suicide saw a provider within the past six months prior. Physical effects that increase risk factors include disfigurement, loss of mobility, and chronic pain. If these effects impact the individual’s relationships and/or work life, that can increase suicide risk even more (3).  

Mental Health 

Almost 95% of those who die by suicide have at least one diagnosed mental health disorder. Depressive disorders like major depressive disorder account for 80% of all suicides, and a diagnosis of delusional depression comes with the highest risk of suicide. Those with schizophrenia have a 10% risk, while those with delirium or dementia have a 5% risk of suicide. Alcohol dependency is found in over one fourth of suicide cases (3).  

Substance Abuse 

As mentioned earlier, alcohol or other substances can play a large factor in suicide. The use of any substance can lead to impairment of judgement, sedation, or manic behavior that can lead to respiratory depression or self-injury (19).  

If there is a suspicion of substance abuse, it is important to consider discussing these concerns with patients in a non-threatening, non-judgmental manner (19). Providers should start with questions regarding socially acceptable habits: exercise or dieting, caffeine, and tobacco can help ease the patient into comfort. This is something that should be done as standard procedure for all patients, and providers can even say that to patients. “We ask these questions to everyone.” Providers need to ask questions such as “how many”, “how much”, “how often” to any “yes” answer the patient provides (37). Below are common substances that are abused: 

• Alcohol: While alcohol is legal to consume for those over the age of 21 in the United States, patients may still be hesitant to answer truthfully. Providers must take patients at their word but make note of any objective data that they gather through their assessment. Appearances of patients who may have a substance abuse disorder will be discussed later. It is important to ask about specific alcoholic beverages as some cultures may not consider beer or wine to be alcohol (37). 
• Over-the-counter medications: These medications can be a source of intentional or unintentional substance abuse, so providers must ensure that they are asking about herbal supplements, cold and cough medications, or diet aids. Prescription medications might be prescribed to the patient or someone else and usually consists of sleeping aids, pain medications, diet medications, or attention deficit (hyperactive) disorder medications (37). 
• Cannabis/Marijuana: Cannabis or marijuana use has various levels of legality in states across the United States, so providers should be aware of their state’s rules and regulations regarding its use. Regardless, it is important to screen for usage during any patient interaction as treatments can be affected (37). 
• Illicit Drugs: Illicit or street drugs consist of cocaine, heroin, methamphetamine, inhalants, hallucinogens, and more. Asking about use of the substances is important, and again should be done in a non-judgmental manner. Methods include saying the name of each substance as opposed to calling them illegal or street drugs are a great way of doing this. Providers need to assess the amount, method of usage, if patients are doing these substances with someone who they consider safe, if they have access to Narcan, if they are buying from the same person, and if they are sharing needles, or using dirty or clean needles (37). 

Knowing the patient’s own view of their substance use can be very helpful. If the patient does not see their usage as a problem or reason for concern, they are less likely to seek out help or accept it. The same goes for consequences (19). Below is a table of tools providers can use to screen for substance abuse in adults and adolescents (32) [See figure 8]. 

Figure 8: List of Substance Abuse Screening Tools for Adults and Adolescents (32) 

As mentioned above, patients may not be completely honest when providing substance use history. Providers need to collect both subjective and objective data to assist them in providing the proper care. 

Patients may vocalize thoughts of continuously thinking about the substance they are using. They might forget things or have a hard time focusing or concentrating. If they are aware or know they are abusing a substance, they may be unable to stop regardless of a physical and/or mental challenge that is a result of the substance (19). 

There may be reports of strong cravings to use the substance. Patients may report a desire to decrease use of the substance, stop using it all together, or they may take actions to obtain the substance that leaves them feeling guilty or remorseful. Depending on the substance used, the patient may report changes in mood or mood swings (19). 

Behaviors may vary from patient to patient, and the type of substance they are using. They may dedicate extensive amounts of time to obtain the substance, neglect important tasks or individuals within their lives, or actively appear intoxicated. They may argue or get in trouble with family, friends, or law enforcement. They may take the substance when it is hazardous to the health and safety of themselves and others. They may also start taking the substance in higher doses for longer than recommended (19). 

The physical appearance of the patient can consist of noticeable changes in weight, bloodshot eyes, increased tolerance for a particular substance, constricted or dilated pupils, or irregular sleep patterns. Patients may also have signs of withdrawal that consist of shakiness, sweating, agitation, headaches, nausea and/or vomiting, fatigue, and possibly seizures (19).  

Stigma 

Stigma is known as negative thoughts that are held towards other individuals, groups, or circumstances (19, 30). Usually stigma stems from differences. Differences can encompass any part of life, ranging from clothing to gender to race to medical or mental health diagnoses. Stigma impacts how society addresses those differences. If most of society sees mental health and suicide as shameful, those that have mental health diagnoses or have attempted/thought of suicide may be less likely to seek help—this is social stigma. Those with mental health diagnoses may have self or perceived stigma. These individuals internalize society’s opinions or their own perception of discrimination (30).  

Traumatic Childhood 

Traumatic childhood events such as sexual abuse are directly linked to increased risks of suicide or suicide attempts. It is vital that healthcare providers assess children and adults for this history to assist with appropriate treatment and support in order to decrease risks and guide the individual to recovery (19).  

Genetics 

Recent studies have discovered a locus in the form of a DNA variation on chromosome seven that can increase an individual’s risk for suicide. Other variations in this region can lead to risk-taking behaviors, smoking, and insomnia. This variation was present even after “conditioning on major depressive disorder.” The locus has been deemed to be independent from psychiatric diagnoses as well, meaning that those without a mental health disorder could still be at risk for suicide attempts or suicide if this variation is present (22).  

General/Other Risk Factors 

There are other general risk factors that can impact an individual and their risk for suicide. The Centers for Disease Control and Prevention rank these risks from individual risk factors to societal risk factors and describes them: (6) 

• Individual Risk Factors: serious or chronic illness such as chronic pain, previous attempts of suicide, criminal and/or legal problems, substance use, history of mental illnesses like depression, feelings of hopelessness, job or financial loss or problems, current and/or prior history of adverse childhood experiences, and victim of violence or perpetration. 
• Relationship Risk Factors: family or loved one having a history of suicide, social isolation, loss of relationship, bullying, and violent or high-conflict relationships. 
• Community Risk Factors: stress of acculturation, historical trauma, violence in the community, discrimination, lack of access to healthcare, and cluster of suicide within the community. 
• Society Risk Factors: stigma regarding seeking help for mental health or mental illness, unsafe/inaccurate medical portrayal of suicide/self-harm, and access to lethal means in populations at risk for suicide. 

Protective factors are those that improve mental health and provide support to the individual. These can range from individual to societal levels of protection. It is important to know that everyone can participate in preventing suicide within their relationships, communities, or society through equal support (6). Below are some protective factors: (6) 

• Individual Protective Factors: strong sense of culture, reasons for living (like friends, family, pets, etc.), effective coping skills, and effective problem-solving skills. 
• Relationship Protective Factors: partner, family, and friend support, and having or feeling a connection to others. 
• Community Protective Factors: feeling a connection to school, work, or community, and having consistent and high-quality mental and physical healthcare. 
• Society Protective Factors: reducing the access and availability of lethal means to those that are at a higher risk of suicide, and religious, moral, or cultural objection to suicide and/or suicide attempts. 

Case Study Reflection 

Below is a case study divided into three parts. This case study will take you through a scenario and ask questions about what should or should not be done with this patient based on the information that has been covered so far (6).  

Case Study Reflection 1 

Noelle has lived in your neighborhood for years and is one of your favorite neighbors. She would sometimes watch your children when they were young and worked as a waitress until she retired recently. She mentioned to you once, shortly after her retirement, that her funds are “not what they used to be” as she is relying on her social security’s fixed income. This forces her to budget more than she ever needed to, and she is contemplating finding a job. However, her knee pain has been getting worse, keeping her from moving around and sleeping. You notice she doesn’t garden like she used to. One day when you stop by, you ask her about her children, who you have not seen visit. She tells you they are busy, but she would like to see them because she is lonely. She appears restless and sullen.  

A few days later, you realize you have not seen Noelle outside of her house, nor have you seen her two dogs. Since you know her children, you call the older son to reach out and see if he has spoken with his mother. The son sounds rushed on the phone and says they only talked for a few minutes the day before. Deciding to call Noelle yourself, you are surprised that she answers the phone. She again reiterates that it is hard for her to move and leave the house because of her knees and age. She says that she is lonely. You state you would like to check on her every day for a few days, but she adamantly declines. “I just get irritable around people,” she tells you.  

The day after your conversation with Noelle, you go to check on her as you are still concerned. When you knock on the door, no one answers, but you know someone is home because of the noises coming from the house. You are able to enter her house through the patio, something she had given you permission to do in the past, and you can now hear her dogs barking continuously. After calling for Noelle and not receiving an answer, you head upstairs to her room. You find Noelle in bed with an empty bottle of prescribed pain medication that she uses for her knees. She seems to be “out of it” but is crying and muttering that she “can’t do this anymore.”  

Non-Suicidal Self-Injury 

As discussed earlier, self-injury can either be non-suicidal or suicidal in nature. Those who perform non-suicidal self-injury are not looking to end their lives, but instead are trying to escape emotions, thoughts, or other feelings that are causing distress (i.e., not being good enough; feeling anguish, despair, desperate, or depressed; needing a way to relieve stress; believing that people do not care). Physical pain is created through a variety of means, including cutting, burning, biting, scratching, pulling out hair, kicking or punching objects to injure self, or snapping rubber bands on their bodies (19).  

To determine if the injury is related to a suicide attempt or not, providers must perform a suicide assessment and discuss actions and behaviors with the patient in a non-judgmental manner. It is important to remember that non-suicidal self-injury is a coping mechanism for individuals, and it may be the last coping mechanism available before an individual makes a suicide attempt. Providers need to refrain from preventing self-injurious behavior until they provide the patient with other coping mechanisms. Always follow facility policy and procedures when addressing non-suicidal self-injury (19). 

Understanding the Risk of Suicide: Using Assessment Information 

As discussed, suicide has many risk factors, one of which is past suicide attempts. Studies have shown this correlation to be more serious than previously thought, with higher rates of a second attempt within the first three months of the first attempt. What does this mean? As providers we should be providing more support during that initial post-attempt phase to ensure patients have better coping skills and resources to decrease the chances of another attempt. 

The provider must look at a variety of factors gained during the suicide assessment interview such as any previous self-harming behaviors, suicide attempts, and/or aborted attempts (stopped by themselves or someone else). If you are not the patient’s regular provider, consider consulting their primary care provider or psychiatric provider to assess past history of suicide (3).  

Previous hospitalizations for suicide attempts and/or past psychiatric treatment provides important information to the provider that they should be aware of. Consulting with the patient, family, or friends can provide valuable insight into the patient’s history and coping skills (3). Patients may have a history of agitation, anxiety, depression, feelings of hopelessness, changes in mood (which can be severe), insomnia, or substance use (19).  

Family history and dynamics can impact a patient and be a factor for suicide, either a risk or preventative. Dysfunctions within the family have a direct link to suicide and self-injurious behaviors. Providers should ask about family history regarding mental health and illnesses as well as family dynamics. Separations, family history of substance abuse, legal or financial trouble, abuse, or domestic violence should be documented and reported as required by law (3).  

Assessing the patient’s presentation at the time of the interview is vital and can provide significant objective data on the patient’s psychological status. Providers should ask questions about current stressors in their lives: financial hardships, interpersonal loss, or changes in their economic status. As already discussed, loss of job or residence, family dynamics, religious beliefs, and cultural customs can impact the patient as well (3).  

Determining strengths and areas for improvement will guide the provider in providing support, treatment, and referrals as care progresses. These traits may include coping skills, support (from family, friends, religion, or community), personality, and methods of thinking or solving problems. It is important that patients are guided to adjust their thought processes, such as mentalities and self-expectations, that can be detrimental to mental health (3). 

Case Study Reflection 2 

Marc is a new patient at your organization, who recently relocated to Washington from Wisconsin for a new job. He has moved to your city with his wife and young children. While talking with Marc, you can tell that the move has not been easy on him while his family seems to be settling in well. He makes a comment about “feeling inadequate at work” because everyone has expectations for him despite the fact that he is new to the company and role. He reports that he does not feel a sense of community where he lives, saying that the city he came from was much friendlier and warmer.  

You note that Marc does not mention any current coping skills, but you do identify that he used to bike-ride to de-stress after work. The environment is different for him, and he has different work hours with the new position, making it challenging for him to find time or energy to bike. Marc says he thinks that relocating was not the right decision for his family as he has barely any time for them and less time for himself. He says he is a failure.  

Suicide Risk: Documentation 

Documentation of the patient’s suicide assessment is a vital part of the provider’s job. Based on the hospital or facility’s policies, providers might document a suicide risk assessment each time they encounter the patient. Ensure that you are following proper policies and procedures regarding when a suicide risk assessment should be documented. Some best practices include documenting during the first inpatient hospitalization or the initial psychiatric assessment, when there is a significant change, and when there is an occurrence of suicidal ideation or behavior (3). 

Providers should consider documenting the following: (3)  

• Any changes in treatment 
• Risk assessments 
• Prescription medications 
• Previous treatments, especially regarding past suicide attempts  
• Decision making processes 
• Conversations with other providers  
• The patient’s access to firearms  

Actions and Referrals for the Various Levels of Suicide Risk  

Patient statements and actions guide the actions and steps a healthcare provider must take. If a patient has attempted suicide, admission to a hospital to treat any medical injuries is the first step, followed by admission to an inpatient behavioral health unit or hospital. Some facilities may have psychiatrists or clinical psychologists see the patient when they are on the medical floor, so both types of treatments can occur simultaneously. Individuals who may benefit from an inpatient psychiatric admission include those who have acute suicidal ideation with previous attempts, previous suicide attempts with no suicidal ideation (but has other psychiatric concerns), or an exacerbation of a mental illness. Individuals who would benefit from outpatient services include those with suicidal ideation or strong support systems (3).  

Table 5: Suicide Attempt Criteria for Recommended Treatment Services (3) 

While some patients may agree to inpatient treatment after a suicide attempt, others may not. The state of Washington has an Involuntary Treatment Act that manages the psychiatric hold. For additional information, review Title 71.05 of the Revised Code of Washington (39).  

Per Washington legislation, any individual that has firsthand knowledge of an individual they are concerned about can refer them for an evaluation that must be completed by a trained professional such as a psychiatric nurse practitioner or a psychiatrist. The following two points meet the criteria for involuntary admission: (39) 

• The individual must have a diagnosed or diagnosable mental health disorder. This is defined as an organic, emotional, or mental impairment that severely impacts the individual’s volitional or cognitive behavior.  
• They present with harm to others, property, or self, or the patient is classified as gravely disabled (unable to care for themselves safely).  

The trained mental health provider can make a determination if the patient meets the criteria, and if they do, they can initiate a 72-hour involuntary hold. After this hold is initiated, the patient will be transferred to a psychiatric hospital or receiving facility to receive the appropriate treatment. It is important to remember that patients under these holds still maintain their individual rights while in the facility and are presumed competent. This places the patient in a confidential status (39). 

Once the 72 hours have passed, the patient can request legal counsel and be evaluated by the court if they continue to refuse voluntary treatment. Psychologists typically evaluate the patients by performing independent exams to determine if the patient still meets the criteria for involuntary placement. The patient and the legal counsel (who is representing the patient) will meet and discuss the patient's desires in a Probable Cause Hearing (39).  

In this meeting, the judge will determine if there is probable cause for the patient to continue treatment on an involuntary placement. During the hearing, the following four decisions can be made (39): 

• Involuntary petition is dropped, and the patient is released. 
• The case is dismissed by the judge, resulting in the patient being released. 
• The patient can make the decision to stay voluntarily. 
• The patient can be ordered by the judge to continue involuntarily placement and can stay at the facility for 14 additional days. 

If a patient is ordered to stay at the facility for 14 additional days and the provider believes that additional treatment longer than 14 days is needed, a 90-day petition can be filed. This will lead to another hearing where the judge can agree or disagree with the petition. An agreement of the petition would lead to the patient being transferred to the Western State Hospital for adults or the Fairfax Hospital for children (39).   

Case Study Reflection 3 

Jack is a 19-year-old teenager who has just been admitted to your unit following an overdose of prescription medications. It is unclear from the emergency department notes if his actions were accidental or not, and today is your first day speaking with him. He tells you that he was in a car accident last year and has been having a hard time ever since. Past medical history reports depression and feelings of hopelessness. When you ask him about what brought him to your facility, he admits to you that he was trying to end his life. Jake tells you he has seen a provider in the past but does not feel like they listened to him. 

Management and Treatment 

Within any healthcare setting, the provider and patient must develop a therapeutic rapport or alliance to ensure that the relationship is productive and respectful. Trust should be a key factor in these relationships. If the patient cannot trust the provider, then they may not wish to disclose personal information that could aid the provider in treatments and care. The opposite can be true as well (17). 

Patient safety must be a concern at all times during the provider/patient relationship. If there is concern for the safety of the patient at any time, the proper assessments should be performed, and professional staff should be notified (17).  

Together with the patient, the provider needs to create an effective treatment plan for the patient with a focus on the treatment setting, proper education for the patient and their family or other support, and care coordination with other providers. Treatment should be the most beneficial but least restrictive (17).  

Non-Pharmacological Interventions and Treatments 

Cognitive Behavioral Therapy 

The Department of Veteran Affairs recommends the use of suicide-focused cognitive behavioral therapy (CBT) with patients who have a recent history of self-harm or injury (35). Overall, this type of treatment can be beneficial for patients with diagnoses including anxiety disorders, depression, eating disorders, severe mental illness, alcohol and other substance abuse disorders, and even martial problems. The basis for CBT is built on the following three core principles: (2) 

• Psychological behaviors can be a result of learned patterns of negative behavior  
• Psychological behaviors can be a result of unhelpful ways of thinking 
• Those who have psychological diagnoses can learn and develop better coping mechanisms that may help in being more effective in daily life and relieving the symptoms they are experiencing. 

Changes in thinking patterns can be attained by training individuals to recognize alterations in their thinking that might create problems in their life. Changes can also occur when the training focuses on reframing an individual’s thinking, which may occur through reevaluating the thoughts realistically rather than based on negativity. Patients can look into obtaining a better understanding of how others are motivated or behave. Problem solving skills can be taught or expanded to help patients cope. Providers can promote role play (to prepare for particular situations), teach patients mind and body relaxation techniques, or encourage patients to face fears rather than avoid them. Patients and providers can work together to come up with the best method to implement CBT (2).  

Dialect Behavioral Therapy 

Those with recent self-injury or harm as well as borderline personality disorders can benefit from dialect behavior therapy (DBT) (35). It can also be used for those with depression, anxiety, eating disorders, and post-traumatic stress disorder. A type of talk therapy, DBT helps patients accept the reality of their lives and behaviors with the goal to help change the unhelpful behaviors and ultimately change their lives. This is beneficial in many conditions as it focuses on addressing the negative coping skills used to manage negative emotions. Patients may participate one-on-one with the provider, or they may enter DBT group therapy to advance skills gained in one-on-one sessions (10).  

Other Psychotherapies 

Interpersonal Therapy – helps patients understand interpersonal problems such as conflicts with family or friends, difficulty relating to others, unresolved grief, and changes in work or social roles. This type of therapy assists patients to learn healthier ways to cope and express themselves through effective communication (3). 

Psychodynamic Therapy – used with adults to reflect on childhood and other past experiences in order to bring to light some emotions, feelings, thoughts that may have been suppressed. Patients may have developed patterns that can be deemed unhealthy, and this type of therapy can help change those unhealthy coping strategies. Psychoanalysis is a more in-depth form of psychodynamic therapy that is held several times a week (3). 

Supportive Therapy – used to support patients in developing their own coping strategies and resources. This process can be used to build self-esteem, improve community and social interactions, and reduce anxiety (3). 

Pet, Play, and Creative Art Therapy – can be used in combination with any of the above therapies. 

Case Study Reflection 4 

Sabrina and her mother come to your outpatient facility for a routine medical visit. Sabrina started high school and wants to join the lacrosse team, so she needs a physical in order to participate. During your assessment you notice that she has lost a significant amount of weight. When her mother steps out of the room, you ask her how she is doing. Sabrina reports that she has been in the nurse’s office more often with stomachaches and nausea. She also reports she fainted in class but was able to convince the school to not call her mother. She tells you that she would like to talk to her mother about all of the stress with school she is experiencing though she is not sure how. 

Medical Treatments and Interventions 

Providers need to be aware of medications that can cause or exacerbate depression in patients and increase the risk of suicide. While the list is not all inclusive, some common medications include calcium channel blockers, sedatives, corticosteroids, beta-blockers, H2 blockers, and chemotherapy agents. After a suicide attempt, the provider should assess all medications and diagnoses the patient has. From there, the providers should decide if adjustments should be made (3).  

As discussed previously, depression is a major factor in suicide and is present in many other medical and mental health conditions. Anxiety (includes general phobia, specific phobia, generalized anxiety, obsessive compulsive, social anxiety, agoraphobia without panic, and panic disorder), trauma/stress related disorders, bipolar disorder, psychosis, eating disorders, substance use disorders, and non-suicidal self-injury can all have depression as a symptom (19). Medical conditions that co-exist with or exacerbate depression consist of cancer, heart disease, dementia, diabetes, Parkinson’s Disease, and stroke (3). 

Medication 

The goal of medication administration is to assist the patient to regain balance in their brain’s chemistry and restore it to optimal functioning by controlling the signs and symptoms the patient may have. These medications do not usually result in a cure; instead, they should be taken for extended periods of time, possibly for the patient’s lifetime. These medications can also be combined with other treatment options to give the patient the best possible outcomes (3).   

Controversy exists with patients taking antidepressants. In 2004, the Food and Drug Administration made the decision to require that antidepressants have a black box warning addressing increased risks of suicide in young adults. There was a similar claim regarding antiepileptic medications, but the black box warning was not required due to the scientific advisory committee voting against it. Regardless, providers need to stay up to date on medications and warnings, ensuring that they are administering medications in the best interest of their patients. One medication that may work for one patient may not work for another (13).  

Antidepressants come in several categories that are based on the type of brain chemical (dopamine, norepinephrine, and serotonin). These categories include serotonin modulators, norepinephrine dopamine reuptake inhibitor, monoamine oxidase inhibitor, tricyclic agents, selective serotonin reuptake inhibitors, and serotonin norepinephrine reuptake inhibitors. 

Figure 9: Monoamine Oxidase Inhibitors (28)

Figure 10: Selective Serotonin Reuptake Inhibitors and Serotonin Modulators (9)

Figure 11: Norepinephrine Dopamine Reuptake Inhibitor (16) 

Figure 12: Serotonin and nor-epinephrine reuptake inhibitors (18) 

Figure 13: Tricyclic Antidepressants (20) 

Case Study Reflection 5 

Hope is a 35-year-old who recently moved to your town with her husband, Douglas. She is a teacher at the nearby elementary school while Douglas works in a tech startup, but he was suddenly laid off from his job. After this, Hope brings him to your facility to be evaluated. She tells you that Douglas has become increasingly agitated. He told her that he is a failure and “did not make the right choices in my life.” Douglas admits to drinking heavily with friends since he was laid off.  

Substance Abuse Care 

Research shows that the longer substance abuse goes on, the harder it is to recover from. Early recognition and treatment can decrease the chance of serious medical conditions or death (19). There are multiple treatment options for patients with substance use disorders, but providers must be aware of each patient’s individual circumstances: time, family and friend support, cost/expenses, and willingness.  

All individuals go through the five stages of change when they want to make adjustments in their lives. Those with substance abuse disorders must be willing to make a change for themselves. Even though a person with a substance abuse disorder may want to change for another person or situation (changing for grandchildren, a spouse/romantic partner, children, etc.), they must consider that this person/situation may not remain in their lives. For this reason, they must be willing to make a change for themselves. Sometimes family or friends become too overburdened with the individual’s substance abuse, driving them away. That could inhibit or completely stop the person’s desire to change. The patient may say, “they’re no longer around, what’s the point?” Providers should not deter patients from having support systems as these could be motivation for change. However, patients should also be encouraged to find support within themselves (19). The following are the five stages of change: (19) 

• Stage 1: the pre contemplation phase; they do not believe they have a problem. They are not thinking of making changes in their lives or considering how the substance may be harming them. 
• Stage 2: the individual begins contemplating the need for change. They begin to realize that the substance is affecting them. This is a great time for providers to encourage them to keep contemplating and consider making a change by identifying the pros and cons of using the substance. 
• Stage 3: the preparation phase; the patient has made the decision to change. More encouragement is needed. Healthcare providers should assist patients in planning and providing resources. 
• Stage 4: the patient makes the change. They may start decreasing the use of substances or stop using them completely. The best thing to do for the patient is to be as supportive as possible. Patients should develop strategies on how to say “no” to situations regarding the substance. 
• Stage 5: the patient is maintaining the change. Patients should focus on the positives of not using the substance and their achievements during this process. 

Providers should be honest with patients regarding relapse. Recovery from substance abuse is not a linear path that is 100% successful. Everyone has moments of relapse when it comes to new habits, and it should not be discouraging. Remind patients that there is always help from providers who are non-judgmental. 

Treatment strategies can include managing withdrawal symptoms in the acute phase, remaining in treatment, and preventing relapses. Many psychotherapies such as cognitive behavioral therapy can be very beneficial for recovery from substance abuse. Twelve step facilitation programs are twelve weekly sessions done individually that prepare patients for twelve step mutual support programs such as Alcoholics Anonymous and Narcotic Anonymous. While these support programs are not treatments, they are beneficial as additional support to other treatments.  

Contingency management programs are similar to a rewards program. Patients, families, friends, or providers may offer rewards or privileges for meeting certain requirements of substance abuse recovery. These requirements might be taking medications as prescribed, participating in sessions, or remaining free of the substance. Rewards can be decided upon by the patient in collaboration with family, friends, and providers (26).  

Safety Planning Strategies and Monitoring the Usage of the Safety Plan 

Active suicidal ideation and behaviors are considered a medical emergency and should be treated accordingly. Providers in the emergency department setting should focus on medical emergencies and treatments first before moving on to any mental health treatments or consultations (19). Since suicide can be prevented, it is the duty of healthcare providers to ensure the patient is in a safe environment.  

Ensuring safety can encompass a variety of methods. One example is searching belongings to remove any weapons or items that can be used to harm the individual or others such as lighters, shoelaces, strings from hoodies, and medications. 

Patients may be placed under various observation statuses based on orders made by the physician or a mid-level provider. These observation statuses are also based on facility policies and best practices guided by evidence. Patients withdrawing from substances may need to be closely monitored on a medical floor due to worsening signs and symptoms. Seizures can be life-threatening for these patients.  

Restraints and/or seclusion may be required as a last resort for patients. Per Washington law, patients must be under a one-to-one status, meaning there is one staff member always observing the patient. Observation can be done via audio and video equipment, or in-person. There must be documentation discussing the patient’s behavior and condition, attempts for a least restrictive method of treatment, response to seclusion and/or restraints, and the need to continue seclusion and/or restraints. A face-to-face assessment must be performed by a trained professional within one hour of the patient being placed in restraint or seclusion (38).  

General regulations for restraints and seclusion include: (38) 

• Within one hour of seclusion and/or restraints being initiated, an order from the physician must be entered. 
• The nurse must communicate with the family or patient’s legal caregiver regarding the restraints and or/seclusion and the process that will be followed. 
• The nurse must discuss with the patient the need for seclusion and/or restraints and attempt to get cooperation from the patient.  
• There is to be support from others to assist with the seclusion and/or restraint process. 
• Continuous observation is to be maintained while the patient is in seclusion or restraints. 
• Physical and psychological needs must be addressed at regular intervals. 
• The nurse is responsible for documenting the need for seclusion and/or restraints and patient assessments.  
• The nurse is required to maintain education and competence on restraints. 

Obtaining Support and Engagement from Third Parties 

As reflected in this course, family and friends are vital supportive factors for the individual with suicidal ideation or attempts. If the patient is willing, education should be given to their support system so that everyone understands medications, treatments, follow-up and outpatient treatment, and what to do in another crisis resulting in a suicide attempt or exacerbation of suicidal ideation.  

Case Study Reflection 6 

Courtney is a 25-year-old female patient who is at your facility with her husband. She was discharged from the hospital a few weeks ago for an aborted suicide attempt. Her friend found her overdosed in the bathroom of her house. She was given follow-up with your facility. Now that she is with you, she reports that she would like resources to help her cope better. After being told she has a history of depression and post-traumatic stress disorder, you begin to think of resources and treatment you can offer her. 

Restricting Access to Lethal Means 

Statistics report that 55% of those that attempt suicide use firearms, 26% use suffocation, and 12% use poisoning. The last 8% is classified as “other” (8). Reducing or limiting access to lethal means can be defined as increasing the distance between someone with suicidal ideation and lethal means. An example would be to have the patient give their firearms over to another responsible adult that lives over 30 minutes away (12). 

All providers should discuss this information with their patients and their support systems. By reducing access to lethal means, it is possible to decrease rates of suicide. However, providers must be aware that patients may not tell the full truth when it comes to availability of lethal means, and restricting access is only part of treatment and care (12). 

Transition of Care: Discharge and Referrals for Continuity of Care 

Treatment of the patient who has suicidal ideation or had a suicide attempt does not stop once they leave the hospital setting. Care must be continued outside of the hospital setting through outpatient psychiatric providers such as a psychiatrist or psychiatric nurse practitioner. These providers can prescribe medications, adjust treatments, and provide additional therapy referrals that may be beneficial for the patient. These psychiatric providers should collaborate with the patient’s primary care provider. As discussed previously, certain psychiatric medications can interact with medication for medical diagnoses. 

Veteran Populations 

Data from 2020 reports that there were over six thousand veteran suicides in the United States, an average of 17 veterans dying by suicide each day. Substance use and mental health prevalence among those using the Veterans Health Administration rose from 27.9% to 41.9% from the years 2001 to 2020 (14). These numbers are staggering as veterans have a 1.5 higher risk of suicide than those in the general population and women Veterans have a suicide rate that is 2.5 times higher than civilian women (36). The chart below shows the suicide rates based on gender as classified by male and female [See figure 14].  

Figure 14: Suicide Rates Among Veterans by Gender From 2001 to 2020 (36) 

Rates of suicide were also affected by age. Veterans in the 18- to 34-year age range had a 95.3% increase between 2001 to 2020. Those aged 55 to 74 only rose to 58.2% during that same time period. From 2019 to 2020, older veterans’ suicide rates decreased while those in the 18 to 34 age group increased (14). As with the civilian population, methods of suicide were relatively similar; data was gathered from 2001 to 2020 [See figure 15]. Additionally, rates for suicide are higher among the veteran population in comparison to civilians; the change percentage is based on 2001 data [See figure 16]. 

Figure 15: Methods for Suicide Among Veterans from 2001 to 2020 (36)

Figure 16: Methods for Suicide among Veterans and Non-Veterans (36)

Veterans have similar risk factors that have different causes from their civilian counterparts. They have complex mental health conditions such as post-traumatic stress disorder, anxiety, depression, manic-depressive disorder, and traumatic brain injuries as a result of combat exposure. Others have combat wounds that can lead to severe medical diagnoses and possible prescribing of opioid medications for controlling pain. Veterans may have insomnia which can exacerbate any of their other symptoms or diagnoses. These individuals may turn to substance abuse instead of other forms of treatment due to the ease of accessibility. Studies show that over one in 10 veterans are diagnosed with at least one substance use disorder. There is an increased risk of opioid overdose, but this population is more likely to turn to alcohol (36).  

The Department of Veteran Affairs has taken steps to provide resources for mental health and suicide prevention to all veterans. Veterans and families are given suicide prevention education upon discharge, and suicide assessments are completed during every visit. Each facility has a Suicide Prevention Coordinator that can be contacted at any time. Veterans, and their families and friends can utilize Veterans Chat, a free, anonymous messaging service that gets them in touch with a Veterans Affairs counselor. If needed, the counselor can transfer the individual to the Veterans Crisis Line for further counseling or referral services (35). 

Veteran Resources (All civilian resources are available to veterans): 

https://www.veteranscrisisline.net/ 

https://www.va.gov/health-care/health-needs-conditions/mental-health/suicide-prevention/ 

https://theactionalliance.org/veteran-and-military-suicide-prevention-resources  

Case Study Reflection 7  

Cory is a 45-year-old male patient that presents to your emergency department for severe abdominal pain. During your initial assessment, Cory tells you he also feels dehydrated and has been more tired than usual lately. He says he ran out of his sleep medication, “but the providers at the VA are so hard to see. It takes months for an appointment.” When you ask him the standard questions (if he drinks alcohol or uses any other substances), he becomes angry and snaps at you before immediately apologizing. Cory admits that he has been drinking more than usual for the past few months because his chronic leg pain—an injury from when he was in combat—has been bothering him more than normal. 

Suicide Loss Survivors 

As highlighted throughout this course, suicide can happen to anyone, and they leave behind many people. Friends, families, coworkers, and acquaintances can all be affected by the loss. Those who have lost a loved one to suicide are often referred to as suicide loss survivors. 

If a healthcare provider encounters a suicide loss survivor, they should always assess the risk for suicide. As discussed previously in this course, some individuals may attempt suicide on the anniversary of their loved one’s passing. In addition, they could attempt on a day of significance to the individual that passed or a major holiday that held special meaning. If the suicide loss survivor is at a high risk for suicide, follow your facility’s protocols for additional assessment or treatment (1).  

If there is no significant risk for suicide, provide support and resources. Remember that some individuals have chronic suicidal ideation. Support can be through active listening, having a non-judgmental attitude that is free of bias or criticism. Some individuals may be hesitant to tell their story due to the nature of the loved one’s death. Encourage them to talk to someone they can trust if they do not want to share that information with you. Reassure them that bereavement is not a linear process and that they do not have a time limit to when they should be done grieving. Every person is different, and how they progress through the stages of grieving varies (1).  

Resources that can be provided include any of the above options discussed earlier in this course. Psychiatric providers, therapy, and medications may be indicated for survivors of suicide loss. Offer them resources and referrals per your facility’s protocols, but also let them know they are always able to return to your facility if needed, especially emergency departments. Medical providers may need to be involved as well if the patient has any medical concerns (1).  

Conclusion

Suicide impacts everyone. With the ever-growing need for mental health services and the rise in mental health decline, it is no surprise that suicide rates have increased among all populations. Without proper assessments, knowledge of risk and protective factors, and proper treatment requirements at each level of suicide risk, individuals in need may be missed. It is the job of the healthcare provider to ensure that all individuals are screened and treated appropriately. You may be the last point-of-contact a patient has with a provider prior to taking their own life. Ensure that you ask the questions.  

➀ Read and Learn

The following course content

LGBTQ+ Cultural Competence

LGBTQ+ patients may experience healthcare disparities due to multiple factors, including lack of provider knowledge. In this course we will discuss how to deliver care, with LGBTQ cultural competence.

Introduction   

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ+) individuals represent a rapidly growing segment of the U.S. population [1]. This rapid growth brings with it risk for stigmatization [1]. Implicit healthcare provider biases may result in LGBTQ+ patients receiving a lower standard of care or restricted access to services as compared to the general population [2]. Even when institutions and providers make commitments to equitable care explicit and implicit biases operating outside of conscious awareness may undermine that commitment. There is an urgent need to ensure that healthcare providers are prepared to identify and address their own implicit biases to ensure they do not contribute to the health care disparities experienced by LGBTQ+ and other vulnerable populations. Only by addressing their own implicit biases will health care providers be able to provide patient care in accordance with LGBTQ+ cultural competence.

LGBTQ+ individuals face significant disparities in physical and mental health outcomes [3]. Compared to their heterosexual counterparts, LGBTQ+ patients have higher rates of anal cancer [4], asthma, cardiovascular disease [5,7,8], obesity [6], substance abuse [8,9,10], cigarette smoking [11], and suicide [14]. Sexual minority women report fewer lifetime Pap tests [13,15, 16], transgender youth have less access to health care and LGBTQ+ individuals are more likely to delay or avoid necessary medical care [17] compared to heterosexual individuals. These disparities are due, in part, to lower health care utilization by LGBTQ+ individuals [3]. Perceived discrimination from health care providers and denial of health care altogether are common experiences among LGBTQ patients and have been identified as contributing factors to health disparities [19,20,21,22]. Disparities in health care access and outcomes experienced by LGBTQ+ patients are compounded by vulnerabilities linked to racial identity [23,24,25] and geographic location [6].

Biases among health care students and providers toward LGBTQ+ patients are common [27,28] despite commitments to patient care equality. These biases, also known as negative stereotypes, may be either explicit or implicit [29]. These biases contribute to a lack of LGBTQ+ cultural competence in patient care. A large study of heterosexual, first-year medical students demonstrated that about half of students reported having negative attitudes, explicit bias, towards lesbian and gay people and over 80% exhibited increased negative evaluations of lesbian and gay people compared to heterosexual people  (implicit bias) [27]. Research in social-cognitive psychology on intergroup processes defines explicit biases as attitudes and beliefs that are consciously-accessible and controlled; these characteristics are typically assessed via self-report measures and are limited by an individual’s awareness of their attitudes, motivation to reveal these attitudes, and ability to accurately report these attitudes [30,31]. In contrast, the term implicit bias refers to attitudes and beliefs that are unconscious (i.e., outside of conscious awareness) and automatic [32,33]. Implicit bias can be assessed with the Implicit Association Test (IAT) [34], which aims to define the relationships between concepts (ex. race, sex, idea), and positive or negative associations and/or stereotypes. Idenitfied biases are then delegated as slight, moderate, or strong [35].

Healthcare provider biases are correlated with poorer access to services, quality of care, and health outcomes [29, 36, 37, 38]. Explicit biases held by health professionals towards racial/ethnic minorities, women, and older adults are known to affect clinical assessments, medical treatment, and quality of care [39]. Importantly, implicit bias measures are more strongly associated with real-world behaviors than explicit bias measures [40] and are linked to intergroup discrimination [43]. Health care provider’s implicit biases towards vulnerable patient groups may persist despite an absence of negative explicit attitudes [36], resulting in preconceived notions about patient adherence, poor doctor-patient communication, and micro-aggressions, all of which can interfere with optimal care. With less time and limited information processing capacity, provider’s decisions are increasingly governed by stereotypes and implicit biases [42]. Medical student and provider biases may contribute to health disparities in vulnerable populations by negatively impacting communication with patients and decisions about patient care [29, 33]. Taken together, these findings suggest that medical students and healthcare providers are likely to underestimate or to be unaware of their implicit biases towards LGBTQ+ patients, particularly when they are rushed or fatigued, which could impact their behavior and judgments in ways that contribute to health disparities experienced by LGBTQ+ populations. By learning about and addressing their implicit biases, health care providers can work towards demonstrating LGBTQ+ cultural competence and providing optimal care(Introduction section courtesy of Morris, M., Cooper, R. L., Ramesh, A., Tabatabai, M., Arcury, T. A., Shinn, M., Im, W., Juarez, P., & Matthews-Juarez, P.-  reference 2).

Terminology

Understanding the standard terminology utilized is pivotal to treating and interacting with LGBTQ+ patients. Below are listed some of the common terms and how they should be referenced.

Ally- A person not identifying as LGBTQ+, but whom promotes equality and support of LGBTQ+ peoples in a variety of ways.

Androgynous– Identifying as neither masculine nor feminine.

Bisexual – A person who is emotionally, romantically, or sexually attracted to more than one sex, gender, or gender identity.

Cisgender – A person whom identifies with their gender which as assigned at birth. For example, a person assigned female gender at birth who identifies as female.

Gay – A person who is emotionally, romantically and/or sexually attracted to those of the same gender.

Gender-fluid – A person who identifies as a fluid or unfixed gender identity.

Lesbian – A woman who is emotionally, sexually, and/or romantically attracted to other women.

LGBTQ+ – Acronym for “lesbian, gay, bisexual, transgender, and queer.”. The plus sign stands for the innumerable other identities.

Non-binary – Adjective describing person(s) who do not identify exclusively as man nor woman.

Pansexual – A person who has the potential for romantic, emotional, and/or sexual attraction to people of any gender.

Queer – Often used interchangeably with “LGBTQ+”, or to express fluid identities or orientations.

Sexual orientation – An inherent or enduring emotional, romantic, or sexual attraction to other people.

Transgender –Umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth. It does not imply any specific sexual orientation and transgender persons may identify as straight, gay, lesbian, bisexual, etc.

*Definitions largely derived from (44, 45).

Best Practices

Below we will list and discuss the best practices for ensuring a positive, equitable healthcare experience for LGBTQ+ persons, according to the Joint Commission (this is not a comprehensive list, nor inviolable, but rather highlights).

Create a welcoming environment that is inclusive of LGBT patients and demonstrates LGBTQ+ cultural competence.

• Prominently display the hospital nondiscrimination policy and/or patient bill of rights.
• Waiting rooms and common areas should be inclusive of LGBTQ+ patients and families.
• Unisex or single-stall restrooms should be available.
• Ensure that visitation policies are fair and do not discriminate (even inadvertently) against LGBTQ+ patients and families.
• Foster an environment that supports and nurtures all patients and families.

Avoid assumptions about sexual orientation and gender identity.

• Refrain from making assumptions about a person’s sexual orientation and/or gender identity.
• Be cognizant of bias, stereotypes, and other communication barriers.
• Recognize that self-identification and behaviors do not always align.

Facilitate disclosure of sexual orientation and gender identity, but be aware that disclosure is an individual process.

• Honor and respect patient’s decisions to provide or not provide sexual and/or gender information.
• All forms should contain inclusive, gender-neutral language that allows patients to self-identify.
• Use neutral and inclusive language when communicating with patients.
• Listen to and respect patients’ choice of language when they describe their own sexual orientation.
• Conduct confidential patient satisfaction surveys that include questions regarding sexual orientation and gender identity

*Information largely derived from Joint Commission field guide, reference 45.

For more information on best-practices in the workforce, visit the Joint Commission website by clicking here.

Establishing Relationships with LGBTQ+ Patients

When interacting with patients, one should not assume gender or sexuality. Addressing a patient whom identifies as a female as a male can cause grave harm to the relationship. Instead, nurses should use open-ended questions. For example, rather than saying “Hi sir, what brings you to the hospital,” a nurse might say, “Welcome, what brings you to the hospital today (45)?”

If a nurse uses the incorrect pronoun, the best practice is to apologize and ask the patient what pronoun and name they prefer. For example, a nurse may say, “I apologize for assuming your gender. How would you like to be addressed? (45).

In conversation, the nurse should use the name and/or pronoun the patient prefers without drawing special attention to the subject (45). For example, if a patient prefers to be identified as their partner’s wife, you should follow suit.

The core of relationship-building with LGBTQ+ patients is no different than any other patient, fundamentally. If nurses have a basic understanding of best practices and a healthy dose of respect and compassion for LGBTQ+ patients, a positive relationship is likely to develop.

Health Disparities of LGBTQ+ Patients

LGBTQ+ Americans are at higher risk of substance use, sexually transmitted diseases, cancer, cardiovascular disease, obesity, bullying, isolation, anxiety, depression, and suicide when compared to the general population (49). LGBTQ+ youth are frequently bullied at schools (46). In fact, early victimization and subsequent emotional distress accounted for 50% of the disparities between LGBTQ+ youth (46).  In other words, LGBTQ+ Americans are discriminated against and disadvantaged from a very young age.

When home life also reflects a lack of LGBTQ+ cultural competence, more problems arise.  A major cause of LGBTQ+ distress is family rejection. Disclosure of gender identity or sexuality can cause very significant interpersonal conflicts among family and friends of LGBTQ+ persons (46). This explains some hesitancy and should help nurses understand the importance of respecting privacy, while giving options to patients about disclosing sexuality and gender.

Providing an Inclusive and Accepting Care Environment

LGBTQ+ patients often experience difficulty in finding healthcare environments in which they feel accepted and understood (45). Past negative experiences, lack of knowledge among healthcare providers, and limited access to healthcare in general may become major barriers for LGBTQ+ persons when seeking care (45).

The core tenant of providing an inclusive environment is understanding the needs of LGBTQ+ patients, and working diligently to create an environment which does not disadvantage or discourage them from seeking care.

Policies and procedures at institutions should be designed to reflect a non-discriminatory environment. For example, many hospital policies dictate that only legal family spouses or partners can visit in specific circumstances. Policies such as this are inherently discriminatory toward LGBTQ+ patients, as they may not have legal spousal status due to social, legal, or personal reasons.

Laws Specific to Washington D.C.

1973: Title 34 is passed, which prohibits discrimination based on sexual orientation.

2006: The D.C. Human Rights Act is updated to ensure residents of the district are protected regarding employment, house, and public accommodations.

2016: The Armstrong Amendment is repealed in D.C., which allows religious schools exemptions from complying with anti-discrimination laws.

2016: LGBTQ Cultural Competency CE Act is passed. This requires that all licensed healthcare providers take a 2-credit hour course to increase competency (such as the one you are currently taking!).

Exercises on LGBTQ+ Cultural Competence

To help solidify your learning, please complete the following exercises at your own pace. The answers/guidance for each are provided below.

Scenario 1

A patient enters your emergency department and you assume the patient identifies as a female. You introduce yourself and say, “Ma’am, how can we help you? What brings you in today?"

The patient appears dismayed but answers the question. The nurse is confused and does not understand why the patient appears distressed. What is the best course of action?

Answer: The nurse should apologize to the patient and ask the patient how they would like to be addressed. Then, the nurse should update the patient’s records to reflect such, to reduce further confusion.

If the nurse does not address the issue, the patient may feel uncomfortable and develop a negative association with healthcare, which can lead to disparities in the future.

Scenario 2

A patient in your ICU has had a deterioration while his husband was in the room. After a family meeting, a member of the healthcare team makes a derogatory remark about the patient’s sexuality. What is the next best action for the nurse?

Answer: Pre-conceived phobias and stigmatizations can cause significant distress to LGBTQ+ patients, even if not stated directly to them. These type of remarks are abusive and should not be tolerated. The nurse should confront the co-worker (if safe) and consider reporting the comments to the Human Resources department.

Scenario 3

A LGBTQ+ patient is being admitted and prefers not to disclose their sexuality. However, the nurse is unable to proceed with the admission process without this information. What could be done to rectify this system-level issue?

Answer: The nurse should work with administration to ensure that all charting and paperwork allows individuals to self-report sexuality and/or gender if they want. However, healthcare systems should not force patients to “come out” unless it is absolutely medically necessary.

Conclusion

LGBTQ+ cultural competence must be ingrained in our healthcare systems in order to foster excellent relationships between members of the LGBTQ+ community and medical staff.  Hospitals and healthcare systems have a great deal of work to do in becoming LGBTQ+ friendly.  The efforts must continue until LGBTQ+ patients and families do not feel disadvantaged, anxious, or frustrated when interacting with healthcare systems.  As the patient’s ultimate advocate, nurses are at the front-line and should advocate for patients both individually and from a policy perspective. Nurses should work with and spearhead efforts to ensure that healthcare policies reflect best-practice and do not discriminate against LGBTQ+ patients in any way.

➀ Read and Learn

The following course content

Washington State Telemedicine Training

Introduction   

Telehealth has become more popular and widespread across the United States. With its widespread use and popularity, more nurses and health care practitioners are required to complete courses like this Washington Telehealth Training. The earliest encounter with telehealth involved Alexander Graham Bell in 1876 when he used his telephone as a means of getting help from his assistant after he had an accident involving spilled acid on his trousers (1). The origin of telehealth officially began in 1959, with clinicians at the University of Nebraska utilizing video communication for medical purposes. These clinicians established a two-way television setup to transmit information to medical students across campus. Five years later, the setup was linked with a state hospital to perform video consultations. Telemedicine first became popular in rural areas, where populations with limited healthcare access could now reach specialists from afar. In the 1960s and 70s, the Public Health Department, NASA, the Department of Defense, and the U.S. Health and Human Services Department all invested time and money into telemedicine research.

In this Washington Telehealth Training course, the following outcomes and objectives will be reviewed:

• Discuss the background, origin, and scope of telehealth practice.
• Explain policies and regulations related to telehealth.
• Describe ways to determine if an organization is ready and prepared for telehealth and the process for the actual telehealth visit.

Telehealth Background

Definition

This Washington Telehealth Training course defines telehealth as the delivery of healthcare services using digital technology and can include services in the behavioral health field, such as substance use disorder treatment, serious mental illness treatment (SMI), and counseling. The clinic is considered the originating site (where the patient is located during the telehealth visit) and the specialist at the other location is the distant site.

In organizations that serve individuals with intellectual and developmental disabilities (IDD), telehealth is the practice of healthcare within a professionally designated scope of practice using electronic communication, information technology, or other means between a licensee in one location and a client in another location with or without an interviewing healthcare provider.

Telehealth allows patients to have better access to a variety of specialists which, in turn, increases the number of people receiving appropriate care. Overall, it can provide cost savings to the patient and increase the quality of care.

Telehealth and its Scope of Practice

The practice of nurses using telehealth is within the legal scope of practice for licensed nurses, registered nurses, licensed practical nurses, and advanced practice registered nurses (2). It can be used among these professionals as needed or when a patient is unable to make an in-person visit.

Telehealth Policy and Regulations

In-State/Out-of-State Requirements

Most providers are only allowed to see patients located in states where the provider is licensed or certified. However, many states temporarily changed this policy during COVID-19. These in-state restrictions are often due to the nature of the services a clinic provides.

Organizations can choose if they want to provide telehealth services. However, if the topic is suggested, the organization must have team members in place to discuss the options, pros, cons, and feasibility of telehealth within its practice.

Additional Credentialing and Protocols

There are no additional credentialing or privilege protocols in place for those located out-of-state as those individuals are required to seek services within their area and state. The credentialing requirements must abide by the specific guidelines set forth by each organization and these can vary from one place to another.

It is imperative that the right billing codes are used in order for the insurance company to reimburse for services rendered. Typically, there are codes known as the Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS). It is important to pay attention to any changes, as these codes do change from time to time. If ever in doubt, always double-check to ensure that the codes being entered are the correct ones for proper billing and reimbursement.

Reimbursement of In-Person Visits

Telehealth visits are typically reimbursed at an equal rate to in-person visits, but the reimbursement for those with intellectual and developmental disabilities (IDD) relies mostly on Medicaid Home and Community Based Services (HCBS) waivers. The overwhelming majority of waivers permit the temporary use of telehealth services for those individuals with IDD; however, only a small percentage include the use of telehealth on a permanent basis for this population. The limitations that were noted involved those individuals that were not a part of the following services: employment, day, and prevocational services, and in-home residential supports. Controlled substances are also not allowed to be prescribed by using telehealth until an in-person visit takes place.

Ryan Haight Act of 2008

The Ryan Haight Act summarizes that no controlled substance may be delivered, distributed, or dispensed by an electronic method such as the Internet without a valid prescription and requires at least one in-person medical evaluation (3).

This Washington Telehealth Training course asks nurses to consider the following example: if a patient undergoing a telehealth visit needs to be prescribed a controlled substance, the person issuing the prescription must have a doctor-patient relationship with the patient. This may seem reasonable, but the narrow definition in the law indicates that a telehealth visit may be inadequate due to the law specifically requiring an “in-person evaluation”.

Telehealth Readiness

When an organization begins to consider whether or not telehealth service is right for them, there are four critical factors that must be considered. These four factors include 1) workflow, 2) practitioner availability and acceptance, 3) infrastructure and cost, and 4) sustainability. All of these factors must be considered when attempting to decide if telehealth services would prove beneficial to an organization. An organization must meet as a team to discuss these components in order to assure that these factors can or cannot be met successfully.

Standards of care must be implemented and followed at any given practice and specialty area. The same is true for practices utilizing telehealth. The following serve as standards of care (4):

• Training of staff – staff must be trained in the use of the technology used and must be competent.
• Evaluations and Examinations – diagnosis should be established by establishing the patient’s history, mental evaluation, physical examination, and appropriate laboratory and diagnostic testing.
• Licensee-Patient Relationship – proper identification must be made prior to any telehealth encounter. Failure to verify the patient’s identity may lead to fraudulent activity or disclosure of patient information that is confidential. The location and identity of the patient must be verified. The licensee’s name, professional credentials, and location should be provided to the patient. Appropriate follow-up care and a complete medical record must be available to the patient and other health care providers involved in the treatment plan.
• Prescribing – the concept of “Contact with Patients before Prescribing” must be practiced – other providers must be involved in ongoing care and evaluations of the patient. All federal and state laws must be followed and are expected to participate in the Controlled Substances Reporting System.
• Medical Records – complete records must be maintained and must be consistent with prevailing medical record standards. HIPAA and security related documents must be present and signed appropriately. Confidentiality must be maintained and a copy of the medical records consistent with state and federal laws must be in place.
• Disclaimers – a statement that includes any unique limitations of the electronic model being used should be present, if applicable.
• Licensure – the practice of medicine is deemed to occur in the state in which the patient is located. If the licensee intends to practice telehealth outside of their current state must first check with other state’s licensing board to ensure if this is allowed.

Protocols for the necessity of visits

Typically, most patients can receive an appointment for a telehealth visit without any difficulty as long as the following are not present: conditions causing severe pain or those requiring a detailed in-person examination, prescription and refill of controlled substances, any condition that requires in-person drug administration, highly complex medical conditions, and psychiatric emergencies.

There are certain protocols regarding the type of visit that is appropriate for telehealth and when one should be referred to an in-person visit. The following are some common types of visits that meet the standards of telehealth:

• Lab tests or x-ray results
• Recurring conditions such as migraines or urinary tract infections
• Skin conditions
• Mental health treatment, online therapy, counseling, and medication management
• Prescription management
• Urgent care issues such as colds, coughs, and stomach aches

A patient should be referred to an in-person visit when they require highly specialized care, such as cancer treatments or complex specialty care.

How to Receive a Telehealth Appointment

With most telehealth appointments, it is best and easier if the patient will download the app and initially set up an account. There is also a 1-800 number that can typically be called as well if the patient needs additional help. Each patient will need to complete a brief medical history just as one would at the doctor’s office and once submitted, the telehealth specialist will connect the patient with the right medical professional – doctor, therapist, or a specialist. The telehealth specialist will assist the patient with setting up a date/time for the appointment and the appointment can be completed by phone, video, or app.

General Overview of Telehealth Software

This Washington Telehealth Training course recommends following five things should be considered when looking to choose a platform to implement telehealth services: integration using the same interface which allows everything to be accessed; user-friendly design – all patients should feel comfortable using the platform and not frustrated; specialty care solution – look for a platform that caters to providers that provide specialty services; configuration and customization – the platform needs to be customizable to meet each patient’s unique preferences along with the preferences of the healthcare facility; data analytics – it is important to gain new insights by recoding and logging each patient interaction, which allows the organization to better manage the practice and the experiences of the patients. The collected data assists with identifying issues early and creating resolutions in a timely manner.

In general, the practice of telehealth requires a good source of internet access by all parties, supported by broadband internet connection and mobile communication. The following list includes hardware requirements:

• Desktop
• Computer
• Laptop
• Smartphone with a camera
• Tablet with a camera and microphone
• Telemedicine care

Guide on Approved Software

It is important to ensure that the software platforms used are HIPAA compliant. The list below includes vendors that represent HIPAA-compliant video communication products that are recommended by this Washington Telehealth Training course:

• Skype/Microsoft Teams
• Updox
• VSee
• Zoom for Healthcare
• me
• Google G Suite Hangouts Meet
• Cisco Webex Meetings/Webex Teams
• Amazon Chime

Obtaining Patient Consent for Telehealth

Once the patient has decided to use telehealth for an appointment, official informed consent may be required. It is important to keep in mind that specific informed consent laws vary by state, but this Washington Telehealth Training course recommends the following actions that are always a good idea to follow (5):

• Explain to the patient what they can expect from the telehealth visit and what their rights consist of.
• Check in with the patient about their responsibilities during online counseling or telehealth visits such as wearing headphones and finding a place to be alone to ensure privacy.
• Inform the patient to get anyone’s consent from the start that may be observing the patient.
• Instruct patients to complete required forms ahead of time and bring them to the telehealth visit.
• Ensure the informed consent form and any other documentation has been done during the check-in process, including verbal consent.

It is important to have your medical intake forms reviewed by the legal team. Obtaining informed consent from each patient is important to have completed before the first appointment.

Verbal consent is where a patient gives their consent to a procedure in a verbal manner and does not sign any written form. This Washington Telehealth Training course provides the following example:

My name is ________________________________ and I am verbally consenting to participate in the study. By signing above, I give permission to be a part of the study and to allow the data collected to be used for the resulting process.

IT Support Services

In order for telehealth to be productive, IT support services must be in place to ensure that all areas are fully functioning and if a problem occurs, the IT department must be available and ready to intervene 24/7/365. If a patient is experiencing problems making an appointment or with any connectivity issues, IT can be notified to assist in these areas.

Practice First

Telehealth is a relatively new technology and as it gains widespread usage it is important for each organization using telehealth to do a practice run first to ensure that all of the elements are working properly. Every platform is used differently, and it is important to understand the requirements for each one. Also, the patient may need to have an app downloaded beforehand to make the entire process smoother.

Emergency Outage Plan

Planning can go a long way to prepare for an emergency situation during a telehealth appointment. If an emergency outage situation occurs, answer the following questions with the patient before or at the beginning of their first appointment:

• What is your current location?
  • Confirm the patient’s exact location and obtain their full address.
• What is the information for your emergency contact?
  • There should always be more than one number given in case disconnection occurs.
• Do you have an alternate way of contacting the clinic if disconnection occurs?
  • If not, this needs to be made known at the beginning of the call.
• Do you have an alternate video platform to use if disconnection occurs?
  • If so, this needs to be communicated with the provider at the start of the call.

Patient Information Security/HIPAA Protocols

This Washington Telehealth Training course recommends that all telehealth services provided by insured health-care providers and health plans must comply with the established HIPAA rules according to the Health Insurance Portability and Accountability Act of 1996. The HIPAA rules are in place to ensure that both paper and digital medical histories remain private. During the actual call, the health care provider is required to call the patient from a private setting such as their office or an appointment room. The patient should also be in a private, safe location in which they can freely discuss their health.

There are four important ways to stay compliant with the telehealth HIPAA regulations, 1) check one’s remote communications, 2) double-check the tracking of data, 3) keep all vendor agreements in writing, and 4) protect any and all stored communications.

Connecting Interpreter Services to Telehealth

Many virtual meeting platforms offer an option to connect an interpreter if requested by the patient. Once conencted, a Language Line can be added to the address book that enables the interpreter to be accessed. The service assists in building trust, reducing misunderstandings, and improving the overall patient experience. The patient will be connected to experienced professionals who will securely and patiently assist those with language barriers to make important healthcare decisions. The patient can also access telehealth resources translated from English on the platform that allows the patient to view the information in their own preferred language.

Billing and Documentation Protocols

When submitting documentation for a telehealth visit, the following elements must be included: date of visit; consent for visit from the patient or patient representative (either verbal or written consent); category of office visit, real-time audio with audio/telephone or video only.

In order to ensure that medical records are accurate and supported by telehealth services, the following must be documented in the health record (6):

• Method of telehealth (video connection, phone call, etc.)
• Location of provider (name of clinic, city, home, other)
• Listing of all clinical participants, roles, and actions
• Member location (name of clinic, city, home, other)
• Time actually spent in medical discussion – start/stop times.
• Patient consent – documented confirmation or verbal consent must be documented

Telehealth Visit

Guidelines

Just as bedside manner encompasses much more superficial appearance, web-side manner transcends how an individual looks on camera, including empathy and understanding for patients regardless of physical distance. The same standards apply for in-person visits, but a patient is likely to observe and evaluate how the telehealth visit goes based on the visual manners given during the visit. The medical professional should be dressed in an appropriate and professional manner. The lighting, angle of the camera, and background are all important factors to consider when doing a telehealth visit. This Washington Telehealth Training course provides the following fundamentals for each telehealth visit:

• Ensure that all professional identification is within clear view for the patient.
• Place yourself in the center of the video frame. You are the focal point – not the background.
• Ask the patient for a contact phone number or alternative communication in case a disconnection occurs.
• If this is the first telehealth visit with the patient, consent must be obtained.
• Ensure that you are HIPAA-compliant by confirming that anyone else in the room and is approved by the patient and that the patient is comfortable performing the visit.
• Position lighting to reduce any glare or spotlights. Uniform lighting is the best and allows the patient to see your face.
• Eliminate background items which may distract the patient.
• Confirm the patient’s location to ensure you have the proper licensure.
• Ask the patient to make any rearrangements regarding furniture, lighting, or body position in order to give you a better view of the patient and a more accurate exam.

Telehealth is not for everyone or for every medical condition. It is important for an individual to discuss the risks, advantages, and disadvantages with one’s healthcare provider.

How to Start a Telehealth Visit

This Washington Telehealth Training course recommends the following four steps will help you successfully conduct a telehealth visit from start to finish:

1. Ensure the patient has the resources to schedule a telehealth appointment– patients need to be aware of how to schedule an appointment and how to contact a customer service representative if any problems arise.
2. Prepare for the telehealth visit – send the patient a reminder a day before the appointment reminding them to connect 10 minutes prior to the appointment for registration and check-in. The co-payment can also be collected at this time.
3. Conduct the telehealth visit – the provider should carefully review the patient’s chart and medical history just as they would for an in-person appointment. Additionally, any messages or information in the patient portal should be reviewed and imported beforehand. The provider should start the visit note, use the appropriate telehealth template, and begin the visit. A proper web-side manner should be implemented the entire time with intentional listening and clear communication. During the evaluation, the provider will document any complaints and symptoms reported by the patient. Note any assessments or treatment plans including the proper diagnosis codes, orders, mediations, and relevant instructions. After ending the telehealth visit, the provider should complete any documentation and sign the note.
4. Follow up and complete the telehealth coding and billing – the practice should send a follow-up text message or email the day after the appointment offering contact information for any questions or concerns with a link to a patient survey. The patient can log into the patient portal to review a summary or the visit, education resources, pay a balance, and communicate with the practice if needed.

The following can three diagnostic errors that may create issues during telehealth visits: 1) inadequate history taking due to poor or inadequate communication, 2) limited physical examinations such as the omission of auscultation and accessibility of private areas of the body, and 3 )reliance on patients and their families to accurately measure vital signs, report them, and describe physical findings.

Diabetic Ketoacidosis Management

Introduction   

Diabetic ketoacidosis is considered one of the most life-threatening complications of diabetes mellitus. More importantly, it is also one of the most preventable complications of diabetes. Through proper education and empowerment of persons with diabetes to self-manage this chronic medication condition, the overall mortality rates associated with this complication have steadily declined in the United States. An interdisciplinary team approach (including medical providers, social workers, case managers, and community resources) has been proven to reduce recurrences of DKA in vulnerable populations. (2)

Definition

DKA, or diabetic ketoacidosis, is defined as the potentially life-threatening medical condition that occurs in people with diabetes. While it usually occurs in persons with type 1 diabetes mellitus, who are dependent on daily insulin injections, it may also occur in individuals with type 2 diabetes for a variety of reasons (underlying physiologic stress, such as an acute infection or trauma, or uncontrolled blood glucose levels and missed routine diabetic medications).

In an acute case of diabetic ketoacidosis, the body is not producing enough insulin to move glucose into the cell for energy, and the liver then begins to break down fat for fuel instead, producing ketones. This buildup of ketones in the body results in ketoacidosis. Left untreated, diabetic ketoacidosis can lead to a diabetic coma and eventual death. (3)

Epidemiology

Epidemiology is the study of how often a disease process occurs in different populations. By studying the rates of occurrence, epidemiologists are able to evaluate treatment options and develop long term strategies to lower the risk of ongoing or recurrent disease related episodes.

Diabetic ketoacidosis is currently a leading cause of both morbidity and mortality in children with Type 1 diabetes. It usually occurs at the time of the initial diagnosis in as much as 30-40 percent of the children in the United States alone. In children living with a confirmed Type 1 diabetes condition (previously diagnosed), these percentages decrease to average rates of 6-8 percent annually.

The drastic reduction of such occurrences is believed to be directly related to ongoing patient and family education and medication adherence. Diabetic ketoacidosis is potentially life-threatening, but it is for the most part, also preventable. Throughout this educational offering, key components of patient education in diabetic self-management, including reducing the risk of diabetic ketoacidosis, will be discussed (4) (5).

By comparison, other countries, challenged by annual income, healthcare access, cost management, and food insecurity, do not fare so well. Various studies were funded by the Leona M. and Harry B. Helmsley Charitable Trust, and the Juvenile Diabetes Research Foundation Ltd. Several countries included in these studies were deemed “LLMIC” (low and low middle-income countries). Countries, including Haiti, Ethiopia, Senegal, Nepal, and Tanzania, to name a few were found to have inadequate supplies, medications, and equipment to both initially diagnose, and successfully manage diabetes mellitus long term. Critical items necessary for the treatment and stabilization of acute diabetic ketoacidosis were in even shorter supply. These barriers to treatment resulted in delayed or missed diagnosis, increased overall complication rates and premature deaths.

“Evidence from single-center studies suggest that DKA in new-onset T1D is more common in LLMICs compared to upper and upper-middle income countries, with rates ranging from 62.2 to 77.1% in Nigeria, 69.8% in South Africa, and 92.1% in Sudan. In comparison, in upper and upper-middle income countries in North America and Europe the rates range from 14.7% (Denmark) to 42.0% (France”). (6)

Ongoing education of healthcare professionals and patients/families alike, coupled with availability of and easy access to self-management medications, and monitoring equipment, positively affect DKA related health outcomes and quality of health and well-being.

The development of insulin delivery systems (insulin pumps) has further positively impacted the rate of DKA occurrence. Patient comfort, ongoing education, streamlined medication delivery and enhanced monitoring systems have afforded patients with diabetes a better understanding of their condition and empowered them to successfully self-manage their health conditions. While reported rates of DKA in previously diagnosed persons with T1DM were 6.3% in one study, that number decreased to 2.2% at 3 years out.

Ongoing improvements in closed insulin delivery systems medication continues to improve (lower) DKA occurrence rates, when compared to those previously using multiple daily injection therapy. The development of continuous glucose monitoring (CGM) devices, in addition to insulin delivery systems, provides for early detection and treatment of both hypoglycemia and hyperglycemia. The addition of remote app devices further allows constant monitoring and two-way communication between patients, family members, and even healthcare providers.

Sadly, the population identified as being at highest risk for DKA is that of children who are uninsured/underinsured, lacking the insurance coverage for many closed delivery medication systems as well as specialty care (pediatric endocrinology) provider access.

The acute complications associated with DKA account for a high percentage of premature deaths in T1DM patients under the age of 30 years old. (7) Given these statistics of prevalence and incident rates, DKA is an ever-increasing global concern which is best addressed and managed through ongoing, patient specific disease management education.

The prognosis for DKA worsens in the presence of coma, hypotension and in the presence of severe (chronic and acute) comorbidities. Yet, with early identification, ongoing education, and improved glucose monitoring/treatment options, DKA, often life threatening, is also highly preventable. The goal, therefore, is to ensure all patients with diabetes mellitus are given equal opportunity to access both the education and materials necessary to successfully monitor their health condition. (8)

Pathophysiology

Diabetic ketoacidosis occurs when the body is under stress and responds with an increase in catecholamines, cortisol and growth hormones. The release of such hormones decreases the ability of insulin, further increasing insulin resistance and resulting in serum hyperglycemia. Without cellular glucose for energy the body then begins to break down fat and protein for energy, resulting in increased levels of serum ketones. The combination of hyperglycemia and ketosis, as well as dehydration and various electrolyte imbalances, form the basis of diabetic ketoacidosis. (9)

While it is believed that the omission of insulin (nonadherence/ noncompliance, or mechanical failure of insulin delivery systems) accounts for the largest percentage of DKA admissions, other factors may be responsible for the development of this condition. Any disease process that increases insulin resistance, impairs insulin secretion, or interferes with carbohydrate metabolism may contribute to the onset of acute diabetic ketoacidosis in a vulnerable, health compromised patient.

Clinical Signs and Symptoms

Diabetic ketoacidosis is caused by the underlying presence of hyperglycemia, ketoacidosis and ketonuria. Early signs and symptoms may include any of the following:

• Generalized weakness and fatigue.
• Nausea and vomiting
• Diffuse abdominal pain.
• Decreased appetite and anorexia.
• Decreased/ altered levels of consciousness, such as mild disorientation and confusion.
• Dry skin and mucus membranes and decreased perspiration
• Tachycardia (increased heart rate) and tachypnea (increased respiratory rate)
• Acetone/ketone smell on breath
• Significant weight loss (usually a rapid onset in the newly diagnosed Type 1 diabetes mellitus patients)
• A patient history of noncompliance with prescribed insulin therapy (due to coexisting medical issues in which patient may have intentionally stopped insulin due to decreased food/fluid intake), costs factors (unable to afford prescribed therapy) and missed insulin doses (mechanical failure of the patient’s current insulin delivery system).

Additional signs and symptoms may be present, related to the patient’s age. While an adult patient would be able to verbalize symptoms, a child may not be able to do so, especially in cases where the diagnosis of T1DM is done during their initial presentation to an emergency department for suspected DKA.

In all cases, there may be other factors (illness, injury, medication side effects) that cause DKA to occur; thus, thorough examination and diagnostic testing must be done in all cases prior to initiation of treatment. Likewise, discharge planning and ongoing follow-up care must be patient specific to address behaviors and treatments required for optimal health maintenance.

Teens/Young Adults

In the teenager/ young adult population, the following symptoms may occur: (11)

• Increases in urination, thirst, and appetite.
• Unintentional/ unexplained weight loss despite increases in food and fluid intake.
• Changes in energy level (increased fatigue)
• Vision changes

Please note that normal growth and development stages/patterns in a teenager/young adult will influence glucose metabolism (related to hormone levels).

Young Children

In the young children’s population, symptoms usually strike suddenly and, unlike the adult population, are usually not related to a specific lifestyle or dietary practice. Most children present with the following symptoms:

• Increased urination
• Increased thirst
• Fatigue
• Vision problems (blurred vision)
• Acetone/ketone “fruity smell” on breath
• Unexplained weight loss, often despite appearing to eat (and drink) more.
• Changes in mood and behavior

Infants/Toddlers

In the infant/toddler population, symptoms may present as follows:

• Increased food and fluid intake (always appearing thirsty despite normal fluid intake)
• Frequent urination (in the potty-trained child, this may present as a new onset of bed wetting behaviors)
• Increasing fatigue and changes in normal activity levels
• Unexplained weight loss despite increased food and fluid intake
• Increased occurrences in diaper rashes (suspected increase in yeast infection)
• Fruity/acetone smell to breath
• Unusual behavior (child specific)

Etiology

Etiology: Causes of Diabetic Ketoacidosis

Hyperglycemia and low insulin levels lead to diabetic ketoacidosis. Common causes include the following:

• Acute illness, altering a person’s intake of food or drink, makes glucose management more difficult. This is a two-fold situation. The person with diabetes, recognizing the change in their normal food/fluid intake may also choose to intentionally decrease/skip their routine diabetic medications to avoid episodes of hypoglycemia.
• Insufficient levels of insulin due to the demands of normal growth and development patterns in children and young adults.
• Missed insulin doses (intentional decision to take inadequate doses, inadvertently held doses, inaccurate dose amounts, clogged insulin pump tubing).

Other causes of DKA, unrelated to insulin dose administration, are thought to be related to increased stress levels (inflammation/ infection) and normal hormone disruption, physiologic stressors. Persons with Type 2 diabetes may experience DKA due to prolonged, untreated hyperglycemia. (12), (13)

• Myocardial infarction
• Neurological stroke
• Motor vehicle accident with physical injuries (inflammatory response to blunt force/penetrating trauma)
• Abuse of alcohol and illegal drugs
• Medication side effects (diuretic and corticosteroid *use) see below
• Severe or prolonged illness (such as pneumonia and urinary tract infection/ urosepsis/wound infections)

Etiology: Precipitating Factors

Common precipitating factors for diabetic ketoacidosis include the following (14):

• Poor compliance with prescribed insulin therapy (intentional, nonintentional)
• Infections (especially T2DM in the elderly/ adult population)
• Newly diagnosed diabetes (especially T1DM in the pediatric/juvenile population)
• Physiologic based stressors, including coronary syndrome, cerebral vascular accidents, ischemic injuries, shock like states, chronic alcoholism, illicit drug use and certain antipsychotic medications.

Etiology: Diabetic Ketoacidosis and Corticosteroid Use

Diabetic ketoacidosis is related to long term corticosteroid usage. yperglycemia has been reported in a large percentage of patients who are using corticosteroids long term, often as high as “64-71%”. The elevated glucose levels combined with the ongoing physiologic stressors warranting use of these medications, increases the risk of DKA. The benefit/risk of using these medications long term must be assessed, especially in patients with pre-existing metabolic risk factors. Ongoing patient monitoring is essential to lower the risk of long-term complications. (15) (16).

Risk factors that “may” increase the likelihood of developing type 2 diabetes after long term steroid usage include the following:

• Overweight (BMI 25.0 -29.9 percent) / obesity (BMI 30 percent or above)
• History of gestational diabetes
• History of polycystic ovarian syndrome
• History of family members with type 2 diabetes

Treatment

Emergency Treatment

The initial or emergency treatment of diabetic ketoacidosis may require complex, frequent monitoring, often necessitating an intensive care admission. The following generic guidelines refer to intensive care nursing management. Please refer to your specific organization for nursing protocols related to DKA management. Many facilities have strict admission guidelines to ensure the appropriate use of intensive care resources. With respect to patients with DKA, suitable ICU admissions may include the following:

• A newly diagnosed diabetic during an episode of DKA
• Any infectious disease condition that triggers an episode of DKA
• An episode of DKA occurring concurrently with a physiologic stressor event (acute myocardial infarction, cerebrovascular accident/stroke)

The goals of emergency treatment of diabetic ketoacidosis are multifactorial and listed below. Interventions will include, but not be limited to, insulin intravenous infusions, hourly vital sign monitoring (or more frequent), and hourly glucose checks.

• Treatment/correction of dehydration with IV fluids
• Treatment of hyperglycemia with insulin therapy
• Treatment of electrolyte imbalances
• Treatment/correction of acid-base imbalance

Initial/Emergency treatment of DKA includes (20):

• Initial assessment and stabilization ABC airway, breathing and circulation.
• Aggressive fluid therapy to restore circulating volume.
• Isotonic saline IV infusion
• IV with dextrose component once glucose level 200-250mg/dl

Laboratory Findings

The following laboratory ranges provide a generic overview of normal ranges and abnormal findings associated with DKA (17) (18) (19). The confirmation of acute diabetic ketoacidosis is dependent on both laboratory findings as well as patient assessment. Please refer to your specific medical organization (unit specific) for further guidance and treatment parameters.

• Serum potassium levels: Normal range (3.5 to 5.0 mEq/L) hyperkalemia range approximately 5.0 to 5.5mEq/L. 
• Serum sodium levels: Normal range (137 to 142 mEq/L) severe hyponatremia range approximately 125mEq/L or lower; severe hypernatremia range above 145mE/L 
• Serum Amylase level: Normal range (40 to 140 units per liter) (U/L); may be elevated in cases of pancreatitis/ pancreatic inflammation, which may coexist with DKA 
• Serum Lipase level: Normal range (0-160 units per liter) (U/L); may be elevated in cases of pancreatitis/ pancreatic inflammation, which may coexist with DKA 
• Serum Osmolality level: Normal range 275-295 mOsm/kg: may be elevated to between 300-320 mOsm/kg in DKA       
• Arterial blood gas analysis: Arterial ph below 7.3 (normal range 7.35-7.45)   
• Anion Gap: Normal 4-12 mEq/L ; levels above  > 10 may indicate existing acidosis in DKA 
• Serum glucose level (normal fasting below 100mg/dl). Hyperglycemia range above 250mg/dl 
• Serum ketone level (normal negative); serum ketones detected in blood; usually greater than 5mEq/L       
• Serum bicarbonate level (normal 22-29 mEq/l); usually less than 18mEq/L  
• Anion gap level (normal 4-12mmol/L); usually greater than 12 mmol/L)

To rule out physiologic stressors associated with the development of DKA (systemic infections, acute myocardial infarction, pneumonia, urosepsis), refer to your medical organization (unit specific) guidelines regarding these additional diagnostics:

• Serial blood and wound cultures
• Serial EKG and Troponin levels
• Sputum cultures and sensitivity
• Urinalysis and culture with sensitivity
• Chest Xray

Fluid Resuscitation Guidelines

The American Diabetes Association (ADA) recommends the following initial fluid resuscitation in the adult population; additional boluses may be required after each hourly reassessment: (21). Please refer to your unit specific guidelines regarding fluid boluses, and fluid resuscitation. Caution in use with patients with preexisting heart failure, kidney failure or other medically indicated “fluid restrictions”.

0.9% SC (Sodium Chloride Solution) initially as a 15–20 mL/Kg bolus for hemodynamic resuscitation

• then 250–500 mL/h of fluid until glucose is normalized (usually faster than DKA resolution) 
• then 150–250 mL/h until DKA resolution  
• For the replenishment, 0.45% SC (Sodium Chloride Solution) unless hyperglycemia-corrected hyponatremia is present.

In the pediatric population, fluid resuscitation boluses are indicated in children who present with the following symptoms: (22)

• Dry mucus membranes 
•  Poor skin turgor 
•  Lethargy; altered level of consciousness. 
• Nausea and vomiting 
• Tachycardia and tachypnea 
• Kussmaul type respirations (deep and labored respiratory breathing patterns)

Fluid recommendation: 10–20 mL/kg bolus of isotonic saline given over 30–60 mins.

Insulin Therapy and Acute Diabetic Ketoacidosis

Intravenous use of insulin is preferred in patients with acute diabetic ketoacidosis, as subcutaneous absorption of insulin would most likely be ineffective in light of dehydration.

Intravenous continuous infusion of insulin at a rate of at 0.14 U/kg/hour or

Insulin bolus of 0.1U/kg, followed by insulin continuous infusion at a rate of 0.1U/kg/hour.

Hourly (or more frequent glucose checks) with a decrease in insulin delivery dose when glucose level is 250mg/dl or less. At this time, insulin dose is further decreased to 0.05 or 0.1U/kg hourly until DKA is resolved. 

• Patients, once stabilized and deemed able to eat, can be transitioned to subcutaneous insulin administration and routine glucose monitoring (point of care/ POC glucometers)

Laboratory Tests Guidelines Therapy Goals

• Serum glucose levels below 200mg/dl 
• Serum bicarbonate level greater than 15mEq/L 
• Serum potassium level 4.0 -5.0 mEq/L 
• Venous pH greater than 7.30  
• Anion gap equal to/less than 12eEq/l. (23)

Electrolyte Imbalance (Hyperkalemia-> Hypokalemia)

Serum potassium levels are usually high/elevated due to the cellular changes occurring as the result of acidosis and decreased insulin. Electrolyte replacement should be monitored very closely in diabetic ketoacidosis. During the rehydration/ volume restoration phase and insulin administration, extracellular potassium shifts back into the intracellular space (causing hypokalemia). In addition, insufficient insulin levels may deplete various serum electrolytes; thus, frequent serum electrolyte levels with appropriate intravenous replacement ensure proper cellular activity.

Treatment-Related Complications

• Hypoglycemia (blood glucose levels below 70mg/dl); treat; accordingly, patient should be transitioned to subcutaneous insulin injections when serum glucose level 200-250mg/dl, and patient is able to tolerate oral intake.
• Hypokalemia (blood potassium levels below 3-3.4 mmol/L); intravenous therapy to include potassium supplements; oral supplements as tolerated once patient transitions to diabetic diet.
• Cerebral edema

Cerebral Edema

Cerebral edema, or brain swelling, occurs for a variety of conditions (brain tumors, blunt trauma, inflammatory conditions, and even infections). Diabetic ketoacidosis and hyponatremia can cause cerebral edema. (24) Cerebral edema is the leading cause of mortality in children. A normal ICP (intracranial pressure) reading is 7-15mmHG; an increased reading in excess of 20-25mmHG, coupled with the following symptoms, may be indicative of cerebral edema.

Initial symptoms of cerebral edema may include the following:

• Headache 
• Visual changes (double vision (diplopia) or blurred vision) 
• Changes in speech/ ability to talk/ personality. 
• Nausea and vomiting 
• Changes in level of consciousness (lethargy-> unresponsiveness) 
• Changes in respirations/ difficulty breathing

Symptoms that may indicate worsening of cerebral edema. 

• decorticate and decerebrate posturing. 
• cranial nerve palsies  
• fluctuating level of consciousness 
• sustained heart rate deceleration, 
• increased vomiting, headache, and lethargy 

Confirmation Testing: 

• CT (Computerized Tomography) scan 
• MRI Magnetic Resonance Imaging

Treatment for DKA Related Cerebral Edema

When cerebral edema is confirmed by radiologic testing, the administration of Mannitol (or hypertonic sodium) is recommended as follows (25) (26):

• 0.5-1 g/kg intravenous mannitol may be given over the course of 20 minutes and repeated if no response is seen in 30-120 minutes.  
• If no response to mannitol occurs, hypertonic saline (3%) may be given at 5-10 mg/kg over the course of 30 minutes. 
• Additional treatments may be warranted, including diuretics, corticosteroids, and possible surgical intervention (to prevent herniation syndrome).

Nursing Care and Management

Nursing Care: Patient Placement

Initial/hourly (or more frequent) assessment to include the following:

Due to the frequency of monitoring and medication administration during the acute phase of DKA, patients are usually placed in the Intensive Care Unit. ICU treatment often includes hourly physical assessments (intake, output, neurological assessment, vital signs; frequent laboratory testing (glucose testing); and rapid identification of complications (cerebral edema, hypoglycemia, hypokalemia).

Transfer to a step-down unit usually occurs when the patient is fully awake, tolerating oral intake (both solid food and liquids), vital signs are stable, and fluid and electrolyte replacements are complete. The average timeline may be 1-2 clinical days. The focus of care now shifts to discharge planning, patient education, and ongoing management.

Nursing Care: Acute Phase

• Monitoring of vital signs, level of consciousness/ neurological status, urine output
• Administration of IV fluids as ordered.
• Frequent blood glucose assessment and insulin administration

Nursing Care: Patient Education, Discharge Planning, and Follow-up Care

• Compliance with medications, healthy diet, glucose monitoring, sick day management
• Signs and symptoms of infection
• Importance of follow-up care with primary medical provider/endocrinologist
• Lifestyle behavior changes (smoking cessation, physical activity, healthy diet)
• Medical Alert ID bracelet or wallet insert regarding chronic medical conditions and medication.
• Coordination of follow-up care to ensure ongoing medical support, educational services and financial assistance when appropriate (medical provider, endocrinologist, pharmacist, social worker/ case management services, DSMES classes) (27)

Patient Education

Diabetes Self-Management Education and Support (DSMES)

The Centers for Disease Control and Prevention offer a Diabetes Self-Management Education and Support Toolkit on their website available to the public, designed for various health organizations/ community organizations and others interested in educating persons with diabetes to live a healthier lifestyle. Studies have shown that people who receive such education have better overall health and wellbeing. Despite these studies, a very low percentage of those qualified to receive such services access them. Check out the link below for more information.

• DSMES Program Review: https://www.cdc.gov/diabetes/dsmes/index.html
• DSMES Tooliit: https://www.cdc.gov/diabetes/dsmes-toolkit/index.html

Additional Resources

The following websites are being provided to assist the healthcare professional in accessing appropriate diabetes related information, including insulin coverage, food insecurities, food bank locations, and DSMES information. https://diabetes.org/

The American Diabetes Association provides information on prediabetes, Type 1, and Type 2 diabetes, as well as gestational diabetes. Included on their website are sections on medications, support groups, diet and activity, advocacy efforts, and prevention efforts. https://www.jdrf.org/

The Juvenile Diabetes Research Foundation is a global organization for Type 1 diabetes mellitus. The site offers information on all things T1DM, including sections for those newly diagnosed, those interested in fundraising, research and clinical trials, daily diabetes management, volunteer opportunities, and access to local chapters worldwide. From the healthcare provider perspective, this website offers continuing education programs and pdf downloads for patient specific education. https://getinsulin.org/

The Get Insulin website provides information for persons with diabetes to access affordable insulin coverage. The site also offers information and guidance on health insurance plans, an insulin related newsletter, and external links to food sources (for patients with food insecurity issues) https://www.feedingamerica.org/find-your-local-foodbank

The Feeding America website enables persons with food insecurities to access food banks in their area, according to state location and zip code.

Patient Education and Follow-up Care (DSMES)

DSMES, or Diabetes Self-Management Education and Support, is the gold standard when it comes to patient education on this chronic medical condition. The goal of this education is to educate and empower the patient to successfully manage their medical condition, in efforts to lower the risk of long term, lifetime complications. DSMES is considered an ongoing process, and is recognized as an integral part of patient education at various critical points in their lifetime:

• At time of initial diagnosis
• During all patient medical appointments and routine follow-up care
• At time of onset for newly diagnosed complications
• Anytime a patient expresses concern over current diabetic management challenges.

Medicare and Medicaid

Medicare (Medicare Part B) and Medicaid plans currently offer the following coverage for diabetes related education (28):

• 10 hours of education (combined individual and group training) for an initial diagnosis of diabetes
• 2 hours of follow-up training annually after initial training completion

Qualifying Labs for DSMES

In general, a patient must be diagnosed with type 1, type 2, or gestational diabetes to qualify for DSMES, such as:

• Fasting Blood glucose of 126 mg/dL on 2 separate occasions
• 2-hour Post-Glucose Challenge of ≥200 mg/dL on 2 separate occasions
• Random Glucose Test of >200 mg/dL with symptoms of unmanaged diabetes

DSME Contents Overview

• Diabetes disease process pathophysiology and treatment to increase risk reduction for long term complications.
• Healthy eating includes meal planning, food label reading, carbohydrate counting, and strategies for eating out.
• Physical activity includes the benefits of activity as they related to better weight control, sleep habits and stress reduction.
• Medication usage overview to include medication administration, side effects, storage and cost issues.
• Blood glucose monitoring and management to include proper use of monitoring devices and associated equipment cleaning/repair.
• Prevention of complications (early detection, treatment, acute and chronic complications such as kidney disease and nerve damage; proper foot care)
• Healthy coping strategies to include stress reduction, effective self-management behaviors, and symptom recognition (hypoglycemia/hyperglycemia)
• Sick day management includes intake/output monitoring, over the counter medication usage, carbohydrate counting, ketone assessment, fever control and when to seek emergency services.
• Problem solving to include diabetes management during emergencies (power outages, flooding, tornados, hurricanes)

For more DSMES information visit: https://www.cdc.gov/diabetes/dsmes/dsmes-living-with-diabetes.html

Safety Considerations (Sick Day Management)

Successful management (prevention) of diabetic ketoacidosis requires patient education and empowerment in managing situations where glucose levels may be elevated and/or insulin levels (doses) are substandard (29).

There are many situations that can put a patient at risk for the development of DKA, including the following (29):

• Illness (acute and chronic), affecting normal food and fluid intake which negatively affects glucose management.
• Missed medication (insulin therapy) due to a clogged insulin pump tubing, a malfunctioning insulin pump, partial doses/skipped doses of insulin (whether related to costs, cognition, or mental health issues {diabetes distress}),
• Medication side effects
• Concurrent use of alcohol or drugs
• Physiologic stress (heart attack, stroke, physical injury)

Patient Education: Sick Day Management

Home treatment/ self-care (30)

The importance of preplanning cannot be understated. All persons with diabetes should have adequate supplies at home, to address an acute illness, including medications to treat basic symptoms before they escalate. These medications may include over the counter medications to treat pain, nausea, vomiting, diarrhea, as well as adequate supplies to manage their diabetes (alcohol prep pads, syringes, prescription medications).

In addition, it is important to stock up on diabetic friendly foods and drinks to maintain nutrition and hydration levels during an acute illness. Such items might include sports drinks, soft drinks, instant cooked cereals, puddings, soups. In the event that a patient cannot eat their regular meals, the goal is to eat or drink 50 grams of carbohydrate every 4 hours to maintain glucose levels.

Sick Day Management Guidelines

• Monitor glucose levels every 4 hours.
• Stay hydrated – 4 to 6 ounces of fluid every ½ hour to prevent dehydration.
• Daily weight
• Temperature checks (rule out underlying infection)
• Current medication compliance- do not stop taking insulin or diabetic oral agents ** notify provider immediately if you choose to stop medications.

Seek emergency care for the following signs/ symptoms:

• Persistent vomiting/diarrhea to the point that you cannot tolerate any food or fluid intake for several hours
• Ongoing glucose levels above 240mg/dl
• The presence of moderate/high levels of ketones in urine
• Unexplained weight loss during an illness
• Any difficulty breathing
• Fruity/acetone smell on breath
• Changes in gait/balance/ vision

Research Findings

Research: Diabetes Distress and Burnout

Diabetes is a 24/7/365 chronic medical condition. Unlike many conditions that are simply managed with lifestyle changes or a single, once a day medication regimen, diabetes mellitus requires lifelong, around the clock commitment. Whether diet, activity, or medication management, a person with diabetes may easily feel overwhelmed by even the basic requirements for self-management. (31)

Ongoing health challenges, comorbid medical conditions, medication and diet cost issues and family dynamics can all affect a person’s ability to successfully manage any health condition. When emotions (sadness, anger, hostility, frustration, and even fear) become overwhelming, diabetic distress (a feeling of defeat) can often occur. Without prompt, patient specific interventions (mental health services, financial assistance, self-management education), these feeling will progress to diabetic burnout, and increase the risk of unhealthy habits (poor medication adherence and overall glycemic control). (32)

Diabetes distress can easily progress to diabetes burnout without appropriate ongoing medical treatment and mental health interventions. When a person with diabetes reaches the point of burnout, they often appear to disconnect from their routine healthcare, exhibiting indifference towards their overall health and well-being. They may become both mentally and physically exhausted from the daily requirements of this chronic medical condition. At this point, it is not uncommon to observe a person’s total disregard for their ongoing medical treatments, daily medications, routine self-care, and more. Missed medications, missed medical appointments, poor dietary intake, and a visible lack of basic hygienic practices are cause for concern.

A multidisciplinary approach to treating suspected diabetic distress and burnout is highly encouraged. From ongoing education, physical and mental health assessments, and enrollment in therapies (individual therapy sessions, and support groups), the person with diabetes needs a supportive environment in which to become empowered in the self-management of their disease progress. In doing so, it is believed that health outcomes are optimal, and the risk of long-term complications is lowered. (33)

Reserach: Diabulimia

Bulimia nervosa is a potentially life-threatening eating disorder characterized by episodic binge eating of large amounts of food, followed by forced vomiting and possibly laxative use to then “purge” the food. These alternating behaviors are the result of a person fearful of weight gain and willingness to lose weight in unhealthy ways. (34) (35)

Diabulimia is a serious, life threatening eating disorder affecting persons with Type 1 diabetes. Through intentional restricted/ limited use of prescribed insulin, weight loss occurs. This eating disorder is more common in young female adolescents and young adults. (34) (35)

Signs and symptoms may include the following (34) (35):

• Unexplained weight loss
• Hemoglobin A1C > 9
• Multiple episodes of DKA
• Unfilled insulin prescriptions, missed diabetes related medical appointments,
• Expressed fear of insulin related weight gain
• Anxiety related to body image
• Obsessive interest in calories and dieting

Research: Insulin Affordability

For many persons with diabetes, the perceived noncompliance with therapy (on behalf of the healthcare professional) is actually that of a cost related issue. Many persons cannot afford ongoing therapies related to management of this chronic medical condition. In attempts to “cut costs”, patients have admitted to skipping certain medications, cutting medications in half, reducing prescribed doses of insulin, and purchasing poorer quality, less expensive foods (that are often lacking in nutritional value). Poorly controlled / uncontrolled diabetes heightens the risk of both acute and chronic complications.

In an attempt to ensure accessibility and affordability of insulin therapy to persons with diabetes, the Inflation Reduction Act of 2022 in part ensures that persons with diabetes on Medicare pay no more than $35 for a month’s supply of insulin product under their prescription drug coverage. Similar drug coverage benefits were also extended to many state-based insurance plans. (36)

In addition, most Medicaid insurance plans, as well as private insurance companies have now enacted reduced insulin costs/ cost sharing programs. Finally, for patients with no insulin costs benefits, many national insurance providers offer free/ reduced cost insulin through their patient assistance program. For a comprehensive list of these resources, please see the following website link (American Diabetes Association): https://diabetes.org/tools-resources/affordable-insulin

Research: Insulin Delivery Systems

With the creation of advanced insulin delivery /monitoring devices (insulin pumps, and continuous glucose monitoring devices), the person with diabetes is afforded a more streamlined process to control their chronic medical condition. Most patients using such devices report better glucose control {“time in range”}, meaning the time their blood glucose levels remained in an acceptable range, ease of portability (of supplies), increased comfort (no more finger sticks), and decreased rates of anxiety, depression and distress.

The following website links represent various insulin delivery devices. Consider making a resource book containing various delivery devices for your specific unit (or hospital organization). Many have 24/7 customer service representatives available if you need to trouble shoot a device suspected of malfunctioning or require additional staff/patient educational resources.

This list contains a variety of websites but is not all inclusive. If you are caring for a patient with an insulin delivery device in place, please contact that specific company for more directions on its usage, removal, replacement parts and more.

Examples of insulin delivery devices:

• Makers of the MiniMed 780G System and the MiniMed 630G system: https://www.medtronic.com/us-en/healthcare-professionals/products/diabetes/insulin-pump-systems.html
• Makers of the Omnipod 5 and the Omnipod DASH Insulin Management System: https://www.omnipod.com/
• Quick overview of various insulin pumps currently on the market: https://consumerguide.diabetes.org/collections/pumps

Case Studies

Case Study #1

A 3-year-old female child is sent, by ambulance, from her local pediatrician’s office with reports of increased lethargy, increased thirst and appetite, and new onset of bedwetting (child had stopped wearing diapers at age 2.5 years). Parents report that the child’s appetite appears increased lately, but pediatrician noted several pounds weight loss since last visit.

• Based on these signs and symptoms alone, what is your initial diagnosis for this child?
• What are your priority nursing interventions for this child?
• How would you assess hydration status on a 3-year-old child?

The child is diagnosed with new onset Type 1 Diabetes and stabilized in the Emergency Department. The parents of this child are visibly distraught over the diagnosis, stating “no one in our family is diabetic; this can’t be happening”.

• What are some of the initial nursing patient/family education areas you could address at this time?
• What are some in hospital consultations that should be considered for this patient and her family?
• What are some community resources you have in your area that you could offer this family?

Case Study #2

A 78-year-old female, with a previous history of CVA, is transferred to your facility from a local nursing home for evaluation of fever and hyperglycemia. The nursing home staff reported the patients’ blood glucose level was 400mg/dl earlier today and her WBC count was 14,500. Upon arrival, the patient is unresponsive, with a temperature 102F , her glucose is 350mg/dl, with +ketones (moderate) and a urinalysis (indwelling catheter) confirms a UTI.

Patient past medical history includes old CVA, T2DM.

• Based on these signs and symptoms alone, what is your initial diagnosis for this patient?
• What diagnostic studies would be warranted in light of hyperglycemia, fever, urinary tract infection, and altered level of consciousness?
• What questions would you ask the nursing home staff, in light of this patient’s initial presentation?
• When this patient is stabilized for transfer back to the nursing home, what information should be included in the discharge instructions/ transfer of care?

Case Study #3

A 60-year-old male present to the Emergency Department with an Acute Myocardial Infarction.

Patient past medical history includes borderline hypertension, and prediabetic HgbA1C 5.8.

The patient was found to have severe coronary artery disease and received Coronary Artery Bypass Graft x 3. During the immediate post operative recovery phase, he receives insulin therapy to control glucose levels >300mg/dl. He is eventually sent home on insulin therapy, pending follow-up with his cardiologist as well as a new consultation for an endocrinologist.

At the time of discharge, the patient is adamant that he was “prediabetic and could easily control my glucose levels with diet alone”; he doesn’t understand how he is now “an insulin diabetic”.

• What are key points in nursing education for this patient, regarding his new “diabetic status”
• How would you explain to the patient the connection between his myocardial infarction, bypass surgery, and currently elevated glucose levels?
• What nursing interventions can you provide PRIOR to discharge to assess his comfort level with insulin injections and glucose monitoring?
• What community resources are available to your patient for a new diagnosis of diabetes?
• The patient wants to know when he can stop the insulin injections. What is your response?

Successful management of acute diabetic ketoacidosis requires resuscitation with intravenous fluids and insulin therapy, replacement of electrolytes and early identification of any events (medical, surgical, and psychological) that contributed to this medical emergency. With the continued increase in diagnosis of diabetes, and ongoing challenges in healthcare costs and coverage, chronic medical conditions will continue to burden the already overwhelmed healthcare arena. By educating and empowering patients to self-manage their disease process, we can lower the risk of long-term complications and improve health outcomes worldwide.

Conclusion

The International Diabetes Federation reports that, in 2021, approximately 10.5 % of the global adult population (ages 20-79 years old) has diabetes, and that nearly 50% of this population are unaware that they are living with this chronic condition. Left untreated, the rates of long-term, nonreversible complications are quite alarming. (37) By the year 2045, it is projected that 1 in every 8 persons (approximately 12.5 %) will be living with diabetes. This will equate to an increase of 46 percent, with nearly 783 million people being affected. This single health condition will represent staggering health expenditures and increased mortality and morbidity associated rates worldwide.

Diabetes ketoacidosis continues to be a potentially life-threatening complication for persons with diabetes. DKA is also, in most cases, a highly preventable condition, with early identification and treatment. The importance of ongoing, patient specific education to address all aspects of diabetes self-management is a key factor in lowering the occurrence of DKA. Dr William Polonsky, a licensed clinical psychologist and certified diabetes educator, is the President of the Behavioral Diabetes Institute in San Diego, California. With regards to the importance of patient education and empowerment, he said the following:

“Well-controlled diabetes is the leading cause of nothing!” Dr William Polonsky. (38)

As healthcare professionals, we have the responsibility to ensure that our patients with diabetes are afforded the education and ongoing support necessary for them to successfully manage their specific disease process. In doing so, we positively impact patient satisfaction, improve medication adherence rates, and lower the risk of long-term complications.

Nutrition for a Healthy Heart

Introduction   

Research indicates that a heart-healthy diet is a powerful tool for the prevention and control of cardiovascular disease [1]. A heart-healthy dietary approach to wellness emphasizes the intake of the appropriate proportions of macronutrients, essential vitamins, minerals, and fiber while minimizing the consumption of saturated fats, trans fats, cholesterol, salt (sodium), and the reduction of processed foods, trans-fats, and added sugars [2] [3]. The cornerstone of the diet includes an abundance of fresh fruits and vegetables, whole grains, lean proteins, and healthy fats [2].  

For healthcare providers and patients, the goal of adopting a heart-healthy diet is multifaceted. The diet aims for a reduction in overall cardiometabolic risk, improving blood pressure, lowering cholesterol levels, reducing the risk of developing heart disease and stroke, and preserving the overall health of the circulatory system [3].  

Nurses play a pivotal role in patient education and promoting heart-healthy lifestyles by empowering patients with knowledge and skills related to nutrition and dietary choices. This course aims to equip nurses with comprehensive knowledge of heart-healthy eating principles, enabling them to guide and educate their patients.  

The adoption of healthy lifestyle choices, with nutrition being the most important behavioral factor, is estimated to reduce the risk of myocardial infarction (MI) by 81–94% [5][6][7]. In comparison, treatment with pharmacotherapies alone results in a 20–30% reduction [8]. 

Heart Disease: A Brief Overview 

Heart disease remains one of the leading causes of morbidity and mortality worldwide, with diet and nutrition playing a crucial role in both its development and prevention [4]. Cardiovascular diseases, also known as CVDs, are the primary cause of death worldwide, claiming an estimated 17.9 million lives per year [4].  

Cardiovascular disorders affect the heart and blood vessels, manifesting in coronary heart disease, cerebrovascular disease, rheumatic heart disease, and others. More than four out of five CVD fatalities stem from heart attacks and strokes, with one-third of these deaths occurring in individuals under the age of 70 [4].  

The term "heart disease" encompasses various conditions affecting the heart's structure and function, many of which are influenced by dietary habits [9]. Cardiovascular risk factors, including malnutrition, tobacco and alcohol use, stress, obesity, sedentary lifestyle, hypertension, diabetes, hyperlipidemia, and genetic predisposition, can increase an individual's likelihood of developing cardiovascular diseases [10] [12].  

The modifiable risk factors include sedentary lifestyle, smoking, high blood pressure, diabetes, hypercholesterolemia [12]. Almost three quarters of patients (73%) had at least three risk factors compared to 31% of healthy subjects. 

Family history of cardiovascular disease (CVD) is a significant independent risk factor for premature coronary heart disease (CHD). The risk of premature CHD increases in a linear fashion as the number of affected family members grows. [11]. Cardiovascular risk factors, including malnutrition, tobacco and alcohol use, stress, obesity, sedentary lifestyle, hypertension, diabetes, hyperlipidemia, and genetic predisposition, can increase an individual's likelihood of developing cardiovascular diseases [10].  

The five modifiable risk factors include sedentary lifestyle, smoking, high blood pressure, diabetes, and hypercholesterolemia [10]. A higher proportion of cardiovascular patients (73%) had at least three risk factors compared to healthy individuals, where less than one-third had three or more risk factors [10]. 

Types of Heart Disease / Statistics 

There are multiple types of heart disease, each with distinct mechanisms and implications for dietary management [13]. Coronary artery disease (CAD), heart failure, hypertensive heart disease, and arrhythmias represent a fraction of these conditions. The four main types of CVD include coronary heart disease, stroke, peripheral arterial disease, and aortic disease [15].  

Coronary artery disease (CAD) is the most common type of heart disease [14]. Cerebrovascular disease is the second leading cause of heart disease. Other forms of heart disease include congenital heart disease, heart valve disease, cardiomyopathy, pericardial disease, arrhythmia, and aortic dissection.  

Congenital heart disease (CHD) is the most common type of birth defect, affecting about 1 in 100 babies born in the United States [16]. CHDs can range from mild to severe and can affect the heart's structure, function, or both [16].  

Heart valve disease is a condition in which one or more of the heart valves are damaged or diseased, which causes blood to flow backward through the valves, damaging the heart and other organs [17]. Heart valve disease affects 2.5% of the U.S population and can be caused by several factors, including infection, injury, and aging [17].  

Heart failure is the heart's inability to pump blood, leading to symptoms such as fatigue, shortness of breath, swelling, chest pain, palpitations, weight gain, swelling in the ankles, legs, and abdomen, bloated or hard stomach, dry and hacking cough, and nausea [18] [19]. More than 6 million adults in the United States have heart failure [18].  

Cardiomyopathy represents a collection of diverse conditions of the heart which makes it weaker and less able to pump blood. Cardiomyopathy can be caused by several factors, including infection, toxins, and genetic disorders [20]. Due to the potential for underdiagnosis, estimates of cardiomyopathy prevalence can vary. It is estimated that up to 1 in 500 adults may be affected by this condition [21].  

Pericardial disease is a condition that affects the pericardium, the sac that surrounds the heart [22]. This can cause inflammation, infection, or scarring of the pericardium, which can interfere with the heart's ability to function. Pericardial disease can manifest as acute pericarditis, pericardial effusion, cardiac tamponade, or constrictive pericarditis [22].  

Arrhythmia is a cardiac disorder characterized by an abnormal heart rhythm, manifesting as tachycardia (excessively rapid heartbeat), bradycardia (abnormally slow heartbeat), or irregular heartbeat patterns [23]. These irregularities can induce symptoms such as palpitations, dizziness, and syncope (fainting episodes) and can arise from various etiologies, including underlying heart conditions, electrolyte imbalances, and adverse effects of certain medications [23]. One in 18 people, or 5 percent of the U.S. population has an arrhythmia with a-fib (atrial fibrillation) being the most common [24].  

Aortic dissection is a rare, life-threatening condition in which the inner layer of the body’s main artery (aorta), tears [25]. This can cause blood to leak between the layers of the aorta, which can weaken the artery and cause it to rupture. Aortic dissection can be caused by several factors, including high blood pressure, atherosclerosis, and connective tissue disorders [25].  

Aortic dissection affects about 30 in 1 million people each year and more than 13,000 die each year [26]. Aortic dissection is most common in those individuals over the age of 60 and if not treated, the tear can worsen, ripping the outer layer of the aorta and allowing blood to escape the artery [25] [26]. As many as 40 percent of individuals who suffer from an aortic dissection die, and the risk of death increases by 3-4 percent every hour the condition is left untreated [26]. 

Evidence on Diet and Heart Health / Diet Options 

When considering the diet options for heart health, the Mediterranean diet, DASH diet, and plant-based diets are among the most researched and recommended. These diets share common elements such as an emphasis on whole foods, minimal intake of red meat, and a high volume of fruits and vegetables. Extensive research has demonstrated that the DASH dietary pattern lowers the risk of cardiovascular disease [37]. Numerous prospective studies have demonstrated the consistent benefits of the Mediterranean diet on cardiovascular health [30]. 

There is substantial evidence that most vascular events may be prevented by avoiding smoking, participating in regular physical activity, maintaining normal body mass index, and eating a healthy diet [27].  

Observational studies have demonstrated that dietary patterns rich in fruits and vegetables, excluding white potatoes, are linked to a lower risk of CVD [28] [29]. Regular consumption of whole grain foods has been linked to a reduced risk of cardiovascular disease (CVD), coronary heart disease (CHD), stroke, metabolic syndrome, and various cardiometabolic risk factors, as evidenced by robust observational studies and clinical trials [28]. Numerous randomized controlled intervention studies have demonstrated that replacing refined grains with whole grains leads to significant improvements in cardiovascular risk factors [28] [31].  

Except for a small trial that demonstrated a reduction in arrhythmia recurrences among regular drinkers with atrial fibrillation upon alcohol abstinence, no other studies have reported favorable outcomes associated with alcohol consumption for cardiovascular health [32].  

Dietary fiber, abundant in plant-based foods like fruits, vegetables, whole grains, nuts, seeds, beans, and legumes, have shown an inverse association with a lower risk of metabolic syndrome and cardiometabolic risk factors [33].  

A systematic review and meta-analysis provided evidence that substituting saturated fat with unsaturated fat can improve cardiovascular outcomes and reduce the risk of CVD [34]. Plant-based diets rich in foods like whole grains, fruits, vegetables, and nuts, have been linked to a reduced risk of cardiovascular events and intermediate risk factors [36].  

Current evidence does not support the widespread use of high-dose vitamin and mineral supplements for the prevention of cardiovascular disease (CVD) [28]. 

Role of Sodium and Fats 

Sodium and fats hold significant impact over heart health. High sodium intake is associated with hypertension, a risk factor for heart disease, while certain types of saturated and trans fats, are linked to an increase in LDL cholesterol and the development of atherosclerosis [28]. A systematic review and meta-analysis revealed the detrimental effects of saturated fat on cardiovascular disease (CVD) outcomes and risk factors compared to unsaturated fat. [36] 

A strong body of evidence has documented the adverse effects of trans fatty acids on cardiometabolic risk factors [37]. Adhering to current recommendations to replace saturated fat from meat and dairy with nontropical plant oils also lowers dietary trans fatty acids [38]. 

Healthy Eating Tips and Strategies 

Incorporating a heart-healthy diet into a patient’s lifestyle requires practical tips and strategies. First, make gradual changes instead of overhauling the entire diet. Meal planning can help with healthier choices.  

Setting realistic goals and collaborating with the patients to set achievable dietary goals. Controlling portion size, using smaller plates and bowls, prioritizing low-calorie, nutrient-rich foods like fruits and vegetables and limit high-calorie, high-sodium foods like refined, processed, or fast foods [39].  

Paying attention to the amount of saturated and trans fats, cholesterol, and sodium. Suggest lean protein sources such as fish, poultry, beans, and lentils and limit the intake of unhealthy fats and instead opt for healthy fats like those found in olive oil, avocados, and nuts [39].  

Consume at least five servings of fruit and vegetables daily [41]. Choose whole grains over refined grains and limit the intake of added sugars [28]. To have more control over the ingredients, cook and consume meals at home and make gradual changes to diet habits and build on those habits over time. 

Patient Education 

Nurses are well positioned to provide patient education and counseling on heart-healthy eating. The core of patient education lies in translating knowledge into practice. Nurses must communicate with consideration of cultural, linguistic, and individual patient dietary preferences. Education should be patient-centered, with actionable steps that patients can integrate into their daily lives [40].  

Effective patient education strategies can include establishing a rapport, assessing the patient's knowledge, and understanding, tailoring the educational approach, using plain language, incorporating visual aids, encouraging active participation, providing written materials and ongoing support and follow-up, and addressing any barriers and concerns [42]. 

Resources 

A wealth of resources is available to support nurses in their role as patient educators, from professional organizations like the American Heart Association to local community programs and online platforms [43]. These resources offer educational materials, dietary guidelines, and support tools that nurses can utilize to enhance their teaching.  

A heart-healthy diet is one that is low in saturated and trans fats, cholesterol, and sodium. It is also high in fiber, fruits, vegetables, and whole grains [2][3]. Eating a heart-healthy diet can help to lower your blood pressure, cholesterol levels, and risk of heart disease [2]. 

The National Heart, Lung, and Blood Institute (NHLBI) has a website with information on heart-healthy eating, including recipes, meal plans, and tips for eating out. The American Heart Association (AHA) has a website with information on heart-healthy eating, including recipes, meal plans, and tips for shopping for heart-healthy foods.  

The Dietary Approaches to Stop Hypertension (DASH) diet is a heart-healthy eating plan that has been shown to lower blood pressure [45].  

The Mediterranean diet is a heart-healthy eating plan that has been shown to have several health benefits, including reducing the risk of heart disease, stroke, and type 2 diabetes [44]. You can find information about the Mediterranean diet on the Mayo Clinic website.  

In addition to these websites, there are many cookbooks and other resources available on heart-healthy eating. Patients can also talk to their doctor or a registered dietitian for personalized advice on how to eat a heart-healthy diet. 

Conclusion

In conclusion, adopting a heart-healthy diet is a crucial step towards maintaining cardiovascular well-being and overall health [30]. The nurse's role as a patient educator in promoting a heart-healthy diet is pivotal. By leveraging a position of trust and frequency of contact with patients, nurses can champion dietary choices that can reduce the risk and impact of heart disease.  

Research underscores the importance of a balanced intake of nutrients to support the cardiovascular system's health, emphasizing whole foods, lean proteins, healthy fats, and a reduction in sodium, saturated fats, and sugars [3]. 

Patients adopting a heart healthy diet require a multifaceted approach, combining knowledge with actionable steps that are practical and sustainable. The role of healthcare professional is instrumental in this dietary transition.  

A heart-healthy diet offers a multitude of benefits beyond reducing heart disease risk. It can improve blood pressure control, lower cholesterol levels, promote healthy weight management, and enhance overall energy levels [2][3]. A heart-healthy diet can contribute to a stronger immune system, reduced inflammation, and improved mental clarity [46]. 

Adverse Childhood Experiences

Introduction   

All children should grow and thrive in a caring, nurturing environment that meets their physical, emotional, and social needs. However, many are not so fortunate. Nearly every two in three Americans (64%) have experienced adverse childhood events (ACEs) (1, 2, 4, 5).  

ACEs are highly associated with future chronic health conditions, mental illness, premature death, and more (1). In fact, the more ACEs an individual has had, the higher their risk for having poor health outcomes as adults (13).  

Fortunately, there are preventive and protective measures that can be taken with the appropriate resources (1). With better awareness of ACEs and the right support in place, healthcare professionals can help improve the quality of life for a myriad of children and the adults they grow up to be. 

Definition 

Adverse childhood events, or ACEs, can occur from birth until age 18, and are great determinants of future health (1). These are any potentially traumatic events that happened to a child. ACEs are strongly linked to mental and physical disease in adults, contributing to at least half of the leading causes of death in the United States (1).  

The ACE score is a 10-item survey to identify any negative occurrences a person had before their 18th birthday (3). The higher a person’s ACE score, the more risk they have for an unhealthy adulthood (1,2). 

ACE was a term coined in a large-scale study published in 1998, describing them as childhood abuse and household dysfunction in seven specific areas (1, 2). In subsequent years, three more areas were added (3, 13). Altogether, the ten ACEs are comprised of the following examples of three broad categories:  

• Childhood abuse 

• • Psychological 

• • Physical 

• • Sexual 

• Household dysfunction 

• • Substance abuse 

• • Mental illness 

• • Parent treated violently. 

• • Family member incarcerated. 

• Neglect 

• • Emotional  

• • Physical  

Statistics and Demographics 

The initial adverse childhood experience (ACE) study, conducted in the late 1990s, included over 17,000 adult participants and revealed the following key demographic data (1, 2, 5):  

• Nearly 66% of women and 62% of men reported at least one ACE in their lives. 

• More than 1 in 6 people (17.3%) said they had experienced four or more types of ACEs.  

• Respondents’ races who reported ACEs were: 74.8% white, 11.2% Hispanic, 7.2% Asian/Pacific Islander, 4.5% black, and 2.3% other. 

• About 49% of those with college degrees experienced at least one ACE, compared to 44% without a high school diploma.  

• The age group who reported the highest incidence of ACEs was those from 35-49, where almost 70% had experienced at least one ACE. The lowest incidence was reported by those aged 65 and older, at 40%.  

• Of all women reporting ACEs, 25% said they endured sexual abuse, 30% witnessed substance abuse in the home, and 25% of the respondents’ parents got divorced.  

• Of all men reporting ACEs, 30% went through physical abuse, 24% saw substance abuse at home, and 22% of their parents were divorced.  

More recent data shows that at least 50% of the top causes of death in the US are associated with ACEs (6). As there is also a high association between ACES and depression, preventing these experiences could reduce adult depression by 44% (6).  

Causes and Risk Factors 

The causes of adverse childhood events are varied and multifaceted. They can stem from familial or communal challenges, often referred to as social determinants of health. Many of these determinants can cause ACEs, and may include (8):  

• Lack of access to healthcare or other resources 

• Financial difficulties 

• Homelessness or frequent moving 

• Discrimination 

• Any type of disrupted living situation  

As noted earlier, most of the American population has had some sort of adverse childhood experience. However, there are some factors that make it more likely for these to occur. Societal, communal, and familial cultures all play a role in adverse experiences.  

The following situations or conditions increase the likelihood of ACEs (7):   

Community Risk Factors: 

• High rates of poverty, crime, and violence 

• Limited educational, economic, and employment opportunities  

• Lack of community activities for youth 

• Unstable housing and frequent moves by community residents   

• Readily accessible alcohol and drugs 

• Frequent experiences of food insecurity  

Family and Individual Risk Factors:  

• Social or developmental disabilities or delays  

• Mental or chronic physical illnesses 

• A history of abuse experienced by caregivers themselves. 

• Youth dating or engaging in sexual activity early. 

• Single-parent families, particularly those with young caregivers 

• Low income and/or high economic stress 

• Low education levels 

• Children with few or no friends, or friends who partake in delinquent or aggressive behaviors 

• Caregivers with limited understanding of child development  

• Use of spanking or other corporal punishment as a form of discipline  

• Inconsistent discipline and/or little parental supervision 

• Families isolated from extended family, friends, and/or neighbors 

Cultural Considerations  

Though many people experience ACEs, some populations are affected disproportionately. This includes women and those in racial or ethnic minorities, who are at greater risk for experiencing 4 or more ACEs (6, 8). Specifically, African Americans, American Indians, and Alaska Natives (AI/AN) are far more likely to have multiple ACEs than any other race or ethnicity (9,10).  

The AI/AN community is a relatively young one, with poverty rates up to four times higher than the national average (10). Furthermore, the AI/AN group is often lumped together as “other” as a race category on surveys, making data harder to come by for this population (10).  

AI/AN children, when compared to the total US population, are more likely to have:  

• Parents who are divorced (33% versus 21%) 

• Lived with someone who abused a substance (24% versus 12%) 

• Witnessed domestic violence (15% versus 6%) 

• Lived with a parent who ultimately died (4% versus 2%) 

Lifespan Impact on the Individual 

While adverse childhood experiences affect most Americans, having been through four or more puts a person at significantly higher risk of health problems as an adult (1, 2, 9). In general, the more ACEs an individual has experienced, the more likely they will have poor outcomes later in life, with a specifically high correlation to diabetes, heart disease, obesity, depression, substance abuse, smoking, poor academic achievement, and early death (4).  

In fact, ACEs can reduce an individual’s life expectancy by as many as 20 years, compared to someone who has had zero ACEs (8).  

The original ACEs study was conducted to determine the link between childhood abuse and adult health risk factors (1). The conclusion was overwhelmingly that in the United States, the main causes of morbidity and mortality are related to many of the health behaviors exhibited by those who have experienced ACEs (1). More recent studies find that ACEs contribute significantly to substance abuse, violence, and self-harming behavior (11).  

At least 5 of the top 10 leading causes of death in the United States that are strongly related to ACEs include (9,11, 12):  

• Heart disease (#1 cause of death) 

• Stroke (#5) 

• Chronic lower respiratory diseases (#6)  

• Diabetes (#8) 

• Chronic liver disease and cirrhosis (#9) 

As far as mental health goes, the link with ACEs is clear: The higher one’s ACE score, the more likely they are to be depressed, experience impaired work performance, and have suicidal tendencies (13). Harmful behaviors associated with high ACE scores include smoking, drinking, and drug abuse, as these methods are often used to cope with past traumatic experiences (13).  

Societal Implications 

Adverse childhood events are preventable and have been shown to contribute to at least half of the leading causes of death in the United States (1, 9, 11). Thus, the impact of ACEs on public health is vast. Since the CDC considers ACEs a public health concern, it is of utmost importance to decrease their incidence (1). Through the reduction and prevention of ACEs, general public health would improve markedly, drastically cutting down on healthcare costs and resources (1, 5, 6, 9).  

The societal implications for reducing ACEs are manifold:  

• Dramatic reduction of preventable causes of death 

• Longer lifespans for the general population  

• Better mental health  

• More cost-effective physical and mental healthcare 

• Lower rates of disease and depression in the general population 

Ways to Mitigate ACEs 

Though ACEs are widely pervasive in American society, they need not be so. With proper resources and support systems, many -if not all- ACEs may be eradicated. The best way to mitigate ACEs would be to prevent them in the first place (4). This requires creating safe, stable, nurturing environments for children and their families (9). Furthermore, as ACEs can occur for a wide array of reasons, they need to be addressed at both the family and communal levels. 

With individuals, a first step would be prevention of ACEs in the home. This could involve a vast array of mental health, education, and social work services such as: home visits, parenting classes, therapy sessions, and more (8, 9). Different emotion management techniques and child development concepts could be taught to at-risk families, promoting bonding and trust between children and their caregivers.  

High-quality childcare and after-school programs with trusted adults can help mitigate ACEs as well (9). Screening for ACEs at regular intervals would also be helpful. This could include annual check-ups at the doctor’s office, visits with the school nurse or counselor, or a consultation with a home health provider. Medical management of physical and mental health conditions would be made available, including routine health screenings and necessary medications (4, 8, 9).  

At the community level, prevention could take the form of free education for family members, food and housing assistance, adequate access to healthcare services, and fostering safe neighborhoods (4, 9). Economic support for families could include family-friendly work policies, earned income tax credits, and so forth. Children could partake in community events like after-school clubs and sports, helping them build bonds with trusted and supportive adults.  

Three principles are the most helpful preventing long-term effects of ACEs, (4):  

• Reducing stress by ensuring basic needs are met, as well as tending to abusive situations, community crime, substance abuse, discrimination, and poverty. 

• Strengthening life skills can strengthen the resilience of children and their family members by practicing planning, focus, and self-control. 

• Building responsive relationships by having adults listen to their children and respond adequately to their needs, thereby fostering a safe, trusting relationship. 

Reporting ACEs 

Considering there are various types of ACEs, they can be difficult to identify and thus report. However, some are clear-cut. In situations where child abuse or neglect is occurring or suspected, a mandated reporter (e.g., nurse, teacher, counselor) would need to report it as soon as possible. If the child is in imminent danger, take them to a safe place and make a report.  

To report child abuse in the United States, call or text 1-800-4-A-CHILD (1-800-422-4453). The website is https://www.childhelphotline.org/.  

If there is suspicion that a child is being sexually exploited, the phone number to call is 1-800-THE-LOST (1-800-843-5678), and the website is https://report.cybertip.org/.  

To report human trafficking, call 1-888-373-7888, use TTY at 711, text BEFREE (233733), or visit the website at https://humantraffickinghotline.org/.  

For anyone experiencing feelings of self-harm or suicide, 988 is the national Suicide and Crisis Lifeline that can be called or texted. The website is https://988lifeline.org/.  

Support and Additional Resources 

While there is no single way to prevent ACEs from occurring, there is a plethora of resources available to help mitigate the effects and to educate others. Visting a healthcare provider can connect a patient to mental health professionals, support groups, or specialty services like social work and support groups (8).  

The Substance Abuse and Mental Health Services Administration (SAMHSA) has an abundance of resources on topics like trauma-informed care, early childhood mental health programs, Native Connections for the AI/AN population, school, and campus health, and much more. More information can be found at https://www.samhsa.gov/programs.  

Healthy Outcomes from Positive Experiences (HOPE) is a national resource center offering research, training, and technical assistance in order to better the lives of children and their families. Their website is https://positiveexperience.org/.  

The Centers for Disease Control and Prevention (CDC) offers ACE-specific information at this website: https://www.cdc.gov/violenceprevention/aces/resources.html.  

Conclusion

Adverse childhood events, or ACES, affect the majority of the American population. Strongly correlated with many leading causes of death, ACEs are preventable and warrant attention from healthcare providers and the general public alike. Fortunately, many resources exist at the individual, community, and national levels to provide care and prevention for these experiences.  

Though ACEs tend to lead to negative health outcomes, they need not condemn a person to lifelong problems. Through screening tools, community food and housing programs, mental health assistance, education, and adequate medical care, ACEs can be mitigated, well managed, and prevented.  

Despite the misfortune in a child’s life, there is still much hope available when they reach adulthood.  

Conclusion

Adverse childhood events, or ACES, affect the majority of the American population. Strongly correlated with many leading causes of death, ACEs are preventable and warrant attention from healthcare providers and the general public alike. Fortunately, many resources exist at the individual, community, and national levels to provide care and prevention for these experiences.  

Though ACEs tend to lead to negative health outcomes, they need not condemn a person to lifelong problems. Through screening tools, community food and housing programs, mental health assistance, education, and adequate medical care, ACEs can be mitigated, well managed, and prevented.  

Despite the misfortune in a child’s life, there is still much hope available when they reach adulthood.  

SSRI Use in Anxiety Disorders

Introduction   

Selective Serotonin Reuptake Inhibitors (SSRIs) are a medication class typically used to treat depression. SSRIs are considered first-line treatment for depression and other psychological disorders, including (2): 

• Major Depressive Disorder 
• Generalized Anxiety Disorder 
• Bulimia Nervosa 
• Bipolar Depression 
• Obsessive-Compulsive Disorder 
• Panic Disorder 

• Premenstrual Dysphoric Disorder 
• Treatment-Resistant Depression 
• Pot-traumatic Distress Disorder 
• Social Anxiety Disorder 

Additional disorders may be treated off-label, including (2): 

• Binge Eating Disorder 
• Body Dysmorphia Disorder 
• Fibromyalgia 
• Premature Ejaculation 
• Paraphilias 
• Autism 
• Raynaud’s Phenomenon 
• Vasomotor symptoms associated with menopause.  

SRRIs remain relatively safe, tolerable, and efficient in treating patients (2). 

Fluoxetine 

The Fluoxetine drug class includes brand names of Prozac, Rapiflux, Sarafem, and Selfemra 

(11). 

Indications 

Fluoxetine is an FDA-approved medication used to treat major depressive, obsessive-compulsive, binge eating, premenstrual dysphoric, and panic disorders. Fluoxetine is also prescribed for bulimia and bipolar depression.  

Off-label uses include social anxiety disorder, adult post-traumatic stress disorder (PTSD), borderline personality disorder, Raynaud phenomenon, and selective mutism (21). 

Mechanisms of Action and Pharmacokinetics 

Fluoxetine blocks the reuptake of serotonin into the presynaptic serotonin neurons. This is accomplished by blocking the reuptake transporter proteins located in the presynaptic terminal. There have been some indications of mild activity at the 5HT2A and 5HT2C receptors. Conversely, there is minimal activity on noradrenergic reuptake (21). 

Fluoxetine produces an activating effect that takes two to four weeks to see antidepressant effects. Fluoxetine actives norfluoxetine, a metabolite produced when cytochrome p450 enzyme acts on it. This indicates that fluoxetine has a high risk for drug-drug interactions that metabolize at the CYP2D6 isoenzyme (21). 

Fluoxetine has a half-life of two to four days. Fluoxetine’s active metabolite, norfluoxetine, has a longer half-life of seven to nine days (21). 

Contraindications and Precautions 

Fluoxetine is contraindicated in patients with (21): 

• Hypersensitivity to fluoxetine or its components 
• Use of monoamine oxidase inhibitors (MAOIs) to treat psychiatric disorders 
  • Prescribers should discontinue MAOIs for > 2 weeks before initiation of fluoxetine 
• Prescription of: 
  • Linezolid 
  • Pimozide 
  • Thioridazine 
  • Tamoxifen 
• History of seizures 
• Elderly patients 
• Suicidal thoughts or ideation 
  • Especially in pediatric patients or those aged 18 to 24 years old 
    • Monitor closely for the first two months of initiating therapy 
• During pregnancy 
  • Use in early pregnancy increases the risk of septal heart defects 
  • After 20 weeks, it is linked with a possible risk for pulmonary hypertension in newborns 
  • This may increase the risk of gestational hypertension and preeclampsia 
• Breastfeeding 
  • Trace amounts found in breast milk 

Precautions should be taken when prescribing Fluoxetine in patients with liver cirrhosis, as this diagnosis reduces clearance of fluoxetine and its active metabolite. This increases the elimination or half-life. Lower or less frequent doses should be considered for these patients (21). 

Adverse Effects and Black Box Warnings 

Fluoxetine’s most common side effects include (21): 

• Insomnia 
• Nausea 
• Diarrhea 
• Anorexia 
• Dry mouth 
• Headache 
• Drowsiness 
• Anxiety 
• Nervousness 
• Yawning 
• Decreased libido 
• Decrease arousal or lubrication 
• Bruising 
• Hyperhidrosis 
• Weight gain or loss 
• Decreased orgasm 
• Muscle weakness 
• Tremors 
• Pharyngitis 

Less common adverse effects include (21): 

• Bleeding 
• Seizures 
• Suicidal ideation and behaviors 
  • Especially in teenagers 

Most adverse effects will appear upon initiation of treatment and should fade with time. It is advised to wait for side effects to subside before changing treatment, as most side effects are dose- and time-dependent.  

If side effects continue after several weeks, dose adjustment then changing medication is recommended (21). 

If insomnia is present, patients should take medication in the early morning (21). 

A Black Box Warning is present for Fluoxetine, as this medication increases suicidal thoughts and behaviors. Individuals prescribed this medication should be closely monitored, especially teenagers as they are more prone to experiencing these severe adverse effects (5). 

Drug Interactions 

Fluoxetine interacts with several medications including (22): 

• Monoamine Oxidase inhibitors 
• Medications that increase serotonin levels 
  • Tricyclic antidepressants (TCAs) 
  • Lithium 
  • Triptan migraine medications 
  • Certain opioids 
  • Other SSRIs 
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs) 
• St John’s Wort 
• Medications that raise the risk of bleeding 
  • Warfarin 
  • Apixaban 
  • Rivaroxaban 
  • Clopidogrel 
  • Prasugrel 
• Pimozide and thioridazine 
• Medications metabolized by certain liver enzymes 
  • Flecainide 
  • Propafenone 
  • TCAs 
  • Benzodiazepines 
  • Antipsychotics 
  • Seizures 

Sertraline  

The Sertraline drug class includes the brand name: Zoloft (13). 

Indications 

Sertraline is FDA-approved to treat the following (20): 

• Major depressive disorder 
• Obsessive-compulsive disorder (OCD) 
• Panic disorder 
• Post-traumatic stress disorder (PTSD) 
• Premenstrual Dysphoric Disorder (PMDD) 
• Social Anxiety Disorder (SAD) 

Sertraline may be prescribed off-label for the following disorders (20): 

• Binge eating disorder 
• Body dysmorphic disorder 
• Bulimia Nervosa (BN) 
• Generalized Anxiety Disorder (GAD) 
• Premature ejaculation 

Mechanisms of Action and Pharmacokinetics 

Sertraline inhibits serotonin reuptake on the presynaptic terminals. This leads to an accumulation of serotonin, leading to better mood regulation, personality stability, and wakefulness or arousal (20). 

Sertraline has a half-life of 24 to 32 hours. Sertraline is metabolized by the liver (7). 

Contraindications and Precautions 

Sertraline is contraindicated in (20): 

• Patients with hypersensitivity to this drug or any of its components 
• Coadministration with: 
  • Thioridazine 
  • Pimozide 
  • Monoamine oxidase inhibitors  
    • Sertraline should not start <2 weeks of discontinuing any monoamine oxidase inhibitors, as this may lead to toxicity with serotonin syndrome.  
  • Serotonergic medication 
  • Disulfiram 
    • may cause an alcohol-disulfiram reaction. 

Adverse Effects and Black Box Warnings 

Sertraline has multiple adverse effects, including (20): 

• Syncope 
• Lightheadedness 
• Diarrhea 
• Nausea 
• Sweating 
• Dizziness 
• Xerostomia 
• Confusion 
• Hallucinations 
• Tremor 
• Somnolence 
• Impotence 
• Disorders of ejaculation 
• Fatigue 
• Rhinitis 
• Female sexual disorder 

More serious adverse effects include (20): 

• Prolonged QT interval 
• Inhibiting platelet aggregation, leading to bleeding risk 
• Serotonin syndrome, including symptoms of: 
  • Myoclonus 
  • Muscle rigidity 
  • Diaphoresis 
  • Tremor 
  • Hyperreflexia 
  • Agitated delirium 
  • hyperthermia 

Sertraline has a Black Box Warning related to increased risk of suicidal thoughts and ideation, particularly in pediatric patients and adult patients aged 18 to 24 (20). 

Drug Interactions 

Due to Sertraline’s interaction with many CYP enzymes, several drug-drug interactions are possible (7). These include: 

• Bepridil 
• Bromopride 
• Cisapride 
• Dronedarone 
• Eliglustat 
• Furazolidone 
• Iproniazid 
• Isocarboxazid 
• Levoketoconazole 
• Linezolid 
• Mesoridazine 
• Methylene Blue 
• Metoclopramide 
• Ozanimod 
• Phenelzine 
• Pimozide 
• Piperaquine 
• Procarbazine 
• Rasagiline 
• Safinamide 
• Saquinavir 
• Selegiline 
• Sparfloxacin 
• Terfenadine 
• Thioridazine 
• Toloxatone 
• Tranylcypromine 
• Ziprasidone 

Paroxetine  

The Paroxetine drug class includes brand names of Brisdelle, Paxil, and Pexeca (19). 

Indications 

Paroxetine is FDA-approved to treat the following disorders (19): 

• Major depressive disorder (MDD) 
• Obsessive-compulsive disorder (OCD) 
• Social anxiety disorder (SAD) 
• Panic disorder 
• Post-traumatic stress disorder (PTSD) 
• Generalized anxiety disorder (GAD) 
• Premenstrual dysphoric disorder (PMDD) 
• Vasomotor symptoms associated with menopause 

Paroxetine is prescribed off-label for the following disorders (19): 

• Obsessive-compulsive disorder (in children and adolescents) 
• Social anxiety disorder 
• Dysthymia 
• Body dysmorphic disorder 
• Postpartum depression 
• Premature ejaculation 
• Malignancy related to pruritus 
• unresponsive to standard treatment 

Mechanisms of Action and Pharmacokinetics 

Paroxetine blocks the serotonin reuptake transports (SERT), increasing the concentration of synaptic serotonin. The diminished serotonin concentration induces the upregulation of serotonergic receptors. Paroxetine induces the downregulation of upregulated serotonin receptors to balance the receptor concentration.  

Paroxetine has also shown some affinity for muscarinic, adrenergic (alpha and beta), dopaminergic (D2), serotonergic (5-HT2), and histaminergic (H1) receptors – which assist with antidepressant effects (19). 

Paroxetine is metabolized via hepatics CYPP450 2D6 and has a half-life of approximately 21 hours (19). 

Contraindications and Precautions 

Paroxetine is contraindicated in the following situations (19): 

• Concurrent use: 
  • Monoamine oxidase inhibitors (MAOIs) 
    • Causes serotonin syndrome 
  • Thioridazine 
    • Causes cardiac arrhythmias 
  • Pimozide 
    • Causes serotonin syndrome 

Precautions should be taken when prescribing paroxetine with (19): 

• Tricyclic antidepressant (TCA) use 
  • Inhibits TCA metabolism 
• Tamoxifen use 
  • Inactivates tamoxifen 
• Any drugs affecting hepatic metabolism 
• Pregnant or breastfeeding patients 
  • Increased risk of cardiovascular malformations in the first trimester 

Adverse Effects and Black Box Warnings 

Paroxetine has dose-dependent side effects. The most common side effects include (19):  

• Alopecia 
• Apathy 
• Chest pain  
• Constipation 
• Diarrhea 
• Dizziness 
• Drowsiness 
• Dry mouth 
• Eczema 
• Edema  
• Headache 
• Hypomania 
• Hyponatremia 
• Loss of appetite 
• Mania 
• nausea 
• Palpitations 
• Photosensitivity 
• Sexual side effects 
• Sleep disturbance 
• Sweating 
• Tachycardia 
• Tremor 
• Vasodilation 
• Weight gain 

Discontinuation syndrome is more severe with Paroxetine versus other SSRIs. Withdrawal may occur, and symptoms include (19): 

• Dizziness 
• Lethargy 
• Nausea 
• Vomiting 
• Headache 
• Fever 
• Chills 
• Vivid dreams 
• Electric shock-like sensations 
• Dyskinesia 
• Anxiety 
• Crying 
• Irritability 
• Depersonalization 

A Black Box Warning is present for Paroxetine related to increased suicidal thoughts and behaviors. Anyone under the age of 24 has a higher risk for these serious adverse effects and should be carefully considered and monitored when prescribed (9). 

Drug Interactions 

Drug-drug interactions for Paroxetine include (19): 

• Monoamine oxidase inhibitors (MAOIs) 
• Thioridazine 
• Pimozide 
• Tricyclic Antidepressant (TCA) 
• Tamoxifen use 
• Any drugs affecting hepatic metabolism 

Fluvoxamine  

The Fluvoxamine drug class includes the brand names Luvox and Luvox CR (16). 

Indications 

Fluvoxamine is FDA-approved to treat the following disorders (1): 

• Obsessive-compulsive disorder (OCD) 
• Depression 
• Social anxiety disorder 

Fluvoxamine has recently been prescribed off-label for the treatment of COVID-19. However, the COVID-19 Treatment Guidelines Panel recommends against it. There is insufficient evidence for the use of fluvoxamine in combination with inhaled budesonide for non-hospitalized patients.  

Conversely, patients with are receiving fluvoxamine for underlying treatments should continue therapy if diagnosed with COVID-19 (16). 

Mechanisms of Action and Pharmacokinetics 

Fluvoxamine blocks the reuptake of serotonin at the sodium-dependents serotonin reuptake transports (SERT). This enhances the action of serotonin on the 5HT1A auto receptors, leading to an increase in the concentration of synaptic serotonin (16). 

Fluvoxamine is metabolized by the liver and has a half-life of 12 to 15 hours (4). 

Contraindications and Precautions 

Fluvoxamine is contraindicated in the following situations (16): 

• Concurrent use of: 
  • Ethanol 
  • Tobacco 
• Comorbidities, as this medication may impact the illness or medications to treat: 
  • Bipolar disorder 
  • Bleeding problems 
  • Depression 
  • Glaucoma 
  • Heart-attack 
  • Heart disease 
  • Heart rhythm problems 
  • Hyponatremia 
  • Mania 
  • Mental health problems 
  • Seizures 
  • Liver disease 

Precautions should be taken when prescribing Fluvoxamine to (16): 

• Patients who drink or have a history of alcoholism 
• Patients with vocations that include operating heavy machinery 
• May cause drowsiness 
• Patients with bleeding problems 
• This medication may increase the risk for bleeding 
• Patients who are expecting or trying to conceive 
• There is some link between this medication and infertility 

Adverse Effects and Black Box Warnings 

Fluvoxamine has the following side effects include (16): 

• More common side effects include: 
  • Sexual side effects 
  • Decreased libido, erectile dysfunction 
• Less common side effects include: 
  • Changes to behavior or mood 
  • Decreased orgasm 
  • Difficulty breathing 
  • Difficulty urinating 
  • Twitching  
• Rare 
  • Agitation 
  • Blurred vision 
  • Chills 
  • Clumsiness 
  • Confusion 
  • Diarrhea 
  • Fever 
  • Inability to move eyes 
  • Decreased or increased ability to move the body 
  • Menstrual changes 
  • Nosebleeds 
  • Overactive reflexes 
  • Poor coordination 
  • Red or irritated eyes 
  • Skin issues include:  
    • Redness 
    • Tenderness 
    • Itching 
    • Burning 
    • Peeling 
  • Restlessness 
  • Seizures 
  • Shivering 
  • Skin rash 
  • Sore throat 
  • Sweating 
  • Excitement that cannot be controlled 
  • Trembling or shakiness 
  • Unusual bruising 
  • Unusual or sudden body or facial movements 
  • Unusual secretion of milk in females 
  • weakness 

A Black Box Warning is present for Fluvoxamine related to increased suicidal thoughts and behaviors (6). 

Drug Interactions 

Drug-drug interactions for Fluvoxamine include (16): 

• Alosetron 
• Pimozide 
• Ramelteon 
• Thioridazine 
• Tizanidine 
  • Increase side effects 
• Monoamine oxidase inhibitors (MAOIs) 
  • Should not take until MAOIs are discontinued for > 2 weeks 
• Linezolid 
• Methylene blue injection 
• Phenelzine 
• Selegiline 
• Tranylcypromine 
• Buspirone 
• Fentanyl 
• Lithium 
• Tryptophan 
• St John’s Wort 
• Amphetamines 
• Some pain medications 
• Blood thinners 

Citalopram 

The Citalopram drug class includes the brand name of Celexa (11). 

Indications 

Citalopram is FDA-approved to treat the following disorders (11): 

• Depression in adults 

Citalopram is prescribed off-label to treat: 

• Obsessive-compulsive disorder (OCD) 
• Panic disorder 
• Generalized anxiety disorder (GAD) 
• Social anxiety disorder (SAD) 
• Premenstrual dysmorphic disorder (PMDD) 
• Binge eating disorder 
• Posttraumatic stress disorder (PTSD) 
• Premature ejaculation 
• Poststroke depression 

Mechanisms of Action and Pharmacokinetics 

Citalopram escalates the brain-derived neurotrophic factor (BDNF) in the hippocampus and preferential cortex, which can be decreased in patients with depression (18). 

Citalopram is metabolized by the liver and has a half-life of 24 to 48 hours. This may take longer due to hepatic impairment (18). 

Contraindications and Precautions  

Citalopram is contraindicated in (18): 

• Concomitant use of: 
• monoamine oxidase inhibitors (MAOIs) 
• Serotonin syndrome, including symptoms of: 
  • Myoclonus 
  • Muscle rigidity 
  • Diaphoresis 
  • Tremor 
  • Hyperreflexia 
  • Agitated delirium 
  • Hyperthermia 
• Urokinase 
  • Pimozide 
  • Methylene blue 
  • Linezolid 
  • Dapoxetine 
• Hypersensitivity to the drug or excipient 
  • Increases thioridazine concentrations 
    • Lead to dangerous arrhythmias 

Adverse Effects and Black Box Warnings 

Adverse effects of Citalopram include (18): 

• Most common 
  • Drowsiness 
  • Insomnia 
  • Dizziness 
  • Headache (dose-dependent) 
  • Diaphoresis 
  • Nausea 
  • Vomiting 
  • Xerostomia 
  • Constipation 
  • Diarrhea 
  • Ejaculation disorder (dose-dependent) 
• Less common 
  • Myocardial infarction 
  • Prolonged QT interval 
  • Torsades de pointes 
  • Hemorrhage 
  • Cerebrovascular accident 
  • Suicidal ideation 
  • Manic 
  • Serotonin syndrome 

Citalopram has a Black Box Warning related to increased risk of suicidal thoughts and ideation, particularly in pediatric patients and adult patients aged 18 to 24 (18). 

Drug Interactions 

Citalopram interactions significantly with the following medications, and should be monitored closely (18): 

• Bupropion 
• Omeprazole 
• Esomeprazole 
• Cimetidine 
• Fexinidazole 
• Voriconazole 
• Fluoxetine 
• Fluvoxamine 
• Fluconazole 

Escitalopram 

The Escitalopram drug class includes the brand name Lexapro (14). 

Indications 

Escitalopram is FDA-approved to treat the following disorders (8): 

• Depressive disorder in adults and adolescents, ages 12-17 
• Generalized anxiety disorder for adults and children, ages7+ 

Escitalopram is prescribed off-label for (8): 

• Social anxiety disorder 
• Obsessive-compulsive disorder 
• Panic disorder 
• Posttraumatic disorder 
• Premenstrual dysphoric disorder 
• Vasomotor symptoms associated with menopause 

Mechanisms of Action and Pharmacokinetics 

Escitalopram binds to the sodium-dependent serotonin transporter protein (SERT) in the presynaptic neuron. This inactivates the SERT and causes an elevation in the synaptic serotonin levels (8). 

Escitalopram is metabolized by the liver and has a half-life of 27 to 33 hours (8). 

Contraindications and Precautions 

Escitalopram is contraindicated in the following situations (8): 

• Hypersensitivity to the medication or any of its components 
• Concurrent use of: 
  • MAOIs 
  • pimozide 
• QT prolongation 
  • Or family history 

Precautions should be taken when prescribing Escitalopram, including assessment and reduction of risk for serotonin syndrome. Medications that should be avoided to prevent this include (8): 

• Other antidepressants 
• Triptans 
• Fentanyl 
• Lithium 
• Tramadol 
• Tryptophan 
• Buspirone 
• Amphetamines 
• St John’s Wort 
• Methylene blue 
• Linezolid 
• MAOIs
   

  If possible, obtaining genetic testing for patients before prescribing could show an individual’s enzyme activity. If the patient is classified as a poor metabolized of the enzyme, CYP2C19, they are at a greater risk for drug reactions and may want to reduce the dose or consider alternative treatment (8) 

   

  Adverse Effects and Black Box Warnings 

  Escitalopram has the following side effects include (8): 

• Insomnia 
• Sexual dysfunction 
  • Reduce libido 
  • Anorgasmia 
  • Male ejaculatory delay 
• Nausea 
• Increased sweating 
• Fatigue 
• Somnolence 
• QT prolongation 
• Serotonin syndrome 
  • Rare but serious 

A Black Box Warning is present for Escitalopram for increased risk of suicidal ideation. Patients should be closely monitored for behavioral changes or destructive behaviors, particularly in pediatric and adolescent patients (8). 

Drug Interactions 

Drug-drug interactions for Escitalopram include (8): 

• Rasagiline 
  • Serotonin syndrome risk 
• Antiplatelet agents 
  • Increased risk for bleeding 
• NSAIDS 
  • Upper GI bleeding risk 
• Aspirin or dual antiplatelet therapy 
  • Risk of bleeding 
• Other agents that prolong QTc intervals 
  • Amiodarone 
    • Especially in patients with chronic kidney disease 

Vilazodone 

The Vilazodone drug class includes the brand name Viibryd (3). 

Indications 

Vilazodone is FDA-approved to treat the following disorders (3): 

• Depression 

Mechanisms of Action and Pharmacokinetics