You are asked to assess suicide risks
David is well-known at the practice. In the post is a letter from the A&E department about yet another overdose. He has been referred back to the community mental health team. During a busy morning he attends with his mother. She says she is very worried and believes eventually he will successfully commit suicide and that you must do something.
Dr Peter Moore advises.
Is assessment of suicide risk common in general practice or should it be left to secondary care?
There are about 5,000 suicides in England and Wales each year. In recent years suicides among young unemployed men have risen by 75 per cent. Deliberate self-harm is 30 times more common. The national service framework for mental health sets a target to reduce the number of suicides by 20 per cent by 2010.
GPs are in the frontline 70 per cent of people who commit suicide had seen their GP in the previous six-eight weeks. Many of these did not present with depression. In some cases the GP may not have missed anything as not every person who commits suicide has a psychiatric illness.
Is it possible to reassure his mother?
Predicting self-harm and suicide risk is an imprecise art. It is dangerous to assume that some patients are not at risk. The common quote from patients that 'people who threaten suicide will not carry it out' is a dangerous myth. There is not one 'cause' but a number of risk factors. Suicide risk increases with age and is three times commoner in men of all ages than in women.
For a full assessment we need to look at the history, current medical and psychiatric problems and social situation.
Both personal and family history of self-harm and attempted suicide as well as a longstanding psychiatric illnesses all point to an increased risk. Risk is also increased if the patient has recently been a psychiatric inpatient, especially if he took his own discharge against medical advice.
The psychiatric history must include an assessment of suicidal thoughts and behaviour. Asking about suicidal ideation will not increase the risk. A full assessment of depressive symptoms is important. The highest-risk depressive patients are the ones who develop a feeling of helplessness. It is also vital to uncover any psychiatric illness, not only depression. Another important high-risk group are the patients who misuse substances.
The risk is increased by physical illness especially pain and debilitating illness.
Socially, suicide risk is increased by pending legal proceedings including divorce, unemployment, social class V and social isolation. The risk is known to be higher in some jobs such as farmers and doctors.
It is important to ask about any recent crisis such as bereavement, redundancy or marital breakdown.
How can the registrar assess David?
The commonest reason for suicide is depressive illness and 15 per cent of depressed patients eventually kill themselves. The assessment must include an assessment of depression.
After an attempted suicide, as in this case, the doctor will have to assess the motive, the circumstances of the attempt, any precipitating factors, his coping strategies and future risk. Hoarding of tablets and suicide notes must be taken very seriously.
There are a few simple questions that can be used1 but they are not a substitute for a thorough psychiatric assessment:
· How do you feel about the future?
· Have you ever felt that life is not worth carrying on?
· Have you ever had any thoughts about taking your own life?
· If so have you made any definite plans and what are they?
· How recently have you considered carrying them out?
· What has stopped you?
What treatment can be offered?
The prognosis is similar whether or not they are diagnosed by the GP. If he is at high risk the secondary care services must be involved. The emergency psychiatric services vary throughout the country but, if in any doubt, the registrar must get urgent advice. Most trusts operate a telephone line to a crisis intervention team, community mental health team or specialist emergency team the trainer will know the local arrangements.
Although there are effective drugs great care must be taken in starting a patient on antidepressants. Many suicides occur as treatment starts to be effective.
Patients lose the inertia of severe depression and gain motivation while remaining low. One in 10 suicides is from an overdose of antidepressants. The care needs to be in partnership with the local community mental health team.
Tragically, things can go wrong. If a patient does successfully commit suicide, the doctor will need the support of the team.
· The NSF aims to reduce the number of suicide deaths by 20 per cent by 2010
· 70 per cent of people who commit suicide have seen their GP in the previous six-eight weeks
· Predicting suicide risk is an imprecise art
· There are numerous historical, medical, psychiatric and social factors which predispose to suicide risk
· Treatment of patients at high risk must take place working with secondary care services
1 Neurolink. Suicide risk assessment
2 Craig TKJ and Davies T. ABC of mental health. BMJ Books, 1998
3 Wade A. Dealing with depression. Update,
September 26, 2002