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Key questions on identifying and managing suicide risk

Key points

  • Carefully and sensitively asking about suicidality is an important part of consulting with patients with mental health issues and does not ‘put the idea in their head’
  • The ‘gender paradox of suicide’ means that females are more likely to self-harm but men are most likely to complete suicide
  • Most people who engage in suicidal behaviour are, in fact, ambivalent about wanting to die
  • Risk assessment scales and tools should not be used
  • By far the strongest risk factor for suicide is a previous suicide attempt – which the patient may not admit to, so check the records
  • Key steps in the consultation are risk formulation and making a safety plan
  • When prescribing antidepressants in this situation, consider limited supplies and early review

Dr Emma Nash is a GP partner in Hampshire and clinical lead for mental health at Hampshire, Southampton and Isle of Wight ICB

Q: How common are suicidal thoughts in mental health presentations in primary care? What features suggest a high level of risk?
A: Suicidal ideation, or thoughts, encompass a variety of ideas about death, varying from inquisitive inquiry to contemplation, wishes and planning to end one’s own life. There is no specific definition of what constitutes suicidal thoughts or ideation,1 but on a pragmatic level most thoughts about not wanting to be alive should prompt concern.

There is a lack of data about the prevalence of suicidal thoughts in primary care mental health settings. However, the global lifetime prevalence of suicidal ideation is 9.2%.2 Multiple demographic and sociopolitical factors contribute, but mental ill health is a significant factor, and 90% of people who die by suicide have a psychiatric disorder.3

Assessing risk is a core part of the consultation when a patient presents with mental health difficulty. There are two dimensions to this – one is the nature of the patient in their biopsychosocial setting, and the other is the nature of their thoughts. Transient, fleeting thoughts are common, recognised as inappropriate by the person, (albeit distressing at times) and not accompanied by any planning or intent to act.

However, certain characteristics and contexts indicate a heightened risk of attempted suicide:4

  • High degree of emotional pain.
  • Negative thoughts – hopelessness, helplessness, guilt (for instance, feeling a burden), shame.
  • Sense of being trapped.
  • Suicidal ideas that are becoming worse or have a well-defined plan or preparation.
  • Related psychotic phenomena – persecutory or nihilistic delusions, command hallucinations.

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