1. Suicide is a leading cause of death in the under 35s mostly in those with mood and substance-related disorders
Suicide is one of the leading causes of death in the UK of younger adults in the age group 5-34 years.1 Every year across the world one million people commit suicide. This equates to one death every 40 seconds.
The chart below shows suicide and mental disorders in general population.
2. Know the risk factors.
Biological and psychosocial risk factors include mental illness, alcohol and substance misuse, hopelessness, family history of suicide and abuse, chronic physical illness and previous suicide attempts.
Environmental risk factors include job or financial loss, relationship or social stressors and easy access to equipment that may help them in their suicide bid such as guns or other weapons.
Sociocultural factors can include being of older age, male gender, lack of social support and isolation, and stigma linked to help seeking interventions. There are also certain religious and cultural beliefs where suicide is an acceptable method of personal conflict resolution
Red flags for completed suicide include:
– Male sex
– People in the care of mental health services, including inpatients
– Previous parasuicidal attempts.
– Chronic physical illness
– Those with substance misuse problems
– Those who are divorced or single
– People with a history of self-harm
– People in contact with the criminal justice system
– Specific occupational groups, such as doctors, nurses, veterinary workers, farmers and agricultural workers
3. Remember that suicidal patients are likely to see you
A key study showed that 25% of completed suicides saw their GP in the week prior to the act and 40% of completed suicides had contact with their GP within their last month. Bearing in mind the above risk factors, it may be worthwhile asking how repeat attenders are feeling. Objective assessment tools such as PHQ9 may be of use.
4. Find out more about suicidal thoughts
If a patient says they have suicidal thoughts, ask them about the duration, frequency and intensity of such thoughts. Establish whether the thoughts are passive or active. Questions that can be helpful include:
– Have you ever thought that things would be better if you were dead?
– Have you had thoughts of wanting to take your own life/kill yourself?
– When did you last have thoughts of wanting to kill yourself?
– How long have you been having these thoughts?
– How often do these thoughts come into your mind?
– Have you told anybody, perhaps friends or family that you are planning to kill yourself?
5. Investigate further if patients say that they have a suicide plan
If there is a suicide plan then the timing, location, perceived lethality and level of preparation must be investigated. It is important to know the circumstances and outcomes of previous acts of self-harm, suicidal acts and any ‘rehearsals’.
Useful questions here include:
– Can you tell me more about your plan to kill yourself?
– What exact methods have you been thinking about? Do you have access to any weapons such as guns or knives?
– Where will this take place?
– When is this all likely to occur? Have you decided on a date or time?
– What preparations have you made so far to carry out your plan? Or: how close have you come to acting on these thoughts?
– What has stopped you from doing this until now?
– Have you ever started to try to do something to end your life but changed your mind? Or have you had a “dress rehearsal”? How did you feel afterwards?
– Have you made any arrangements for after you kill yourself, such as writing a will?
– Have you written a note, sent texts or placed messages on social media?
– Have you had thoughts of taking anyone with you?
– Do you have thoughts of exacting revenge or harming anyone before you kill yourself?
– Do you have any hope that things may get better?
6. Review any mental health medications
Some patients may already have a diagnosis of a mental disorder. It will be useful to ask those on medications some screening questions (as mentioned above) or to check their previous PHQ9 scores. Check how they feel the medication is helping them and whether they are compliant.
7. Document the information elicited and the action taken
Post-interview, the symptoms, risk and treatment plan should be documented carefully in your notes along with a brief summary of the discussion.
8. Remember that sometimes an immediate referral will be necessary
Depending on the answers to the questions and the level of risk, the possible outcomes may be that you review the patient, or make a referral. You can refer patients to the primary or community mental health team, or the local crisis resolution and home treatment (CRHT) team. If you feel that the patient is at very high risk then an immediate referral to A&E may be necessary. If possible they should be accompanied by ambulance staff or family.
9. The most common causes of suicide include overdose, hanging and jumping3
Strategies involving the restriction of access to common methods of suicide are a way of preventing suicide.
Prevention methods can include prescribing medications in weekly doses to prevent stockpiling, and asking the patient to return for review in a few days, as access to help and someone to talk to can also help prevent suicide.
10. Ask yourself and others these key questions
– What is the patient’s mental state today?
– How is this different to their usual mental state?
– Is the patient with a friend or relative?
– If so ask them what is new/different?
– What are their main concerns?
– What do they think can be done to help the situation?
The key to triangulating evidence is to obtain collateral history. This may help find hidden intent.
Dr Praveen Soma is a consultant psychiatrist working in a low secure rehab unit, Bowness Unit, Prestwich Hospital, Manchester, and Dr Ankur Khanna is a CT3 trainee at the NW Deanery.
1 Office for National Statistics (2011) Leading causes of death in England and Wales, 2009
2 Bertolote JM, Fleischmann A (2002). Suicide and psychiatric diagnosis: a worldwide perspective. World psychiatry, 1 (3); 181-185
3 Healthcare Quality Improvement Partnership (2012). National confidential inquiry into suicide and homicide by people with mental illness annual report