Take a careful history of events leading up to the assessment. If the person has already made a suicide attempt assess for indicators that this was a high-risk attempt (see box that follows the suicide risk management section).
Suicide Risk Assessment
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When assessing someone who has attempted suicide, or who is presenting with suicidal ideation:
- Manage any physical effect of the attempt and keep the person safe (see management).
- Assess the current risk of suicide – low, medium, or high – and assess whether the patient has depression or another mental illness.
- Always treat the person with respect as you would any other patient. Although suicide is illegal in Malawi, reassure the patient that you will respect their right to confidentiality and that you would only disclose information to anyone outside of the medical team if there was a serious risk to the patient or someone else.
Ask about the key symptoms:
- Depressed mood (most of the day, almost every day)
- Loss of interest or pleasure in activities that are normally pleasurable
- Decreased energy or easily fatigued
If these are present, ask about additional symptoms, including guilty or pessimistic thoughts, disturbed sleep or diminished appetite.
The depressed patient may show self-neglect, slow speech and movement, and poor eye contact on mental state examination.
In psychotic depression there may be false (delusional) beliefs that the person is a bad person, physically ill, or in financial ruin.
Other mental illnesses, such as schizophrenia, have a risk of suicide.
Check for key symptoms:
- delusional beliefs
- hallucinations
- difficult-to-follow or disorganised thinking
Check for command hallucinations such as voices instructing the person to harm himself.
- Chronic painful illnesses.
- Alcohol dependence
- Availability of means: e.g. poisons, paracetamol,
- Family history of suicide.
- Lack of social support or recent adverse life events (loss of job, bereavement, or loss of relationship).
- Being separated or divorced
- Being male and older
- Unemployment
Assessment of risk takes many factors into account.
Indicators of high risk include:
- Committing a dangerous act of self-harm/attempted suicide:
- evidence of pre-planning
- taking steps to avoid being found
- lack of regret
- continuing wish to die or suicidal plans
- Symptoms of depression, psychosis or alcohol dependence
- Drinking alcohol heavily
- Social isolation or continuing extreme social adversity.
- Being an older, male or unemployed
- Having a chronic physical illness
- Being divorced or separated