Suicide Risk Management

If you are assessing someone who has attempted suicide (e.g. hanging, ingested poisons such as organophosphate pesticide (tamec), overdose of medication) first ensure medical stabilisation (AIRWAY, BREATHING, CIRCULATION).

Make an URGENT referral to medical team if needed

How best to manage a patient who has made an attempt on their life, depends on what their level of risk is of making a further attempt.

It is impossible to predict the future but by following the advice in the risk assessment section and asking the questions in the box at the end of this suicide section, you will be better able to make an informed decision on the patient’s risk level.

High Risk Patients - with Mental Illness

The key to reducing the likelihood of future suicide is to treat the mental illness.

Hospital admission is usually needed (or very close family support and frequent outpatient appointments).

If risk is very high, patient may need special supervision to prevent suicide attempt even in hospital. DO NOT leave the person alone; assign a named staff or family member to ensure person’s safety at all times.

Take practical steps to keep the patient safe: remove poisons, weapons, and dangerous items from the patient’s immediate environment, including ligature points, if possible.

High Risk Patients - No Mental Illness

Such patients include those with lots of psychosocial stress and maybe alcohol/substance misuse but without a diagnosable mental illness.

Hospital admission may not be appropriate (but admit if you are uncertain and it is sometimes useful to manage short-term crisis). Out-patient follow-up is needed.

Encourage patient and guardian to cooperate with steps to stay safe: remove poisons, weapons, and dangerous items from the environment.

Encourage the patient to avoid alcohol and other drugs. Offer treatment for drug and alcohol problems if possible.

Offer problem-solving support where this is available – see psychosocial interventions section.

Ensure patient has contact details for local mental health services and ‘crisis plan’ for emergencies.

Moderate Risk Patients

Treat any mental illness and offer further psychiatric treatment where appropriate.

Agree on a plan to keep the patient safe and a ‘crisis plan’ including contact details for future crises.

Low Risk Patients

Remember that patients who have self-harmed, even if they seem at low risk of suicide, are still more likely to die by suicide than the rest of the population.

Offer details of support services in case of future crisis.

Offer advice about alcohol and drug use, where this is present.

Supportive discussion about current stressful issues may be helpful but psychiatric follow-up is not usually required.

For All Patients

Attend to mental state and emotional distress.
Educate the person about the relationship between mental health, stress and the risk of suicide
Educate the guardian likewise
Identify any available psychosocial support.
Offer carers support

Questions to ask following a suicide attempt to determine level of risk

Situation	What were the circumstances of the suicide attempt? What was the immediate precipitant? Any recent stressors such as debt, relationship breakdown, domestic violence? Where was the person at the time? Was the person alone? Were there people nearby?
Substances	Was the person intoxicated by alcohol or another substance? Did they first think of suicide or self-harm before they became intoxicated or after?
Planning	Was the act planned in advance, or impulsive? If the act was planned, how far in advance was a plan made? How detailed was the plan?
Precautions	Had the person made any precautions to prevent being found? For example, cancelling expected visitors or appointments, going to an unfamiliar or distant place, locking doors. Or, was it likely that a family member, visitor, or passer-by would find them?
Last acts	Did the person carry out any final acts, expecting to die? Letters to family A recently made will Funeral arrangements Financial or family arrangements for after the person’s death
The act itself	How dangerous was the act, and how likely to cause death? Very dangerous – hanging, firearms, jumping from height, drowning attempt Moderately dangerous – pesticide ingestion, large overdose of dangerous medication, deep cuts with a blade Less dangerous – smaller overdose of less-dangerous medication, superficial cuts or burns.
Intent	What was the intended outcome? Did the person want to die and believe that they would die? Did the person want to die at the time but soon regret it? Was this an act of self-harm not intended to be fatal but to demonstrate how distressed the person was? Was the self-harm a habitual comforting response to distress, for example by superficial self-cutting?
Help-seeking	Did the person seek help after the suicide attempt? Did they tell somebody or seek help? Or were they only found by chance? For example, by an unexpected visitor or someone returning from work early. Did they go willingly and accept medical treatment? Or did they refuse or resist treatment?
Current attitude to the act	Does the person regret their actions? Or is the person upset because they are still alive?
Future plans	Does the person have future plans of suicide? Ask for full details about thoughts of suicide. Or does the person have other positive plans for the future such as returning to work, addressing financial problems, or trying treatment for mental illness.