Background

Suicide can be described as a fatal act of self-harm initiated with the intention of ending one's own life. Although often seen as impulsive, it is usually associated with years of suicidal behaviour including suicidal ideation or acts of deliberate self-harm.

It is estimated that every year more than one million people commit suicide in the world. It is estimated that up to 50 % of people who commit suicide have previously attempted to do so.¹

Therefore, it follows that patients who attempt suicide and survive are at high risk of committing suicide later - and it may be possible to intervene to prevent this.

On the other hand, deliberate self harm, e.g. slashing arms, is usually based upon differing psychological motives, e.g. cry for help.² Even so, 10% of these patients will eventually die from suicide.

Vigilance about suicidal behaviour

• All health professionals need to be vigilant of patients who express a desire to harm themselves.
• All threats of suicide should be taken seriously and thoroughly investigated.
• They could be a terminally ill patient or a successful professional.
• There is no harm in directly asking questions such as: "do you ever think about ending it all?"

If there is concern that the patient poses a significant risk to themselves then they may need to be admitted e.g. severe depression.

Mental disorders and risk of suicide

The risk of suicide in patients with mental disorders is higher than that for patients without co-existent mental disorders. Although figures as high as 15% have been reported in people with depression, the actual value is much lower. The original 15% represented inpatients with severe depression and the actual figure is probably more around 3%.³

Suicide is a major cause of death in schizophrenic patients and it is thought that up to 1 in 10 patients with schizophrenia will eventually commit suicide.⁴

Determining a patients risk of suicide

• Suicidal intent has been found to be a good predictor of a subsequent completed suicide,⁵ e.g. a 5 year follow-up study of more than 2500 patients showed that those who scored highly for suicidal intent at the time were at high risk of completed suicide especially within the year after the attempt.⁶
• There are a number of risk predicting score systems to determine suicidal intent e.g. Beck's Suicidal Intention Scale, Beck's Hopelessness scale and Motives for present parasuicide.
• The most widely used scales are Pierce Suicide Intent Scale⁷ and Beck's Suicidal Intention Scale. These contain about 15 items - each one scoring from 0 - 2 points. Part of the scale looks at the patient's thoughts and emotions at the time of the attempt and the other questions are about the circumstances around the attempt.

The PATHOS score may be used to identify high risk patients after an overdose:

What to do if a patient expresses suicidal ideation

• Form a good relationship, be empathic and reassure regarding confidentiality.
• Suicide risk - determine as above.
• Assess current mental health or physical health difficulties.
• Determine any support networks available to the patient.
• Determine risk of further harm or suicide:
  • History and details of any attempt or are they making plans.
  • What was/is the intent and are there any precipitating factors, e.g. recent bereavement.
  • Previous attempts at suicide or deliberate self-harm.
  • Use of illicit drugs or alcohol dependence.
  • Social circumstances.
  • Any concurrent mental health issues, e.g. depression.

Management after initial assessment

• If the patient is at low risk then they should be offered regular contact (could be by telephone if possible) and counselling. You may need to consider referral to local mental health services for further follow-up.
• If there are concerns about patient safety or the patient scores highly on the suicide risk score the patient should be referred for urgent mental health assessment. If you are unsure then seek advice from mental health specialists.^2,8
• Usually patients are sent to a designated assessment area and the on-call psychiatrist can direct you as required. One needs to be wary of sending patients to A&E, although most A & E departments have psychiatric liaison staff available on site allowing the patient to be assessed and admitted if necessary.
• If a patient refuses help then a decision regarding their capacity may need to be made with psychiatric evaluation and detention under the Mental Capacity Act considered.⁸
• It is important to remember that scales of risk, although helpful, have a poor predictive value. Therefore, if you have a patient who you are worried about but they score low, then still consider urgent referral for them.

Document references

1. M.G.Gelder et al (Eds) New Oxford Textbook of Psychiatry: Chapter 4.15. (2000) OxfordOxford University Press, .
2. Mitchell AJ, Dennis M; Self harm and attempted suicide in adults: 10 practical questions and answers for emergency department staff. Emerg Med J. 2006 Apr;23(4):251-5. [abstract]
3. Raven MK; Depression should be managed like a chronic disease: myth of 15% suicide rate was promulgated again. BMJ. 2006 May 13;332(7550):1154.
4. MIND; Schizophrenia and suicide
5. Suominen K, Isometsa E, Ostamo A, et al; Level of suicidal intent predicts overall mortality and suicide after attempted suicide: a 12-year follow-up study. BMC Psychiatry. 2004 Apr 20;4:11. [abstract]
6. Harriss L, Hawton K, Zahl D; Value of measuring suicidal intent in the assessment of people attending hospital following self-poisoning or self-injury. Br J Psychiatry. 2005 Jan;186:60-6. [abstract]
7. Pierce Suicide Intent Scale
8. GP-Training.net; Suicide Risk: A guide for Primary Care and Mental Health Staff - Newcastle, North Tyneside and Northumberland Mental Health NHS Trust (2001).

Acknowledgements