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.

The mortality rate in England in 2008-10 was 12.2 deaths per 100,000 population for males and 3.7 deaths for females. This was lower than other countries in Europe and reflects a sustained fall in suicide rates in England in recent years. The previous upward surge in suicide rates in young men under the age of 35 has been reversed and there has also been a fall in inpatient suicides and self-inflicted injuries in prisons.^[1]

It is estimated that up to 50% of people who take their own life have previously attempted to harm themselves.^[2] Therefore, it follows that patients who attempt suicide and survive are at high risk of taking their own life later - and it may be possible to intervene to prevent this.

On the other hand, deliberate self harm - eg, slashing arms - is usually based upon differing psychological motives - eg, a cry for help.^[3] Even so, 10% of these patients will eventually die from suicide.

Vigilance about suicidal behaviour

• All health professionals need to be vigilant about 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?"

Patients who pose a significant risk to themselves may need to be admitted - eg, 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%.^[4]

In Western countries, approximately 90% of people who die from suicide have a mental health disorder. The majority have a depressive disorder. Other associations include bipolar disorder, alcohol, drug misuse and schizophrenia. One UK study found that 10% of people with no history of mental ilness had suicidal thoughts and approximately 2% attempted suicide.^[5]

Suicide is a major cause of death in schizophrenic patients. Studies suggest that patients with schizophrenia have an 8.5-fold greater risk of suicide than the general population.^[6]   

Determining a patient's risk of suicide

Suicidal intent has been found to be a good predictor of subsequent attempts. A 15-year prospective study of 80 formerly psychiatrically hospitalised adolescents who had had several suicide attempts showed that highest intent and lethality (ie potential to cause death) were better predictors of future attempts than intent and lethality of the most recent attempt.^[7]

There are a number of risk-predicting score systems to determine suicidal intent. The most widely used scales are the Pierce Suicide Intent Scale^[8] and Beck's Suicidal Intention Scale.^[9] 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:^[10]

What to do if a patient expresses suicidal ideation

• Form a good relationship, be empathetic 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 whether they are making plans.
  • Establish what was/is the intent and whether there are any precipitating factors - eg,  recent bereavement.
  • Previous attempts at suicide or deliberate self harm.
  • Use of illicit drugs or alcohol dependence.
  • Social circumstances.
  • Any concurrent mental health issues - eg, depression.

Management after initial assessment

• If the patient is at low risk then they should be offered regular contact (this 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 if the patient scores highly on the suicide risk score, the patient should be referred for urgent mental health assessment. In most areas this can be provided by a Crisis Resolution and Home Treatment (CRHT) team. If you are unsure then seek advice from mental health specialists. If the CRHT is unavailable or does not exist, assessment in A&E should be arranged.^[3]
• If a patient refuses help then a decision regarding their capacity may need to be made with psychiatric evaluation and detention under the Mental Health Act considered. See Compulsory Hospitalisation and Consent To Treatment (Mental Capacity and Mental Health Legislation) for further details. 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.