Patient information from BMJ

Suicide risk management

Last published:Mar 13, 2023

Many people have good treatment for depression and other mental-health issues. But some people with these problems try to kill themselves, and some succeed. If you feel suicidal, or if you think someone close to you feels this way, there are people who can help, including your doctor.

What is suicide risk management?

If you seek treatment for a mental health issue and are feeling low, your doctor will want to try to understand whether you feel so bad that you might think about killing yourself.

If your doctor thinks that this is the case, he or she will want to take steps to keep you as safe as possible. This is suicide risk management.

Suicide risk management should have both short- and long-term elements. So, while it is about keeping you safe right now, in the short-term, it should also be part of longer-term help. 

The two things that most commonly lead people to try to kill themselves are:

• bouts of severe depression, and

• issues with substance abuse (abusing alcohol, street drugs, or medications). Substance abuse is a complex issue and can cause problems in lots of ways. For example, drug abuse can lead to mental-health problems.

  But it’s more likely that mental-health problems led to the drug abuse in the first place - and then the drug use makes things worse.

Many other things can lead to someone trying to kill themselves, including:

• struggling to cope with mental-health conditions other than depression, such as anorexia, bipolar disorder, and schizophrenia

• losing a loved one

• being in prison

• divorce or the breakdown of a relationship

• social problems, such as those around unemployment and housing

• money problems, and

• a combination of events that make like feel unbearable.

As well as mental-health issues, some physical illnesses are linked to a greater chance of suicide attempts. These include:

• epilepsy

• Huntington’s disease

• HIV

• stroke

• some types of cancer, and 

• some physical disabilities.

Physical illnesses can cause people to think about suicide for many reasons. For example, it might be that someone is in a lot of pain or feels hopeless. Or maybe someone with a terminal illness wishes to die on his or her own terms.  

Assessing suicide risk

When assessing whether someone is at risk of suicide, doctors look at what are called 'risk factors'. These are things that make something more likely to happen. 

The main risk factors that make someone think about suicide are:

• serious mental-health issues

• having tried suicide in the past

• having self-harmed in the past, and

• having a family history of suicide.

But it’s still possible to feel suicidal without having any of these risk factors. And suicide risk management is not about ticking boxes or treating people as risks.

So, regardless of how many of these risk factors might apply to you, the most important ways for your doctor to understand your mental state are simply talking to you, and listening to what you have to say about how you feel.

Suicide risk management shouldn’t just happen once at the start of your treatment. It should be ongoing, and it should be assessed again if certain things happen, such as if:

• you need emergency treatment

• there are any major changes planned in your treatment: for example, if you change doctors or change where you are treated

• your symptoms suddenly get worse or better, or if your diagnosis changes for any reason

• something in your life happens that upsets you badly

• you suddenly decide to stop having treatment for a mental-health problem.

While suicide risk management is an ongoing part of treatment, there are times when a doctor might need to take immediate action to protect someone. These are when someone is:

• threatening to hurt or kill himself or herself

• looking for ways to kill himself or herself

• seeking access to pills, weapons, or other means of suicide, or

• talking or writing about death, dying, or suicide.

During any assessment of suicide risk your doctor will ask you questions about how you are feeling.

Some of these questions might sound a bit simple and obvious. But they will help your doctor to understand your feelings. He or she might ask questions like:

• have you thought that your life is not worth living?

• have you thought about ending your life?

• do you feel that your reasons for living outweigh your reasons for dying?

• if you had a way, would you try to take your own life?

• how often do you think about dying?

• how do you feel when you start thinking about taking your own life?

• have you ever thought of ways to take your own life?

• have you ever made plans to end your own life?

• do you have access to a way of ending your life, such as pills, poison, or a weapon?

• have you taken steps to prepare to take your own life, such as writing a suicide note or a will, or giving away your possessions?

• do you think that you could take your own life?

• do you feel ready to die?

If you are having an assessment or emergency treatment with a doctor who has not treated you before, he or she will also ask you questions about your medical history, including your mental-health history.

The doctor will also probably ask you about:

• how you are feeling at the moment

• your home life

• how well you are coping and managing with your life in general

• things that are happening in your life that overwhelm or stress you, and

• good things in your life - things that are stopping you from attempting suicide. 

What help is there?

If it becomes clear during an assessment that there is a chance you might attempt suicide, your doctor should offer you help.

This help should be based on whether your doctor feels, after talking with you, that you are at immediate risk of attempting suicide. The doctor’s decision will depend on several things, including:

• how likely your doctor thinks you are to try to kill yourself

• whether you have a mental-health problem that makes you more likely to try to kill yourself, and

• how much support you have in your life: for example, from health services, and from family and friends.

Urgent help

If your doctor thinks that you are very likely to attempt suicide in the near future, he or she might suggest that you be admitted to hospital for treatment. Your doctor might also suggest hospital admission if you:

• have psychosis (you see or hear things that aren’t there)

• need urgent round-the-clock treatment for a mental-health problem, or

• don’t have enough social support outside hospital. For example, you might live alone with no friends or family nearby, which might make you feel lonely and desperate.

Some people also need urgent detoxification treatment ('detox') in hospital for substance use. 

And some people have to be admitted to hospital and given treatment against their wishes. The rules around this are different depending on where you live. But in many countries they will be similar to those in the UK, where this should be done only:

• as a last resort

• when someone needs urgent hospital treatment, and

• usually only if they are judged to be a danger to themselves or others.

In the UK you might hear this called being 'sectioned', as it refers to some sections of a law called the Mental Health Act. 

Under this law you have rights. Your doctor can’t just decide to have you sectioned. It needs two doctors and a mental-health professional to agree that it needs to happen.

If you don’t agree that you should have been sectioned you can appeal against the decision. And you have the right to complain about your treatment.

Longer-term help

Longer-term treatments for people at risk of suicide are similar to some treatments for other mental-health problems.

These treatments include various types of psychotherapy (talking treatments) and medications.

For many people, suicidal thoughts are a result of long-term mental-health conditions: for example, schizophrenia or bipolar disorder. So the best way to treat these suicidal thoughts is to treat those conditions.

Medications

The medications you are offered will depend on what mental-health conditions affect you. For example, different medications are used to treat conditions such as bipolar disorder, attention-deficit hyperactivity disorder (ADHD), and depression.

These medications can cause side effects. Your doctor should discuss these in detail with you.

If the side effects of your medications bother you, tell your doctor. You might be able to change to a different one, or to change to a lower dose.

Certain medications are not safe to take during pregnancy. One in particular, called sodium valproate, causes serious birth defects in babies.

If you are pregnant, tell your doctor. And if you are a woman and your doctor suggests that you take sodium valproate, your doctor will need to make a plan with you to make sure that you don’t get pregnant.

Psychotherapy

Research shows that psychotherapy reduces suicides in people with mental-health problems. Different types of psychotherapy seem to help with different mental-health conditions.

One type that works well with a variety of mental-health issues is cognitive behaviour therapy (CBT). This therapy helps you to cope with negative thoughts and to break down problems and deal them one step at a time. 

What will happen?

If your doctor thinks that you might try to kill yourself, he or she should take some simple steps, even if you don’t need urgent treatment.

• Your doctor should make sure that you go home with someone close to you who can support you in the short term.

• You should be given a contact card with the name and phone number of a crisis worker, in case your situation gets worse.

• The person supporting you at home should be given a similar card.

• You and your supporting person should be advised to make your home as free as possible of things that could aid suicide. This means, for example, that pills should be locked up, and guns and possible poisons should be removed from your home.

Your doctor will want to follow up with you regularly. And, if you are not having any treatment already, your doctor will probably suggest some - possibly some form of psychotherapy, medication, or both.

Your doctor might also help you to find useful online resources for people having suicidal thoughts, such as the Staying Safe website (stayingsafe.net).

It’s not possible to say what will happen to an individual who is at risk of suicide for any reason. But the sad truth is that some people kill themselves, even if they are having the best available treatment.

Many people make multiple suicide attempts over a number of years. And the more times a person tries to kill himself or herself, the more likely he or she is to succeed in the end.

But treatment and support help many people. And most people who attempt suicide - even those who try several times - do not die in this way.