Recommendations
Urgent
Take all patients with suicidal thoughts seriously and respond with compassion and in a timely and proportionate way. Maintain a particularly high level of concern, however, for any patient with:[1][117][118][119]
Suicidal thoughts that are compelling, persistent, or increasing in frequency
Plans and preparations for suicide (e.g., making a will, writing a goodbye note or text, putting affairs in order, giving possessions away) and access to lethal means for suicide
Sudden unexplained changes in behaviour or uncharacteristic behaviour
Hopelessness, negative thoughts (e.g., ‘I’m a burden,’ ‘I have nothing to live for’), agitation, or a sense of shame or entrapment
Recent loss of attachment, perceived lack of social support, major relationship instability, or recent bereavement
Repeated or recent relapse of a mental illness or recent admission or discharge from a psychiatric unit
Psychotic phenomena (e.g., persecutory or nihilistic delusions, command hallucinations)
Use of suicide-promoting websites
Substance misuse, especially if this is caused by loss of interpersonal relationships
History of self harm.
In the community, it is common practice to be particularly alert for patients with suicidal thoughts or behaviours who:
Frequently and repeatedly attend
Have disengaged with services
Are prescribed several different antidepressants
Have heightened concern from family members.
Consider your own safety first before seeing the patient.[120][121][122][123]
Assess the patient’s mental capacity to stay for assessment and treatment and for signs of mental illness.[124] Always involve senior support or contact the appropriate mental health team if in the community.[5][125]
Involve senior support to decide what is in the patient’s best interests if the patient is at at imminent risk of suicide and does not want this to be shared with anyone.[126][127]
If the patient is presenting after an episode of self-harm, ensure they have a psychosocial assessment by a mental health professional at the earliest appropriate opportunity.[5]
Key Recommendations
Assess patients who are at risk of suicide using a compassionate and therapeutic approach and seek consent early to involve those involved in the patient’s care (e.g.,friends/family/carers).[1][5][126]
It is important to consider asking all patients about suicidal thoughts even if this is not their primary reason for presentation. Around 10% of all adult patients attending the accident and emergency department have recent suicidal ideation or behaviours, regardless of the problem they presented with, but many will not disclose this unless asked.[128][129]
Collect information on the patient's psychiatric, medical, psychosocial, and family history as these may provide important context. Take a detailed history of the patient’s suicidal thoughts and identify individual risk and protective factors using a biopsychosocial approach.[5]
Collect information on the patient's psychiatric, medical, psychosocial, and family history as these may provide important context. [5][124]
Undertake a mental state examination to elicit any signs of mental illness.[1][5][124]
A risk formulation should be undertaken by a mental health professional as part of every psychosocial assessment.[5]
Assess any self-harm and identify the context and intent for it.[130] It is also important to identify signs of acute or chronic physical illness, alcohol-use disorder, or substance misuse.[1][131][132][133]
Consider your own safety before seeing the patient.[120][121][122][123]
Find out about the background of the patient you are going to see.[120]
Assess the safety of the environment, balancing respect for the person's autonomy against the need for restrictions. Use the least restrictive measures.[5]
Consider removing items that may be used to self-harm; involve the patient in this decision.[5]
Be wary if the patient has a history of violence or is disorientated or suspicious, or appears unusually distressed.[121]
If there are concerns, take a chaperone with you who is not associated with the patient (e.g., healthcare assistants, nurses, security personnel).[121]
A chaperone is particularly important if the patient has concurrent drug or alcohol intoxication or withdrawal.[120]
Ideally, use a properly equipped psychiatric interview room. If this is not available, use a room that has clear lines of sight and that is easy to leave quickly, such as a curtained cubicle.[122]
Practical tip
You may need to contact the mental health liaison team to access a patient’s mental health records if based in the UK, as mental health hospitals have a different records system to general hospitals. Gaining background information is essential, however, especially out of hours.
If the patient is presenting after an episode of self-harm, ensure they have a psychosocial assessment by a mental health professional at the earliest appropriate opportunity.[5]
If the patient is unable to cognitively engage in the assessment (e.g., they are unconscious or have high levels of intoxication) regularly review them, so assessment can take place as soon as appropriate.[5]
Take all patients with suicidal thoughts seriously and respond with compassion and in a timely and proportionate way. Maintain a particularly high level of concern, however, for any patient with:[1][117][118][119]
Suicidal thoughts that are compelling, persistent, or increasing in frequency
Plans and preparations for suicide (e.g., making a will, writing a goodbye note or text, putting affairs in order, giving possessions away) and access to lethal means for suicide
Sudden unexplained changes in behaviour or uncharacteristic behaviour
Hopelessness, negative thoughts (e.g., ‘I’m a burden,’ ‘I have nothing to live for’), agitation, or a sense of shame or entrapment
Recent loss of attachment, perceived lack of social support, major relationship instability, or recent bereavement
Repeated or recent relapse of a mental illness or recent admission or discharge from a psychiatric unit
Psychotic phenomena (e.g., persecutory or nihilistic delusions, command hallucinations)
Use of suicide-promoting websites
Substance misuse, especially if this is caused by loss of interpersonal relationships.
Be aware that suicide is almost impossible to predict accurately. However, there may be times when patients are at elevated risk. Consider the following general points:
Focus your assessment on identifying the patient’s needs and implementing the necessary interventions
Do not rely wholly on identifying demographic risk factors when assessing individuals
Do not rely on ‘risk assessment tools’ to predict future suicide or self-harm, to stratify risk (into low, medium or high), or to inform management decisions.[5][119][134]
A risk formulation should be undertaken by a mental health professional as part of every psychosocial assessment. This should focus on the patient’s needs and how to best support them psychologically and physically.[5]
Practical tip
Do not use the word ‘deliberate’ in the context of self-harm; this term is considered stigmatising.
Assess suicide risk and intervene as necessary in the following scenarios:
Any patient who is depressed
Accident and emergency department attendance due to self-harm or acute worsening in mental health
Intake evaluation (either as an inpatient or outpatient)
Before a change in observation status or treatment setting (e.g., discontinuation of one-to-one observation, before leave or discharge from inpatient setting)
Abrupt change in clinical presentation (either acute worsening or sudden, dramatic improvement in mental health)
Lack of improvement or gradual worsening of mental health despite treatment
Anticipation or experience of a significant interpersonal loss or psychosocial stressor, especially if very difficult to solve (e.g., divorce, financial loss, legal problems, personal shame or humiliation, coming out to parents about gender or sexuality, disclosing sexual assault)
Onset of a physical illness (particularly if life-threatening, disfiguring, or associated with severe pain or loss of executive functioning)
Any other reason for concern (e.g., concern from another health professional or the patient’s family).
Practical tip
It is important to consider asking all patients about suicidal thoughts even if this is not their primary reason for presentation. Around 10% of all adult patients attending the A&E department have recent suicidal ideation or behaviours, regardless of the problem they presented with, but many will not disclose this unless asked.[128][129]
In the community, it is common practice to be particularly alert for patients with suicidal thoughts or behaviours who:
Frequently and repeatedly attend
Have disengaged with services
Are prescribed several different antidepressants
Have heightened concern from family members.
Ensure the assessment is conducted in an appropriate calm space, such as a quiet and private designated room where it is possible to speak without being overheard.[5]
Seek consent early to liaise with those involved in the patient’s care (e.g., family members and carers as appropriate) to gather information (e.g., if the patient has self-harmed, to understand the context of and reasons for the self-harm).[1][5]
Other sources of information for a collateral history include paramedics, police, or the patient’s general practitioner or community mental health team.[123]
If the patient is suicidal but does not give consent to involve their family, and the patient lacks capacity for this decision, determine what is in their best interests in accordance with local policies and legislation (e.g., section 4 of the Mental Capacity Act 2005 in England and Wales). Disclosure without consent may also be made when there is a legal power to share and it is necessary for public interest.[135]
Involve senior support to decide what is in the patient’s best interests if the patient is at imminent risk of suicide and does not want this to be shared with anyone.[126][127]
Practical tip
Always find and read the ambulance sheet handover if the patient has attended hospital as this is usually the most accurate source of information about the patient’s current circumstances.
Use a compassionate and therapeutic approach to gain the patient’s trust in order to facilitate the disclosure of potentially painful or distressing thoughts and feelings.[1][119]
In general, the following points can be helpful:
Use appropriate, non-medical language and words that the patient uses when describing their symptoms and experiences
Allow the patient enough time to answer questions and avoid any assumptions or interruptions if possible
Ask open questions and avoid any implicit judgement or bias: for example, “How are you feeling today?”
Practical tip
For an adequate assessment, the patient should be cognitively able to participate. Patients who are intoxicated or withdrawing from alcohol or drugs should be observed until they are able to engage.[5][123]
It is very important to spend time gaining the patient’s trust at the beginning of the consultation as it is usually difficult for them to talk openly about suicidal thoughts.
A risk formulation should be undertaken by a mental health professional as part of every psychosocial assessment.[5]
This should be a collaborative process between the mental health professional and the patient.
This risk formulation should aim to summarise the patient’s current risks and difficulties, and understand why they are happening, therefore informing a treatment plan.[5]
Take a detailed history of the patient’s suicidal thoughts. Use clear, non-medical language and words that the patient uses when describing their symptoms and experiences.
Good examples of questions to ask are:
Is life worth living?
Have you wanted to harm yourself?
Have you had thoughts of suicide?
Have you ever wished your life would end?
Have you ever thought about taking your own life?
Have you ever thought about ending your life?
What has stopped you acting on those thoughts so far?
Other points to consider are:
The nature of the suicidal thoughts (e.g., frequency, intensity, persistence, intended outcome)
The patient’s perception of the future (e.g., persistently negative and hopeless, hopeful, alternatives)
The degree of planning for suicide (e.g., internet research, use of social media and suicide-promoting websites, learning about method, looking for place and time, masking discovery, putting affairs in order)
The availability of lethal means
The patient’s ability to resist acting on their thoughts of suicide or self-harm.
Practical tip
Asking about a patient’s thoughts of suicide does not increase their risk or provoke suicidal ideas. Many patients are relieved to be able to talk about these thoughts.[119]
Identify risk and protective factors using a biopsychosocial approach.[5]
Evidence: Assessment of risk
Assessing ‘suicide risk’ is an important part of a holistic assessment that will also include an intervention and management plan. Evidence shows that assessment should not be used as a prediction tool or to categorise risk to exclude people from care. There is no evidence that assessment increases the risk of suicide and it may well be the first step in helping someone stay safe.
It is common in practice for clinicians to undertake suicide risk assessments to categorise probability of risk as low, medium, or high. However this has been shown to be unhelpful and unreliable when it comes to predicting suicidal behaviour.
For example, in the National Confidential Inquiry into Suicide in the UK, between 2010 and 2020 'immediate risk' of suicide was judged to be 'low' or 'not present' in 83% of 10,396 people at the last contact with a healthcare professional before dying from suicide.[136]
This was also shown when assessing suicide risk after self-harm in a systematic review and series of meta-analyses looking at unassisted clinician risk classification (eight studies; n=22,499). The review found pooled estimates for sensitivity 0.31 (95% CI 0.18 to 0.50), specificity 0.85 (0.75 to 0.92), positive predictive value 0.22 (0.21 to 0.23), and negative predictive value 0.89 (0.86 to 0.92). Clinician classification was too inaccurate to be clinically useful.[137]
There is therefore now a shift from predictive assessment to personalised and individualised intervention-focused models where assessment of specific risk areas can directly inform intervention plans.[1][138]
Evidence: Risk assessment tools
Suicide risk assessment tools may help structure clinical assessment, but they lack accuracy and should not be used in isolation to determine current management or future risk.
The UK National Institute for Health and Care Excellence (NICE) makes a recommendation against the use of risk assessment tools and scales to predict future suicide or repetition of self-harm and states they should not be used for decisions on treatment or discharge.[5] In practice, risk assessment tools may be used to structure risk assessments as long as the tool assesses various risk and protection factors, suicide intent, and immediate and long-term risk. One example is the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) tool, which was developed using data and recommendations from the 2003 American Psychiatric Association guidelines and has been recommended as a pragmatic, multidimensional tool.[139]
One prospective observational study (276 people who admitted suicidal ideation) evaluated the use of SAFE-T, SAD PERSONS (SPS), and the Columbia-Suicide Severity Ratings Scale in an accident and emergency department.[140] There was little difference between the tools, with negative predictive values ranging from 0.66 to 0.73, which led the authors to conclude that none of these tools should be used in isolation for decision-making in that setting.
Multiple studies have looked at the diagnostic accuracy of suicide risk assessment tools.
A population-level retrospective cohort study (4000 episodes of self-harm, incidence of suicide 0.5%) compared the accuracy of four scales: the Manchester Self-Harm Rule (MSHR), the ReACT Self-Harm Rule (ReACT), SPS, and the Modified SAD PERSONS Scale (MSPS).[141] The area under the curve was 71% for both MSHR and ReACT, and both of these scales had a high sensitivity (98% and 94%, respectively) but low specificity (15% and 23%). The other two scales both performed around 50% on area under the curve (i.e., their performance was similar to chance) and they had low sensitivity with high specificity. The authors concluded that no test studied was accurate enough to be used alone to determine treatment of the current episode or future risk.[141]
Similar results with studies with high sensitivity having low specificity and low positive predictive values have been found in systematic reviews, suggesting that all of the tools available currently should only form part of the clinical assessment.[142][143]
Similar results have been found for scales used for suicide risk assessment in children and adults.
A systematic review (search date March 2018) found 11 studies (2554 participants) that evaluated 10 different tools for assessing suicide risk in children and adolescents (age 10-25).[144] No meta-analysis was possible due to heterogeneity. Most studies were of unclear risk of bias. The sensitivity of the tools ranged from 27% (95% CI 10.7% to 50.2%) to 95.8% (95% CI 78.9% to 99.9%). However, the tool with the highest sensitivity had a low positive predictive value (25.4%). The reviewers concluded that overall they could not recommend a single tool, and that risk assessment should form “part of a wider comprehensive assessment”.[144]
Collect information on the patient's psychiatric, medical, psychosocial, and family history as these may provide important context.[5]
Psychiatric history including substance misuse
Include previous self-harm or suicide attempts, previous admissions, and current treatment.[124]
Medical history
Identify the presence of current medical diagnoses or physical challenges that may increase both short- and long-term suicide risk, such as terminal illness, cancer, chronic disease, pain, functional impairment, cognitive impairment, loss of sight or hearing, disfigurement, loss of independence, or increased dependency on others.[52][64][65][66][67][68][69]
Psychosocial history
Find out about the patient’s current living situation, level of functioning, acute or chronic stressors, occupational factors, assets such as availability of external social supports, risk-buffering factors, and cultural or religious beliefs relating to death or suicide.[1]
Family history
Practical tip
Many people who are at risk of suicide do not have a diagnosis of mental illness; other factors may cause suicidal thoughts (e.g., significant life events such as divorce, financial loss, legal problems, personal shame or humiliation, coming out to parents about gender or sexuality, disclosing sexual assault).
Evidence: Association of mental illness with suicide risk
There is an increased risk of suicide with mental illness, especially depression or depressive episodes.
The link between mental illness and suicide risk has been long established. In 1997 an important meta-analysis was published that calculated the standardised mortality ratio (SMR) for different disorders, comparing the risk with that of the general population.
Of the 44 conditions they looked at, 41 had a raised SMR (36 of which were statistically significant).
The highest were for eating disorders (SMR 23.1) and major depression (SMR 20.4).
The risk in people with substance-misuse disorders ranged from SMR 3.35 for cannabis misuse to SMR 20.3 with sedative misuse.
The SMR for alcohol misuse was 5.86.
A systematic review of psychological autopsy studies of suicide found that in case series the median proportion of people with mental illness was 91% (95% CI 81% to 98%).[146] Similarly, in case-control studies the median proportion of people with mental illness was 90% (95% CI 88% to 95%) in the cases, compared with 27% (95% CI 14% to 48%) in the control groups.[146]
In Sweden a large cohort study followed 34,219 patients (aged 10 and over, mean age 36 years for women and 40.5 years for men) admitted to hospital after self-harm.[147]
Patients were followed for 3 to 9 years, over which time there were 1182 suicides.
Mental illnesses linked to the highest rates of suicide after previous self-harm were:
Bipolar disorder (in males, adjusted hazard ratio [HR] 6.3, 95% CI 3.8 to 10.3; in females, adjusted HR 5.8, 95% CI 3.4 to 9.7)
Non-organic psychotic disorder (including schizophrenia, schizotypal and delusional, and other non-mood psychotic disorders – in males, adjusted HR 5.1, 95% CI 3.5 to 7.4; in females, adjusted HR 4.6, 95% CI 2.8 to 7.7)
Moderate to severe depression (in males, adjusted HR 4.8, 95% CI 3.5 to 6.4; in females, adjusted HR 4.8, 95% CI 3.5 to 6.8).
Substance-use disorder was more of a risk in men than in women (HR 5.1 in men compared with 4.6 in women).
All the diagnostic categories studied had a higher rate of suicide than the reference category (those in the cohort who had not received a psychiatric diagnosis before the index event or up to 1 year after).
Evidence: Association of internet use with self-harm and suicidal behaviour
Internet use may be associated with self-harm and suicidal behaviour in young people.
A systematic review of the influence of internet use on self-harm and suicidal behaviour in young people found 11 positive studies (38,191 participants), 18 negative studies (119,524 participants), and 17 mixed studies (35,235 participants).[148]
On general internet use the authors found one study of the influence of the internet or social media on self-harm: this was found to be 15% in girls and 26% in boys (self-reported). A school-based survey provided supporting evidence that suicidal ideation is associated with accessing suicide or self-harm information online (odds ratio [OR] 5.11, 95% CI 0.35 to 0.75), anxiety about receiving email replies (OR 2.06, 95% CI 1.33 to 3.20), and hurtful experiences online (OR 1.71, 95% CI 1.03 to 2.84).
There was a significant relationship between internet addiction (as defined by study) and self-harm/suicidal behaviour in all 7 studies that looked at internet addiction or pathological internet use. However, one study also found that people with internet addiction reported high levels of life satisfaction and low levels of loneliness, so more research is required. High levels of internet use and visiting websites with self-harm or suicide content were also risk factors for self-harm and suicide behaviour.
While some studies found the internet reduced isolation and could be used as a source of support or even therapy, others found it could result in normalisation and possibly encouragement or triggering of self-harm/suicidal behaviour.
The systematic review concluded that a discussion about internet use should be a standard part of an assessment with any young person who self-harms or has mental health issues. In practice, any person with a smartphone or access to the internet who is at risk of suicide should be asked about internet use.
If the patient wishes to leave before a psychosocial assessment has been undertaken, assess their safety capacity and for signs of mental illness and ensure these are documented.[5][124]
Always involve senior support or contact the appropriate mental health team if in the community.[5][125]
In general, if there is any doubt about a patient’s capacity to make a decision that may limit their life, favour life-saving measures until a more in-depth assessment can be made.[135]
The patient may need to be admitted involuntarily if a mental illness is present and they are at significant risk to themself or others.[149]
Undertake a mental state examination to elicit any current psychiatric symptoms.[1][124]
Maintain a high level of concern for any patient with hopelessness and evidence of suicidal intent.[150]
Use clinical judgement if the patient does not answer questions directly and there is no collateral information available.[151]
Assess warning signs for hidden suicidal ideation, intent, or plan (e.g., presence of psychosis, despondence, emotional distress, guilt, hopelessness, helplessness, anger, or agitation; inability to develop rapport; difficulty making eye contact) and bear in mind your subjective impression.[1][117]
Review hospital or primary care records for evidence of past self-harm, and pay close attention to signs of self-harm injuries during the physical examination.
Practical tip
Be aware that although the patient may feel emotionally or mentally distressed, they may not display this outwardly.
Assess any self-harm. Common methods of self-harm include poisoning and self-injury.[152]
Examine for signs of acute or chronic physical illness, alcohol-use disorder, and substance misuse.[1][131][132][133]
Practical tip
Be aware of your own attitudes towards people with mental health problems and examine patients carefully for evidence of underlying physical illness as this may be missed. Patients with concurrent mental illness have worse treatment for physical health problems than the general population. This may be due to ongoing stigma, a lack of knowledge about mental disorders, and avoidance of contact with these patients due to fear of violence or aggression.[153]
Evidence: SSRI withdrawal
Changes in dose or discontinuation of selective serotonin-reuptake inhibitors (SSRIs) may increase the risk of suicide, particularly for SSRIs with a short half-life such as paroxetine.
A nested case-control study used retrospective data from a large US claims database (1999-2006) to assess the effects of discontinuing antidepressants on the risk of suicide attempts.[154]
Patients (aged 5-89 years) with new episodes of depression treatment were selected with cases who had a suicide attempt (n=10,456) and matched controls (n=41,815).
The study found antidepressant discontinuation (all antidepressants) had a significant risk for suicide attempt (adjusted odds ratio [OR] 1.61, P <0.05).
It should be noted, however, that the highest risk for suicide attempt was with initiation of antidepressants (adjusted OR 3.42, P <0.05), and the risk with dose changes was greater than that for discontinuation (titration up, adjusted OR 2.62; down, adjusted OR 2.19; P <0.05).
No separate results were reported for SSRIs, but 34% of cases and 50% of controls had been taking an SSRI.
In a small randomised controlled trial, 28 patients treated with SSRIs (23 patients) or serotonin-noradrenaline reuptake inhibitors (SNRIs; venlafaxine, 5 patients) for at least 6 weeks were randomised to either abrupt (3-day, 15 patients) or tapered (14-day, 13 patients) antidepressant discontinuation.[155]
A 'discontinuation syndrome' (≥3 new symptoms on the Discontinuation Emergent Signs and Symptoms checklist) occurred in 46% of patients with a similar frequency in both arms.
The analysis of variance showed that short half-life antidepressants (any except fluoxetine) were associated with significantly greater increases in discontinuation (P=0.003) and depressive symptoms (P=0.018). Four of the eight patients on paroxetine (50%) developed suicidal ideation on discontinuation. No patients on any other antidepressant developed suicidal ideation.
A 2019 opinion article used positron emission tomography imaging data of serotonin transporter occupancy to inform how best to stop SSRIs to minimise withdrawal symptoms.[156] The authors advised slow tapering, with percentage rather than fixed reductions.[156]
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