Recommendations
Urgent
Manage the safety of the patient.
Carefully document a physical description of the patient, including identifying features and clothing.[168]
This can be used to find a patient if they leave without further assessment or treatment.
Ensure the patient is easily observable and checked regularly if there are concerns.[124]
Search for and remove access to objects the patient may use to self-harm.[123]
Try to verbally de-escalate agitated patients. Restraint should be proportionate to the risk presented by the patient and should be carried out by staff who are trained.[124] Use physical or chemical restraint (rapid tranquilisation) only if necessary. Follow local protocols.[123][169][170]
Assess the patient’s mental capacity to stay for treatment and for signs of mental illness.[5] 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.
Treat any self-harm or underlying physical illness.
Key Recommendations
Manage patients in a setting that is least restrictive yet most likely to be safe and effective. If the patient has agreed a care plan, check this with them and follow it as much as possible.[5]
Inform any mental health team involved in the patient’s care of their current presentation as legal procedures (e.g., the 2005 Mental Health Act if based in the UK) may be needed to admit the patient involuntarily if they refuse admission.[149]
Always seek advice from a senior clinician or the on-call mental health team before discharging a patient from hospital.
Ensure all patients have the following before discharge:
A psychosocial assessment by a suitably qualified professional.[5] The local mental health liaison team will typically be involved.
A safety plan[1][119] Staying Safe safety plan template Opens in new window
Access to resources such as the UK-based Staying Safe website and the Stay Alive app Staying Safe Opens in new window Stay Alive app Opens in new window
A management plan, agreed between the patient and all appropriate teams, including follow-up in the community.[5]
Arrangements for aftercare, including clear written communication with the primary care team.[5]
Initial follow-up arranged within 72 hours of discharge, or within 48 hours if there are ongoing safety concerns.[5][171]
A discharge planning meeting with all appropriate teams.[5]
Consider referring the patient to a community mental health team if:
They have a significant psychiatric disorder requiring specialist management
There are high levels of distress either in the patient or in family members, carers, or significant others[5]
They do not have protective factors
They request help from specialist services[5]
Risk of suicide or self-harm is increasing or is unresponsive to current strategies[5]
They are over 65 years old and self-harm
They have any problematic symptoms related to mental illness (e.g., akathisia due to treatment with a selective serotonin-reuptake inhibitor).
Remove, reduce, or mitigate risk factors and strengthen or add protective factors with the aim of reducing the risk of suicide.[1][119]
If the patient has agreed a care plan, check this with them and follow it as much as possible.[5]
Fully involve the patient in decisions about care, support, and treatment.[5]
Respect the patient’s views (whether offered in advance or at the time of presentation) wherever possible.
Consider the views of family, friends, and carers as well.
Explain any reason for decisions that contradict these views.
Use a compassionate, hopeful, and co-productive approach.
Ensure safety
Ensure your own safety first.
Find out about the background of the patient you’re going to see.
Be wary if they have a history of violence or are disorientated, intoxicated, suspicious, or unusually distressed.[121]
If there are concerns, take a chaperone with you who is not associated with the patient (e.g., security personnel, nurses, healthcare assistants).[121]
Practical tip
You may need to contact the on-call mental health 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.
Manage the safety of the patient.
Carefully document a physical description of the patient.[168]
This can be used to find the patient if they leave without further assessment or treatment.
Ensure the patient is easily observable, either in a private room or within close proximity to a member of staff (e.g., nurse’s station if in hospital).[124]
Search for and remove access to potentially dangerous objects (e.g., belts, shoelaces, or sharp medical instruments).[123]
Try to verbally de-escalate agitated patients by maintaining a greater personal space than usual; engaging in collaborative, respectful conversation; and having extra staff stand out of sight.[169][170]
Restraint should be proportionate to the risk presented by the patient and should be carried out by staff who are trained.[124] Only use physical or chemical restraints if they are absolutely necessary as they can be traumatic to the patient and impair rapport.[123][170]
Use the least restrictive option available to ensure the patient's safety.[124] Follow local protocols.
Assess the patient’s mental capacity to stay for treatment 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][149]
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.
Treat any self-harm or underlying physical illness
Treat self-harm and any underlying physical illness if present.
Take every episode of self-harm seriously as self-harm increases the risk of future suicide.[119]
Common methods of self-harm include poisoning and self-injury.[152]
Practical tip
Be aware that older people who have self harmed are at increased risk of suicide. Psychosocial assessment should be carried out by a mental health professional experienced in assessing older people.[5]
Practical tip
Do not delay referral to a mental health team just because a patient is not ‘medically fit’ as this may lead to worse outcomes. A patient may be suitable for a review of their mental health even if they have ongoing physical health problems.[172]
Determine a treatment setting
Manage patients in a setting that is least restrictive yet most likely to be safe and effective.[5]
Inform any mental health team involved in the patient’s care of their current presentation as legal procedures (e.g., the 2005 Mental Health Act if based in the UK) may be needed to admit the patient involuntarily if they refuse admission.[149]
In addition, consider short-term admission based on clinical need for certain patients; reassess the patient the following day or at the earliest opportunity after this. This may include patients who:
Have self-harmed and are very distressed
Have drug or alcohol intoxication that prevents a proper assessment
May be returning to an unsafe or potentially harmful environment.
Admit children and young people to a paediatric ward for a mental health assessment the following day.[173]
Obtain parental (or other legally responsible adults) consent for a mental health assessment of the child or young person.
Evidence: Admission
People with a psychiatric admission are at increased risk of suicide, especially in the first week of admission and the week following discharge.
In current practice, many patients are admitted due to their suicide risk. However, psychiatric admission has not been shown to definitively reduce suicide, with some academics proposing that admission may increase the risk of suicide in some cases.[174][175]
A large case-control study based on Danish national longitudinal registers (1981-1997) looked at 21,169 people who had completed suicide and compared them with 423,128 sex- and age-matched controls.[60] The authors found:
Suicide risk increased with psychiatric admission, especially in women (women: odds ratio [OR] 19.8, 95% CI 18.7 to 20.9; men: OR 10.4, 95% CI 9.9 to 10.9; P <0.001 for between sex difference)
The greatest risk, compared with people with no history of hospital admission, was in the first week of admission (women: OR 81.6, 95% CI 52.1 to 127.7; men OR 59.8, 95% CI 42.1 to 85.1) and the first week post-discharge (women: OR 246.0, 95% CI 152.5 to 396.6; men: OR 102.0, 95% CI 73.2 to 142.1)
People admitted for shorter periods were at increased risk of suicide (women: OR 1.5, 95% CI 1.4 to 1.7; men: OR 1.4, 95% CI 1.3 to 1.6)
Multiple admissions were a significant risk factor in women but not in men
People with affective disorders were at greater risk than people with schizophrenic disorders (women: OR 1.6, 95% CI 1.4 to 1.9; men OR 1.9, 95% CI 1.6 to 2.2); however, for both of these groups the risk decreased with treatment of the underlying condition.
Another case-control study looked specifically at the effects of compulsory versus voluntary admission on the risk of inpatient suicide in people with schizophrenia.[176] Using retrospective data (2007-2013) from the Taiwanese National Health Insurance Database the authors identified 2038 psychiatric inpatients with a first compulsory admission, and matched them with 8152 voluntary inpatients as controls. They found there was:
No protective effect to compulsory admission (log-rank test, P=0.206)
An increased risk of suicide during the first week of admission in both groups.
Practical tip
Check local protocols when referring young people. The age limit for referral to a paediatric ward ranges from 16 to 18 years.
In practice, many paediatric wards may only admit young people aged 14 years and under despite guidance.
Always seek advice from a senior clinician or the appropriate mental health team before discharging a patient from hospital. Ensure all patients have the following before discharge:
A psychosocial assessment by a suitably qualified professional.[5] The local mental health liaison team will typically be involved.
Reduction of access to means of suicide. The most common methods of suicide in the UK are hanging followed by self-poisoning[127][157][158]
Restrict availability of medicines for purchase, prescription, and in the home
Take into account risks of prescribing medication, including dependency, overdose, and diversion[177]
A safety plan that maximises the patient’s social support and includes ways to reduce their access to means. (See below for more information on developing a safety plan)[1][119]
Access to resources such as the UK-based Staying Safe website and the Staying Alive app Stay Alive app Opens in new window Staying Safe Opens in new window
A management plan, agreed between the patient and all appropriate teams, including follow-up in the community.[5]
Arrangements for aftercare, including clear written communication with the primary care team. Follow-up with either a community mental health team or general practitioner.[5]
Initial follow-up arranged within 72 hours of discharge, or within 48 hours if there are ongoing safety concerns.[5][178]
A discharge planning meeting with all appropriate teams.[5]
Evidence: Reduce access to means
Population-level interventions to reduce access to lethal means of suicide play a key role in suicide prevention.
International guidance from the World Health Organization (WHO) highlights that a key component of suicide prevention is reducing access to lethal means. The WHO recognises that restriction policies need to be based on an understanding of methods used by different groups (e.g., access to pesticides, barriers on bridges, gun-control measures, availability of certain medications) and that a multi-sector public health approach is required to achieve this.[179]
The National Institute for Health and Care Excellence in the UK has made evidence-based recommendations on reducing access to lethal means, which include using national data to identify trends in locations and methods, and more specific recommendations such as safer cells in custodial settings, restricting access to painkillers, physical barriers, and measures to reduce the opportunity for suicide such as CCTV or increased visibility of staff.[180]
Develop a safety plan
Develop a safety plan using a collaborative approach with the patient and document this formally.
This plan belongs to the patient, but ideally the clinician (and key others) should have a copy.
A useful resource for developing a safety plan is the Staying Safe website.[1][119] Staying Safe Opens in new window
Review the safety plan regularly as part of routine follow-up and also at points of change or transition (e.g., change in medication or social circumstances).
Practical tip
A safety plan can be thought of as the emotional health equivalent of putting on a car seatbelt. It’s a planned set of actions, strategies, and sources of support that a person keeps with them and can use to help them stay safer when experiencing distress and before they reach a crisis point.
Evidence: Safety plan
Safety plans are an effective approach that can decrease the future risk of suicide in patients at risk.
A safety plan is an agreed set of activities, strategies, people, and organisations to contact for support that are documented in one place, for ease of reference. Evidence shows that minor interventions can help to prevent suicide and that increasing hope, emotional resilience, and reasons for living decrease suicide rates.[181][182][183][184] A safety plan captures all of these and includes specific ways to remove or minimise access to means for suicide. This is an effective approach to reduce risk of suicide.[185][186]
A combination of safety planning and follow-up telephone calls to people following presentation to the accident and emergency department after a suicide attempt or suicidal behaviour was associated with about 50% fewer suicidal behaviours over a 6-month follow-up and increased engagement in outpatient care.[181]
A small retrospective study (48 people) examined the before and after effects of introducing safety plans to an outpatient mental health setting. It found a reduction in suicide attempts (5 attempts before compared with 1 after). It also found that the safety plans reduced inpatient admissions while increasing engagement with outpatients and crisis management teams.[182]
Safety planning is now considered more effective than ‘no-harm’ contracts, which are not recommended.[181][183]
Several randomised controlled trials on safety planning are in progress.[184]
Several smartphone applications can be used to help create safety plans.
A review of apps for suicide prevention found 14 safety plan apps that were the most comprehensive (mean 3.9, range 2-6 techniques) and evidence-informed when compared with other apps for suicide prevention.[187]
Another study looked at the feasibility and effectiveness of a safety planning app over a 2-month period (range 8.71 to 18.29 weeks, mean 10.42 weeks) in a small group of people undergoing treatment for suicide risk (age 16-42 years, 67% female). It found that most people found the app easy to use, although the majority reported only using it occasionally (63.6%). Regression analysis showed a significant reduction in suicidal ideation severity (P <0.001) and intensity (P <0.05) at the end of the study period compared with baseline. There was also a statistically significant increase in coping (P <0.05), but not in resilience.[188]
Use information gathered in the history to identify specific risk factors requiring intervention, including any underlying psychiatric diagnoses or symptoms, distressing psychosocial situations, and personality difficulties. Aim to remove or reduce these risk factors. If this is not possible, aim to mitigate them.[1]
In addition, promote protective factors such as hopefulness, personal resilience, and reasons for living.[1]
Optimise treatment of any mental or physical illness and address any substance misuse.[1]
Practical tip
Patients with chronic suicidal ideation are often seen as difficult or challenging and their needs are often underestimated. It is essential to ask about change in intensity or frequency of suicidal thoughts.
Ensure you maintain an empathetic, non-judgemental, and supportive approach throughout your interaction and consider the degree of emotional pain the patient may be experiencing as well as feelings of entrapment. It is vital to instill hope and offer potential solutions.
Consider referring the patient for psychotherapy.[5][189]
Options include counselling, cognitive behavioural therapy, compassion focused therapy, dialectical behavioural therapy, cognitive analytic therapy, and mentalisation behavioural therapy.[189][190]
Choose the type of psychotherapy based on:
Patient preference including their previous perceived helpfulness of a given type of psychotherapy
Whether specific underlying reasons for suicidal thoughts are identified which might be amenable to therapeutic intervention, e.g., bereavement, loss of role.
It is also important to treat any underlying mental health condition or psychiatric illness. Seek advice from a mental health professional, if needed.
Practical tip
Some patients will not be suitable for psychotherapy. These include patients with heavy substance misuse or patients who are unable to engage. The decision to refer, however, should be made by the assessing therapist or psychiatrist rather than in an acute setting.
Direct patients with anxiety or depression to NHS Talking Therapies, if based in England. This is a self-referral service to access psychotherapy. NHS England: Talking therapies Opens in new window
Evidence: Psychotherapy
Psychotherapy reduces suicidal ideation and may also help prevent suicide attempts. Most of the evidence is for cognitive behavioural therapy and dialectical behavioural therapy. Evidence can be difficult to interpret due to heterogeneity between studies (including number of sessions, duration, delivery method), lack of studies of sufficient size, and inadequate length of follow-up.
A systematic overview of treatments for the prevention and management of suicide found 5 systematic reviews and 12 randomised controlled trials (RCTs) related to non-pharmacological interventions for suicide prevention.[190] Included interventions were provided face-to-face, via the internet, or via smartphone apps. They could be 1:1 or in a small group or community setting. The quality of the five systematic reviews was rated as ‘good’ (United States Preventive Services Task Force [USPSTF] criteria), and the overall quality of the included studies was rated as ‘fair’ in four systematic reviews and ‘poor’ in the remaining one. The quality of the 12 RCTs ranged from good to poor (two good, six fair, and four poor).
One systematic review found cognitive behavioral therapy (CBT) compared with treatment as usual (TAU) reduced suicide attempts (risk ratio [RR] 0.47, 95% CI 0.30 to 0.73; P=0.0009). Another found it reduced suicidal ideation (standardised mean difference [SMD] -0.24, CI -0.41 to -0.07). The third systematic review found CBT reduced both suicidal ideation (SMD -0.32, CI -0.53 to -0.11) and hopelessness (SMD -0.31, CI -0.51 to -0.10). The strength of evidence (using GRADE) for all these outcomes was moderate. CBT did not seem to reduce suicide (two systematic reviews, GRADE = low). No harms related to CBT were reported. Internet-delivered CBT showed some modest benefit compared with wait-list controls (GRADE = very low), but not compared with face-to-face CBT or TAU.
Dialectical behavior therapy (DBT) was found to reduce suicidal ideation compared with wait-list control or crisis planning, but did not reduce suicide attempts (GRADE = low). No differences were found between DBT and TAU, 'expert-led' psychotherapy, or the Collaborative Assessment and Management of Suicidality (CAMS) framework for hopelessness, suicidal ideation, suicide attempts, or death.
A systematic review of observational studies looked at the effectiveness of psychotherapy on suicidal risk.[191] However, the search was limited to PubMed and Web of Science. The authors found 40 studies that met their inclusion criteria. The most common interventions were DBT (27.5%) and CBT (15.0%). Some 13 of the studies were in people with borderline personality disorder, while 10 studies were in people with mood disorders or depression. Most of the studies were small (mean n=154, with 24 studies n <50) and of ‘fair’ quality (Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies: 13 poor-quality, one good, and the rest fair). There was between-study heterogeneity with different durations and numbers of sessions. Follow-up also varied but in general was quite short (one study was 1 month, 12 studies were 3-6 months, eight studies were 10-18 months, and two studies were 2-3 years; in 17 studies follow-up was not reported). In addition, 42.5% of the studies only considered post-treatment results compared with baseline.
In the vast majority of studies, psychotherapy lead to a reduction in suicidal outcomes, with 95.7% of studies assessing suicidal ideation and 88.2% of those measuring suicide attempts.
Group therapies and internet-based therapies were assessed in two studies each, all with positive results. The authors felt these treatments showed promise but that more research was required.
Evidence: No-harm contracts
Do not use self-harm contracts as there is a lack of evidence for their effectiveness and they may have a negative impact on patient care.
A retrospective case series of psychiatric inpatients included a logistic regression analysis that suggested patients with no-harm contracts had a significantly higher likelihood of self-harm behaviour (odds ratio [OR] 7.43).[192] The authors thought this might partly be due to patient selection (contracts being negotiated with patients thought to be at higher risk), but overall concluded that no-harm contracts did not prevent self-harm behaviour.[192]
A survey of 267 psychiatrists in the US found 152 (57%) used no-harm contracts.[193] Some 41% of the psychiatrists who used no-harm contracts reported that they had patients who had made a serious suicide attempt or completed suicide even with a contract in place.[193]
Another questionnaire of physicians, mental health nurses, and allied health professionals in Australia (420 responses, 31% response rate) analysed the use of verbal and written suicide prevention contracts and found detrimental outcomes for both clinicians and patients.[194] The authors advised that there should be education in alternative interventions and that suicide prevention contracts should not be used.
A literature review (published 2008) found a lack of quantitative evidence to support no-harm contracts.[195] It also showed strong opposition to the tool from nurses and patients. In the review the authors summarise the important disadvantages and potential ethical issues, such as the contract may be seen by the patient as coercion resulting in a negative impact in communication and the doctor-patient relationship; the contract offering false reassurance to the clinician; and how a contract can remove even more control from patients who are already struggling. Other review articles have reached similar conclusions.[196][197]
In the community: referral
Prioritise referral to mental health professionals if:
There are high levels of distress or heightened concern either in the patient or in family members, carers, or significant others.[5]
The patient requests help from specialist services[5]
Risk of suicide or self-harm is increasing or is unresponsive to current strategies[5]
The person providing assessment in primary care is concerned.[5]
Refer the patient to a community mental health team if they have a psychiatric disorder requiring specialist assessment or management, such as:[1][5]
Depression (see Depression in adults)
Bipolar disorder (see Bipolar disorder in adults)
Schizophrenia (see Schizophrenia)
Schizoaffective disorder (see Schizoaffective disorder)
Personality disorder (see Personality disorders)
Substance misuse (see Alcohol-use disorder)
Eating disorders
Postnatal psychosis or mental illness during the perinatal period (see Postnatal depression)
Anxiety disorder (see Generalised anxiety disorder)
Consider referring the patient to a community mental health team if there are problematic symptoms related to mental illness (e.g., akathisia due to treatment with a selective serotonin-reuptake inhibitor).
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).
Use of this content is subject to our disclaimer