History and exam
Key diagnostic factors
common
current suicidal intent
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.
Maintain a high level of concern for any patient with:
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).
access to lethal means
risk factors
Identify risk and protective factors using a biopsychosocial approach.[5]
Be aware that suicide is very difficult to predict.
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]
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]
Maintain a high level of concern 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)
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[150]
Recent loss of attachment, perception of 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.
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.
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