Suicide risk mitigation

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

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ACUTE

at risk of suicide

1st line – ensure personal and patient safety

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1st line –

ensure personal and patient safety

Consider your own safety before seeing the patient.

Find out about the background of the patient you are going to see.[120]
Be wary if the patient has a history of violence or is disorientated, suspicious, or 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]
Assess the patient in a safe environment. Ideally, use a properly equipped psychiatric interview room. If this is not available, use a room that has clear lines of sight and is easy to leave quickly, such as a curtained cubicle.[122]

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]Only use physical or chemical restraints if they are absolutely necessary as they can be traumatic to the patient and impair rapport. Follow local protocols.[123][170]
- Use the least restrictive option available to ensure the patient's safety.[124] Follow local protocols.

Plus – treat any self-harm or underlying physical illness

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Plus –

treat any self-harm or underlying physical illness

Treatment recommended for ALL patients in selected patient group

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

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]

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.
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]

Plus – determine treatment setting

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Plus –

determine treatment setting

Treatment recommended for ALL patients in selected patient group

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]

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.

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.
Reduction of access to means of suicide.[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 of suicide (see below for more information on developing 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. 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]

In the community, 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).

Plus – safety plan

Plus – assessment for psychotherapy

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Plus –

assessment for psychotherapy

Treatment recommended for ALL patients in selected patient group

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.

Bear in mind that 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.

Choose the type of psychotherapy based on the reasons identified for suicidal thoughts or behaviours, and any underlying psychiatric illness. Seek advice from a mental health professional.

Plus – treat any underlying psychiatric illness

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Suicide risk mitigation

Treatment algorithm

at risk of suicide

ensure personal and patient safety

treat any self-harm or underlying physical illness

Practical tip

determine treatment setting

safety plan

assessment for psychotherapy

treat any underlying psychiatric illness