Suicide is not inevitable. Most people experiencing suicidal thoughts are ambivalent about dying but may be unable to imagine other potential solutions. With the right support people can find their way through a suicidal crisis and recover.
Many people have been touched in some way by suicide. It is an emotive subject. Suicide is a significant public health concern. Everyone can potentially help someone with suicidal thoughts. The majority of people who end their lives by suicide almost always have had contact with someone in the health services. Every contact a suicidal individual has represents an opportunity to intervene and prevent them from going on to die by suicide.
Suicidal thoughts and feelings are far more common than most people realise and are often not related to the presence of a mental illness. Suicide is a behaviour and not a diagnosis. Suicide cannot be predicted accurately in any given individual at a single point in time. Suicide usually occurs as a result of a multifactorial process, where vulnerability to suicide may be generated over several weeks, months, or years.
Self-harm and suicidal thoughts should be taken seriously, and met with empathy, compassion, and understanding given that they are risk factors for suicide, particularly when associated with a history of a mental illness (most commonly major depressive disorder and substance misuse).
Clinicians, patients, and their carers (supporters) are calling for a paradigm shift in suicide risk assessment that moves away from ‘characterising, predicting, and managing risk’ towards ‘compassion, safeguarding, and safety planning’.
Originally called suicide risk management, suicide risk mitigation aims to be a more realistic and compassionate approach. It refers to the identification, assessment, intervention, and treatment of a person at risk of suicide. It is an ongoing process whether due to a mental illness or a life crisis. Traditionally the term ‘suicidal behaviour’ refers to a suicide attempt, an episode of non-fatal self-harm, a suicide plan, and suicidal ideation. The literature sometimes includes non-suicidal self-harm as a component of suicidal behaviour. The authors of this topic suggest avoiding the term ‘suicidal behaviour’ and being more specific about what you observe. There are several key components to suicide: ideation, intent, plan, access to lethal means, and history of past suicide attempts.
History and exam
- current suicidal plan
- history of mental illness, including substance misuse
- availability of lethal means
- history of childhood abuse or neglect
- family history of death by suicide
- male sex
- prison inmate
- family history of psychiatric illness
- physical illness
- marital status (divorced, single, widowed)
- professions/occupations (unemployed, self-employed, agricultural workers, medical and dental professionals)
- psychosocial stressors
Alys Cole-King, MB, BCh, DGM, MSc, FRCPsych
Consultant Liaison Psychiatrist
Glan Clwyd Hospital
Betsi Cadwaladr Health Board
ACK is an employee and director of 4Mental Health and, in this capacity, has received funding for designing and delivering training. ACK is an author of references cited in this topic.
ST6 General Adult Psychiatry
South London and Maudsley NHS Foundation Trust
AO declares that she has no competing interests.
BMJ Best Practice would like to gratefully acknowledge the previous expert contributor, whose work has been retained in parts of the content:
Angharad de Cates, BMBCh, BA Hons (Oxon), MSc (Warw), MRCPsych
Wellcome Trust Clinical Doctoral Fellow
Department of Psychiatry
University of Oxford
Honorary Clinical Fellow Oxford Health NHS Foundation Trust
Disclosures: AdeC is in receipt of a clinical doctoral training fellowship from the Wellcome Trust (since October 2018) and a travel fellowship from the Royal College of Psychiatrists/Gatsby Foundation. All are external bodies that fund research into and/or release information that includes suicide prevention.
Peter Aitken, MB ChB
Director of Research & Development
Devon Partnership NHS Trust
Honorary Associate Professor
University of Exeter Medical School
PA is Clinical Lead for the NHS SW Strategic Clinical Network, and Trust Lead for Suicide Prevention, Devon Partnership NHS Trust. He is a also a trustee of the Lions Barber Collective Charity and chair of the Royal National Lifeboat Institution Medical Committee.
Section Editor, BMJ Best Practice
AS declares that she has no competing interests.
Lead Section Editor, BMJ Best Practice
SM works as a freelance medical journalist and editor, video editorial director and presenter, and communications trainer. In this capacity, she has been paid, and continues to be paid, by a wide range of organisations for providing these skills on a professional basis. These include: NHS organisations, including the National Institute for Health and Care Excellence, NHS Choices, NHS Kidney Care, and others; publishers and medical education companies, including the BMJ Group, the Lancet group, Medscape, and others; professional organisations, including the British Thoracic Oncology Group, the European Society for Medical Oncology, the National Confidential Enquiry into Patient Outcome and Death, and others; charities and patients’ organisations, including the Roy Castle Lung Cancer Foundation and others; pharmaceutical companies, including Bayer, Boehringer Ingelheim, Novartis, and others; and communications agencies, including Publicis, Red Healthcare and others. She has no stock options or shares in any pharmaceutical or healthcare companies; however, she invests in a personal pension, which may invest in these types of companies. She is managing director of Susan Mayor Limited, the company name under which she provides medical writing and communications services.
Lead Section Editor, BMJ Best Practice
RW declares that she has no competing interests.
Drug Editor, BMJ Best Practice
AM declares that he has no competing interests.
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