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 behavior 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 caregivers (supporters) are calling for a paradigm shift in suicide risk assessment that moves away from "characterizing, 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 behavior" refers to a suicide attempt, an episode of nonfatal self-harm, a suicide plan, and suicidal ideation. The literature sometimes includes nonsuicidal self-harm as a component of suicidal behavior. The authors of this topic suggest avoiding the term "suicidal behavior" 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
Key diagnostic factors
- previous suicide attempt or self-harm episodes
- current suicide plan
- access to lethal means
- history of psychiatric disease, including substance misuse
- family history of suicide or mental illness
Other diagnostic factors
- chronic medical illness, disability, or disfigurement
- significant psychosocial factors
- unhelpful traits
- 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
1st investigations to order
- clinical diagnosis
patients who may be vulnerable to self-harm and suicide
those left behind after a death by suicide
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.
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
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.
Dr Alys Cole-King and Dr Angharad de Cates would like to gratefully acknowledge Dr Stan Kutcher and Dr Magdalena Szumilas, previous contributors to this topic.
SK has received research grants from various foundations and national granting agencies (none from either the pharmaceutical nor psychotherapy industries) to support some of his academic work. He is employed by a university and hospital, and sees patients who sometimes present with a suicide attempt. He has also co-authored a textbook on suicide risk assessment and management, published in 2007 and the second edition in 2012. MS is an author of a reference cited in this topic.
Stephen Platt, BA, MSc, PhD
Emeritus Professor of Health Policy Research
University of Edinburgh
SP is a paid consultant to Samaritans, NHS Health Scotland, the Scottish Government, and the Irish National Office of Suicide Prevention. He is an unpaid adviser to The Listening Place.
Steve Gilbert, BSc Sports & Materials Science
Sports & Materials Science
University of Birmingham
SG is the vice-chair of the Independent Mental Health Act Review; an associate trainer for suicide mitigation at Connecting with People; Programme Lead for the Engager Prison Project; trustee for the Council of Management for Mind and the Association of Mental Health Providers; Service User Representative for West Midlands Mental Health (STP) Alliance; occasional advisor to the National Suicide Prevention Alliance and Public Health England; and a member of the West Midlands Service User Representative Forum, Royal College of Psychiatrists West Midlands Executive Division. He receives a salary and/or travel and subsistence expenses for these roles.
- Clinical practice guideline: suicide risk assessment
- WHO mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings
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