Key learning points:
– Understanding risk factors associated with suicide
– Considering a framework for understanding suicide
– How to assess and manage suicide risk
Suicide rates are increasing in the United Kingdom, with men being at much higher risk than women, and middle aged men being a particular current concern.1 The recession, unemployment and austerity are linked to this increase.2
While depression is evident in the majority of suicides,3 suicide is not just a mental health services concern as 72% of suicides are of people not in contact with mental health services.4 People discharged from acute hospitals can be vulnerable5 and suicide is associated with frequent and increasing primary care presentations.6 Thus all healthcare practitioners have a contribution to make in suicide prevention.7
Patients with suicidal ideation who present to primary care may not articulate their thoughts.8 Primary care practitioners should be aware of risk factors associated with suicide to enable them to detect possible warning signs. Patients who experience depression and anxiety often find primary care nurses easy to talk to9 therefore primary care nurses are in a prime position to identify patients who may be at risk.
Who is at risk?
Risk factors associated with suicide are complex and imprecise.10 As much as we know that depression and self-harm are key risk indicators, for example, most people who experience depression or self harm don’t go on to take their lives and not everyone who dies from suicide has a formal psychiatric or self harm history.
Screening tools such as the patient health questionnaire (PHQ9),11 may help identify patients who are experiencing suicidal ideation11 but they have limited value in determining the context of suicidality.10
The National Institute for Health and Care Excellence (NICE) advises that such tools should not supersede clinical judgement when discerning suicide risk;12 however they can be a helpful start point.
Suicide risk can be categorised into static factors (fixed and historical), stable factors (enduring but not fixed), dynamic factors (highly fluctuating according to recent and current circumstances) and future factors (anticipated).13 These risk factors both interchange and interplay. Box 1 categorises some of the main risk factors for suicide.
Personality traits such as impulsivity, poor problem solving ability and perfectionism should also be taken into consideration when contemplating risk as such traits are likely to trigger extreme reactions to stressful events which may lead to suicidal behaviour.13
Asking about suicide
Any articulation of suicidal ideation should be explored in a caring and concerned manner.
If warning signs are detected but suicidality is not disclosed it is important to be curious and seek more information about how the patient is feeling, including whether or not they have experienced thoughts of suicide (see Box 2 for examples). Asking about suicide will not put the idea into people’s heads,14 in fact it may reduce risk.
Most people who are suicidal are ambivalent about dying15 and this ambivalence should be seen as an opportunity to try and engender hope and life orientated thinking through dialogue.
Compassion is essential when interacting with an individual who may be suicidal.16 Vital openings for preventative interventions could be shut down by a nonchalant clinician.17 If the patient discloses thoughts of suicide it is important to elicit as much information as possible. Exploratory questions are listed in Box 3.
I’ve asked the questions, my patient is experiencing suicidal thoughts and I think he/she is at risk; what should I do now?
1.Tell the patient they have done the right thing by seeking help and confiding in you. Convey that you want to ensure their safety and help them get the support they need.
2. Ascertain support networks. Ask if you can involve the patient’s main carer; this will be helpful to both gain an understanding of the carer’s perspective on the patient’s situation and identify how much support the carer is able to provide. Confidentiality can be a barrier to carer involvement but it is important to try and encourage the patient to allow carer support. Explain what information you need to give the carer and reassure the patient you don’t need to disclose everything you have been told about what they are feeling.
3. The GP should always be notified if it is felt that a patient is at risk of suicide and ideally see the patient before they leave the surgery. Be candid with the patient and let them know you are concerned about their safety and want a second opinion to help decide the best plan. If the patient has been open with you hitherto, they are likely to agree to wait while you speak to a GP. However, if the patient refuses to stay and you feel they are at imminent risk it is appropriate to inform the police and the next of kin. In such cases mental health crisis services will need to be involved to carry out an emergency mental health assessment.
4. If the patient has disclosed access to means there should be a discussion around removing the means. Ideally this should involve help from family or friends but if the patient does not have social support you may need to rely on trust. If the patient has access to a firearm you can inform the police who will remove the firearm to safekeeping if the patient is at risk of using it to take their life.
5. It is essential that you thoroughly document all aspects of your patient contact and all actions you have taken.
6. If the patient is not at immediate risk, ongoing monitoring of mood and support will be required and insomnia and agitation should be treated pharmacologically.15 This might involve referral to a community mental health team or GP treatment of depression and signposting to supportive community resources. Sources of support might include suicide prevention and mental health agencies (see Resources for patients and families section) and other organisations that can help with substance misuse, benefits, accommodation and so on, depending on the issues the patient is experiencing.
7. It is important that patients and carers are made aware of how to access support in a crisis situation (i.e. via GP, mental health services, 111, 999 and A&E), and a plan should be agreed with the patient before they leave the surgery.
8. Dealing with suicide risk is stressful; seek support and supervision. The Resources for primary care clinicians section lists some resources that may help primary care nurses in practice.
Primary care nurses are likely to come across patients who are experiencing suicidality and should be prepared to respond compassionately and assertively to facilitate preventative interventions. However nurses should not work in isolation and it is important to call on colleagues for advice and support.
Resources for patients and families
Samaritans –www.samaritans.org/ offer a confidential 24/7 telephone helpline 08457 90 90 90, email support: firstname.lastname@example.org and text support: 07725 90 90 90.
Campaign Against Living Miserably (CALM) –www.thecalmzone.net/ supports men and boys. Helpline 0800 58 58 58 and Webchat service
Mind –www.mind.org.uk/ offers advice and information to people with mental health problems and those that are helping and supporting people with mental health problems.
Resources for primary care clinicians
Clinical guide for assessing suicide risk in depression –http://cebmh.warne.ox.ac.uk/csr/clinicalguide/index.html
Factsheet on managing suicide risk in primary care –www.connectingwithpeople.org/sites/default/files/SuicideMitigationInPrimaryCareFactsheet_0612.pdf
1. Office for National Statistics. Suicides in the United Kingdom, 2013 Registrations; 2014. www.ons.gov.uk/ons/dcp171778_395145.pdf (accessed May 2015)
2. Haw, C., Hawton, K., Gunnell, D., Platt, S. (2014)
3. Lönnqvist, J. Psychiatric aspects of suicidal behaviour: depression. In: Hawton, K., and van Heeringen, K. The International Handbook of Suicide and Attempted Suicide. New York: Wiley; 2000
4. National Confidential Inquiry into suicide and homicide by people with mental illness; Manchester: University of Manchester 2014
5. Dougall N, Lambert P, Maxwell M, Dawson A, Sinnot ., McCafferty S, Morris C, Clark D, Springbett A. Deaths by suicide and their relationship with general and psychiatric hospital discharge: 30-year record linkage study. The British Journal of Psychiatry 2014; 1–7
6. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Suicide in primary care in England: 2002-2011. Manchester: University of Manchester; 2014
7. Department of Health, Preventing suicide in England: a cross-government outcomes strategy to save lives. 2012. www.gov.uk/government/publications/suicide-prevention-strategy-for-england (accessed 22
8. Michel K. Suicide Prevention and Primary Care. In: Hawton K, van Heeringen K (eds). The International Handbook of Suicide and Attempted Suicide. Chichester: John Wiley & Sons Ltd; 2000. p661-674.
9. Buszewicz M, Griffin M, McMahon EM, Beecham J, King M. Evaluation of a system of structured, pro-active care for chronic depression in primary care: a randomised controlled trial. BMC psychiatry 2010;10(61)
10. Morriss R, Kapur N, Byng R. Assessing risk of suicide or self harm in adults. British Medical Journal 2013; 347 (f:4572)
11. Simon GE, Rutter CM, Peterson D, Oliver M, Whiteside U, Operskalski B, Ludman EL. Do PHQ depression questionnaires completed during outpatient visits predict subsequent suicide attempt or suicide death? Psychiatric Services 2013; 64(12) 1195-1202.
12. NICE. Self harm: longer term management. 2011. http://www.nice.org.uk/guidance/CG133 (accessed May 2015).
13. Bouch J, Marshall JJ. Suicide risk: structured clinical judgement. Advances in Psychiatric Treatment 2005; 11 (84-91).
14. Dazzi T, Gribble R, Wessley S, Fear NT. Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine 2014; 44(16), 3361-3363
15. Joiner TE, Van Orden KA, Witte TK, Rudd D. The Interpersonal Theory of Suicide: guidance for working with suicidal clients. Washington: American Psychological Association; 2009
16. Cole-King A, Green G, Gask L, Hines K, Platt S, Suicide mitigation: a compassionate approach to suicide prevention. Advances in Psychiatric Treatment 2013; 19 (4) 276-283
17. Hawton K, van Heeringen K. Suicide. Lancet 2009; 373: 1372-81
You are currently leaving the Nursing in Practice site. Are you sure you want to proceed?