While there is no single prescribed standard of care or clinical approach for situations involving suicide and self-harm, Working with the suicidal person recommends a series of general practices and principles to guide the assessment and management of people at risk.
The ultimate judgement must be made by the attending clinician, based on their experience, the clinical presentation and the assessment and management options available at their health service.
Risk factors for suicide
Although risk factors cannot identify suicidal individuals with any certainty, they can alert a clinician to take particular care in assessing an individual.
There is a wide range of factors that can influence suicide risk, from mental illness or physical ill-health to abusive relationships, stressful life events such as unemployment or bereavement, or a history of suicidal thoughts.
- Men are three times more likely to die by suicide than women (although women make more suicide attempts).
- There are some groups of people that experience higher rates of suicide due to sustained trauma or discrimination, such as Aboriginal and Torres Strait Islander people and gay, lesbian, bisexual, transgender and intersex people.
- People recently discharged from acute psychiatric services are particularly vulnerable, exhibiting a suicide risk 100 to 200 times greater than normal in the month after discharge.
- Adolescents and young people can also face risk factors that may elevate their suicide risk, from mood and anxiety disorders to substance use, bullying, feelings of isolation, or the influence of close friends who have taken their own lives.
- The elderly face unique risks stemming from their declining health, social isolation, recent bereavements and concerns about being a burden to others.
Guiding principles in assessing suicide risk
There are several general principles for mental health staff to consider in the assessment and management of people at risk of suicide.
Good communication and listening are vital to establish rapport with a person, to validate their feelings and to discuss difficult issues with them in an empathetic way. Clinicians are encouraged to ask a person directly: Are you thinking about suicide?’
Talking about suicide will not encourage a person to take action – it will actually decrease their risk because it lets them know they are able to talk about it with you.
Information gathering from the person
Ascertaining a person’s level of distress and feelings about their life provides a crucial foundation to identify and reinforce any positive thoughts and reasons for living.
Clinicians should find out if they have made any preparations for death, such as giving possessions away or saying goodbye to loved ones. If a suicide attempt has been made, ask about any precipitating events, whether it was impulsive or premeditated, and whether they sought help beforehand.
Information gathering from others
It is very important to gain information, not only from presenting individuals but from their friends, family, caregivers or medical records, which can help gauge their level of risk and determine appropriate clinical options.
Clinicians should take particular care to ensure that pertinent information is accurately documented and passed on to other staff to ensure a consistent approach and prevent adverse outcomes.
Keeping a person safe and comfortable while they are waiting for an assessment is paramount, and any restrictions of their liberty must be kept to an absolute minimum.
For acutely suicidal people, assessment should be made immediately. Intoxication should not delay an assessment, as it can increase impulsiveness and the risk of self-injury in the short term.
The practical quick guide, Working with the suicidal person, Rapid suicide-risk assessment at emergency department triage, provides a useful list of pointers and questions to assist clinicians during the key stages of a risk assessment.
An initial suicide risk assessment should always be followed up with a comprehensive mental health status examination and psychiatric assessment. This applies in particular to people who present after a suicide attempt or an episode of self-harm, with probable mental illness or dual diagnosis, or after a recent discharge from a psychiatric inpatient unit,