- 5000 deaths/year in the UK
- Increasing in young males
- In men <35, suicide is the greatest cause of death
- At all ages, men are at greater risk than women
- In those >35, they are likely to have seen their GP within the last month
- Those <35 are not
- Men more likely to use violent methods (shooting, hanging)
- Women more likely to take prescribed/OTC drug overdoses
In one study in the USA, 10% of adolescents had seriously contemplated suicide within the last 12 months and 6% had a suicide attempt or episode of self harm. In Australia a similar study shows self harm in 4% of adolescents in the preceding 12 months.
Suicidal ideation is almost always associated with a mental health disorder, which is most commonly depression.
- Suicidal behaviour involves in part some wish to end one’s life
- NSSI involves an intent to harm without an attempt to end life
Self Harm – NSSI
- Increasing in the last few decades
- 300 to 400 per 100 000
- In women – most common cause of acute admission
- Peak age – 15-24
- In the UK, women of south Asian origin 2.5x risk than general population
- In men – second most common cause
- Peak age – 25-34
- Roughly equal rates in men and women (women used to be higher)
- Causes – Bipolar, depression, eating disorders, personality disorders
- 15% of cases will have further self harm episodes in the next year
- Most of these occur soon after the initial incident
- Suicide after self harm – there is a 1% suicide rate in the next year in those who have committed self harm. This rises to 3% in 5 years and 7% in 10 years. Those who commit suicide tend to be: Older, Male, Have a mental illness, Have poor physical health
Assessing Suicide Risk
- Some debate exists of whether or not you can truly estimate the suicide risk
Risk factors for suicide
Important factors highlighted
- Older adolescent age
- Non-heterosexual orientation
- Dx of psychiatric disorder
- Recent discharge from psychiatric institution
- Previous suicide attempt
- FHx of suicide
- PMHx of sexual abuse
- Childhood trauma
- Poor physical health
- Low self-esteem
- Poor treatment compliance
- Family and environment
- Life stress – especially unemployment, legal issues or school issues
- Lack of social support
- Exposure to other with suicidal behaviour
- Recent friend or relative with suicide attempt / suicide
- Split family (e.g. divorce)
- Parental mental illness
- Mental State
- Suicidal thoughts, especially is specific acts planned
- Homicidal ideation
- Drug and alcohol use
Suicide risk assessment should be perform both in the acute crisis setting (i.e. after an attempt of self harm or suicide) and routinely as part of a mental health history. Particularly useful in mental health history taking in adolescents is the HEADSS assessment tool:
H – Home and environment
- What is home life like?
- Who do they live with?
- Do they feel safe?
- Is there someone they can talk to?
E – Education
- How is school?
- Are they enjoying it?
- What are their future education and career plans?
A – Activities
- What do they get up to in their spare time?
- Are their friends from school of from elsewhere?
- DO they have a lot of friends?
- Do they feel they can talk openly with their friends?
- DO they spend much time with family?
D – Drugs and alcohol
- Do you drink?
- Do you take any drugs?
- How often? How much?
- How do you pay for them?
- How does it make you feel?
- Are you aware of the risks?
S – Sexuality
- Relationship history
- Sexual orientation
- Current relationship difficulties
- Cervical screening
- STI screening
S – Suicide and depression (as above)
Assessing a patient in crisis
Talk to the patient – but remember they may still be drowsy after any drugs they have taken (both in the suicide attempt, and afterward at hospital)
History from friend or relative if present:
- Look for evidence of continued suicide intention
- Is the patient happy to still be alive?
- If they took an overdose, What did they take?
- Did they think this would be enough to die?
- What did they take it with? (e.g. water, alcohol)
- Did they want to be found?
- Who found them? Was this person expected home? In the house? Did they phone them?
- Did they leave a note?
- Have they been planning it?
- E.g. giving away possessions
- Stocking up on pills over several weeks/days/months
- If the patient tries to leave before the assessment is complete…you may need to detain them – if you believe they pose a risk to their own (or anybody else’s) safety
- Some patients may be fine to go home (usually with care of a relative…e.g. a girl who takes 10 paracetomol in front of her girlfriend after a row. She says she has no intention to kill herself, and seems upset by the incident.)
- When discharging it is VITAL that you inform community care representatives..e.g. the GP, community mental health team. You should phone as well as sending a letter. Usually, there is a follow-up clinic appointment made as well.
- Don’t prescribe any potentially lethal drugs for the patient to take home with them!
- You may need to get a psychiatrist to advise you in other cases/cases where patients may need detaining…e.g. an old man who has been stockpiling paracetomol for a long time. He lives alone, and took an overdose whilst in his shed. He was discovered by chance by a neighbour. He had left a note, and had been giving away his belongings.
- P – Problems – have you had problems for more than 1 month?
- A – Alone – were you alone at the time?
- T – Time – have you planned it for more than 3 hours?
- Ho – Hopeless – are you feeling hopeless about the future
- S – Sad – were you feeling sad for most of the time before the overdose?
- Risk assessment and initial management of suicidal adolescents - RACGP
- Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.