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Flashcards in Suicide and self-harm Deck (22):

Spectrum of Qs to ask for suicidality

  • Future:
    • How do you feel about the future?
  • Hopelessness:
    • ​Have you ever thought life was not worth living?
  • Self-harm:
    • ​Have you ever had thoughts of harming yourself? Have you acted on them?
  • Passive suicidality:
    • Have you ever gone to bed and wished you didn't wake up? 
  • Active suicidal ideation:
    • Have you ever thought of ending your own life?
  • Method:
    • Have you thought about how you would do it?
  • Preparation:
    • Have you made any preparations (e.g. suicide note)
  • Attempt:
    • Have you ever tried to take your own life?


Questions to ask about self-harm

  • Method
  • Frequency
  • Citcumstances
  • Emotion before/after


Principles of risk management (all risks)

  1. Documentation incl crisis plan and specifying of roles
  2. Short-term treatment: incl. pharmacology
  3. Long-term psychosocial intervention
  4. Supervision and monitoring: By whom, how often, early warning signs
  5. Re-assessment date


Static risk factors for suicide

Demographic: Male, elderly, impulsivity/self control

Medical Hx: Concurrent physical illness, any mental disorder, recent hospital discharge

Past suicidal/self-harm behaviour ( 1/3 of completed suicides have >=1 previous attempt)

Social: Exposure to suicide (family/friends), recent bereavement, Hx of abuse

Protective factors


Dynamic risk factors for suicide

  • Social stressors/precipitants:
    • Financial/employment issues
    • Social isolation, lives alone
    • Single, widowed, divorced
  • Psychiatric:
    • Recent/present suicidal behaviour
    • Mental state: hopelessness, relapse, agitation
    • Substance abuse
    • Psychotic symptoms (e.g. command hallucinations
  • Practical:
    • Access to means
    • Intent
    • Final preparations
    • Anniversaries
    • Engagement with services


Order of risk of suicide for psychiatric disorders

Depression + Anorexia


Primary psychosis


Neuroses + anxiety disorders


Completed suicide in 24months following self-harm

1%, highest in first few weeks following initial act


Protective factors for suicide

Family support

Children at home

Strong religious faith

Problem-solving skills

Sense of responsibility


Risk factors about the act of self-harm that require assessment

  1. Perceived lethality
  2. Impulsivity/advance planning
  3. Preparations
  4. Discovery
  5. Actions following act
  6. Comparison to previous acts


Assessment of mental state following suicide attempt

  1. Attitude to survival
  2. Mood: current affective state + symptoms of depression (MDD screening essential)
  3. Screen for: Substance use disorder, psychotic symptoms, bipolar symptoms, borderline PD (hospital admission unhelpful)
  4. Past medical/psychiatric Hx
  5. Recent live events/triggers
  6. ID goals from patient + work towards them: What's important to you? What do you value?


Questions that should be addressed following assessment of suicide attempt

  1. Ongoing suicidal intent?
  2. Psychiatric/physical illness?
  3. Social stressors?


Evidence for ongoing suicidal intent following suicide attempt

  • Hoplessness
  • Ambivalence/disappointment about survival
  • Continued stated wish to die
  • Clear lethal intent of attempt


Management of patient following self-harm

  1. Treat medical illness - routine bloods, drug levels, ?activated charcoal 50mg for paracetamol/NSAIDs, ED referral
  2. Thorough assessment + MSE when patient is in full consciousness
  3. Consider admission to inpatient psychiatric ward if:
    1. Ongoing suicidal intent
    2. Serious mental illness (e.g. first presentation of psychosis)
    3. Need for further assessment to clarify diagnosis
  4. Referral to specialist services for mental health (GP for moderate depression, turning point for substance misuse, etc...)
    1. i.e. identifying available resources
  5. Referral to self-help services: E.g. Samaritans, Papyrus, Survivors of bereavement by suicide
  6. Liaising with services for social issues (e.g. school, social work, abuse counselling)
  7. Contingency plans for any foreseeable changes


1-year prognosis for self-harm presenting to hospital

20% repeated self-harm presentation

1% completed suicide in 24 mo 


Demographics for self-harm

15-24 (20% prevalence)

2/3 of self-harm <35yo

More common in females


Joiner's aetiological factors for suicide/self-harm

Thwarted belonging

Perceived burdensomness

Acquired capability


Factors contributing to thwarted belonging

Social isolation


Recent bereavement

Relationship breakdown


Factors contributing to perceived burdensomeness

Major depressive disorder

Physical illness

Substance use disorder

"They'd be better off without me"


Factors contributing to acquired capability

Hx of abuse/self-harm

Access to means

Contagion effect

Psychiatric disorder


Distinction between risk status and risk state in suicide

Risk status: Relative to specific population (e.g. general, outpatient, inpatient), informed by more static risk factors

Risk state: Relative to patient's baseline, informed by more dynamic risk factors (has it changed over past week/month/several months?)


Steps for creating management plans from suicide risk assessment

  1. Identify available resources: In collaboration with patient, ideally >=2 --> put in place with management plan
    1. Social support, self-help resources
    2. Family + friends
    3. GP
  2. Identify foreseeable changes: Acute changes that could precipitate increase/decrease in risk state. Put together contingency plan
    1. Previous stressors/triggers
    2. Challenging transitions (e.g. discharge)


Treatment for delayed presentation of paracetamol OD

>8h later --> N-acetylcysteine