Suicide risk assessment and management

GPs have a vital role in identifying and supporting patients with severe depression or other mental health problems, assessing suicide risk and initiating treatment and preventive interventions, including referral to specialist services. Doctors may be on the frontline, but everyone in a practice should understand what they can do to support suicide prevention. Dr Shahnaz Russ and Dr Andreas Russ look at how to address the issue

This is an edited version of an article which first appeared on GP Online.

GPs have a vital role in identifying and supporting patients with severe depression or other mental health problems, assessing suicide risk and initiating treatment and preventive interventions, including referral to specialist services.

Your next patient may be one who expresses deep despair and suicidal feelings. Do you know how to complete a risk assessment and manage the risk appropriately?

Of those patients who take their own life, between half and two thirds will have visited their GP in the month before doing so, and 10-40% will have done so in the preceding week. People who self-harm, either through poisoning or injury, are at 50-100 times higher risk of suicide than the general population. Although most people who self-harm never go on to take their own life, the behaviour is, nonetheless, a predictor for suicide risk.

Epidemiology

Every year, about 1m people die by suicide. In 2013, 6,233 suicides were registered in the UK, a rate of 11.9 per 100,000 (19 per 100,000 for men, 5.1 per 100,000 for women). Suicide rates have increased 60% worldwide in the past 45 years and it is one of the leading causes of death in those aged 15-44 years for both men and women.

Traditionally, the suicide rate has been highest among older men, but rates among young people have been increasing. Suicide is more likely to occur during periods of socioeconomic, family and individual crisis.

Risk factors

Increased suicide risk is not always associated with a psychiatric condition, but higher risk is associated with severe depression, bipolar disorder, schizophrenia, borderline personality disorder, anorexia nervosa and alcohol and drug misuse. Physical illness and disability, or being gay, lesbian or transgender, are further risk factors. Unemployment, poverty, divorce and social isolation increase the risk and it is also higher in certain occupations, such as healthcare professionals, vets and farmers.

Assessment

Every GP should be able to assess the risk of suicide, so it is important to be aware of the warning signs. The assessment process is outlined below:

• Listen.
• Show interest and support.
• Talk openly about suicide.
• Be non-judgmental.
• Offer empathy, not sympathy.
• Do not make decisions for the patient.
• Express your concern about the patient’s safety.
• Offer hope that alternatives are available.
• Take action and involve the patient in decision-making.

It is important not to rush, so you may have to ask a colleague to take your next patient. Most practice IT systems allow GPs to send a pre-agreed message, such as, ‘I have a risk assessment – please help out’, to colleagues, which can give them valuable extra time for the assessment.

Management

If the patient is not at immediate risk, it is advisable to ask if they have stored any harmful drugs or are in possession of other lethal means. Review the patient’s medication, checking for drugs that could be used for lethal overdose.

Offer a follow-up appointment at the earliest time possible. Give the patient a list of useful contact numbers, such as your local out-of-hours service, Samaritans and A&E.

Make sure you refer the patient to the appropriate psychiatric team; state that it is an urgent referral and an emergency assessment is required. Follow up your telephone call with a fax, letter or email to confirm the referral. If you feel the patient is safe to go home, with later follow-up from the psychiatric team, ensure you have the patient’s contact details to pass on. It can also be helpful to have family or friends’ contact numbers if the patient will provide them.

If you judge that the patient is at high risk, encourage them not to leave the practice until appropriate safety measures are in place. If the patient decides to leave against your advice, contact the police and ask for a welfare check. The patient may need to be detained under the Mental Health Act.

Conclusion

A thorough risk assessment will help doctors to make the right clinical decision and prevent loss of life. Risk mitigation skills can be further improved by supplementary training and liaising with local psychiatrists.

The assessment and management of suicide risk includes effective communication skills, empathetic interactions to understand the patient’s mental anguish, and the application of risk prevention measures.

<<Box out>> Dr Shahnaz Russ is a community consultant psychiatrist at Cambridgeshire and Peterborough NHS Foundation Trust and Dr Andreas Russ is a GP in Darlington