Suicide Risk Assessment and Deliberate Self Harm (DSH)

Question 1

Assessing the suicidal act - before

Answer 1

• Precipitant?
• Planned or impulsive?
• Final acts? (suicide note, leaving a will, terminating contracts -phone, electricity)
• Precautions against discovery?
• Was alcohol involved?

Question 2

Assessing the suicidal act - during

Answer 2

• What method of self-harm was involved?
• Was the patient alone?
• Where were they when they self-harmed?
• What was going through their mind at the time?Did they think
• their self-harm would kill them?
• What did they do straight after the self-harm?

NB - If medication used how much, where did they get it, what did they take it with, what did they think would happen with that dose. If cutting where are the cuts, how many, how deep, how they felt whilst cutting, what did they hope it would do.

Question 3

Assessing the suicidal act - after

Answer 3

• Did the patient call anyone? How did they get to A&E? Who were they found by?
• How did they feel when help arrived?
• How does the patient feel about the attempt now? Do they regret it?
• What is the patient’s current mood?
• Does the patient still feel suicidal?
• If the patient were to go home today what would they do? (make sure you cover the next few days)
• If you were to feel like this again, what might you do differently?
• What might prevent you from doing this again in the future? Is there anything to live for? (protective factors)
• Will they accept treatment?

Question 4

Other aspects of suicide risk assessment

Answer 4

• Mood symptoms (i.e. depressive episode)
• Past psychiatric history (including past suicidal acts)
• Past medical history
• Drug history (include substance abuse)
• Family history
• Social history
• Risk
  
  • Vulnerability
  • Intent to harm others?
  • Are any others at risk? (CHILDREN)

Question 5

Safety plan

Answer 5

• If unsafe to discharge admit
  
  • Environmental (reduce access to items of self-harm/suicide and mind altering substances)
  • Relational (supervision)
  • Procedural (safety contracts/worsening statement)
• If safe to discharge then post risk assessment must agree to a safety plan:
  
  • The support of their family and friends (who have they already told?)
  • Recognise stressors
  • Avoid harmful alcohol use when stressed
  • If you feel like that again who could you tell? What will you do?
  • Signpost to appropriate agencies (i.e. GP, housing, Citizens Advice, alcohol and drugs service, counselling, Domestic Violence services)

Question 6

Factors that increase suicide risk

Answer 6

• Demographics
  
  • Male
  • Older
  • Widowed/seperated/single
  • Living along/unemployed
  • Low income/unemployed
  • Certain occupation (i.e. doctor, farmer)
  • FHx of suicide
• Diagnoses
  
  • Previous attempt x40
  • Severe depression x20
  • Anorexia x25
  • Haemodialysis x14
  • Recreational opiate use/dependence x14
  • Alcohol dependence x6
• The act itself
  
  • Final acts
  • Researching of methods, preparation e.g. stockpiling tablets
  • High perceived lethality
  • Precautions taken against being found
  • Violent method (e.g. firearms, jumping from height)
  • Patient discovered by chance
  • Patient resists/tries to evade medical intervention
  • Downplaying of seriousness

Question 7

Choose Life

Answer 7

• Scotland’s national suicide prevention strategy and action plan
• Launched in December 2003
• Education and training of staff in the use of suicide assessment tools/suicide prevention training programmes
• 7 objectives:
  
  • Early Prevention and Intervention
  • Responding to Immediate Crisis
  • Longer Term Work to Provide Hope and Support Recovery
  • Coping with Suicidal Behaviour and Completed Suicide
  • Promoting Greater Public Awareness and Encouraging People to Seek Help Early
  • Supporting the Media
  • Knowing What Works

Question 8

Protective factors

Answer 8

• Problem solving ability
• Self control of behaviour, thoughts & emotions
• Hopefulness, optimism
• Perceptions of positive health, participation in sporting activities
• Family relationships
• Marriage & partnership
• Social relationships & social contentedness
• Religious faith & spirituality
• Employment

Social values

Question 9

Associations in depression

Answer 9

• Greater severity of illness
• Self-neglect
• Impaired concentration/memory
• Hopelessness
• Alcohol abuse
• Mood cycling
• History of suicidal behaviour

Question 10

Associations in schizophrenia

Answer 10

• Young & male
• Relapsing pattern of illness
• Past history of depression
• Current depressive illness/comorbid with depression
• Recent discharge from inpatient to outpatient care
• Social isolation in the community
• Relatively good insight into illness

Question 11

Associations with alcohol problems

Answer 11

• Male sex
• Longer duration of problem
• Single / divorced / widowed
• Currently drinking
• Presence of depressive symptoms

Question 12

Deliberate self harm

Answer 12

• More common than suicide (x10)
• Female:male = 2:1
• Peak age 15-44 years
• Self-poisoning most common followed by cutting
• Risk factors include prior self-harm, Hx of trauma in childhood and unstable personal lives
• Reasons include situational crises, feeling helpless, frustration, poor problem solving ability and meant to die

Question 13

Prevention of suicide

Answer 13

• Population approaches (limit on purchasing of tablets)
• Economic factors (increasing employment)
• Education of GPs (better identification)
• Media portrayals
• Educating public (anti-stigma campaigns)

Question 14

Personal safety (i.e. violence)

Answer 14

• Good communication about risk eg labelled case notes, adequate referrals
• Sit nearest the door to avoid being taken hostage
• Present yourself in interviews as professional, self-assured and empathic
• Make sure others know who you’re seeing, where you are, when you’ll be back
• Observation panels on doors
• Personal alarms
• Joint assessments if concerned
• Police/security guards
• Don’t ignore gut feelings