Managing risk

When a patient is at risk of suicide this information should be recorded clearly in the patient’s notes. Where the clinician is working as part of a team it is important to share awareness of risk with other team members. Out-of-hours emergency services need to be able to access information about risk easily.

It is advisable to be open and honest with patients about your concerns regarding the risk of suicide and to arrange timely follow-up contact in order to monitor their mental state and current circumstances.

Patients should be informed how best to contact you in between appointments should an emergency arise. You should encourage them to let you know if they feel worse or the urge to act upon their suicidal thoughts increases. Patients should also be given details of who to contact out of hours when you are not available. Where appropriate, reception or administrative staff may need to be alerted that a patient should be prioritized if they make contact.

Active treatment of any underlying depressive illness is a key feature in the management of a suicidal patient.

It is important to assess whether patients have the potential means for a suicide attempt and, if necessary, to act on this: for example, only prescribing limited supplies of medication that might be taken in overdose and encouraging family members, friends or carers to dispose of stockpiled medication. Medicines that are particularly dangerous in overdosage include tricyclic antidepressants, especially dosulepin, paracetamol and opiate analgesics. Restricting access to other lethal means (e.g. shotguns) should also be considered.

Some internet sites can be a helpful source of support for patients, but there are also pro-suicide websites and those which advise about lethal means. Patients should be asked if they have been accessing internet sites and, if so, which ones.

Suicide and self-harm can be contagious. It is worth enquiring about exposure to such behaviours, including in family, friends and in the media, and the patient’s reactions to this.

Active treatment of any underlying depressive illness is a key feature in the management of a suicidal patient and should be instigated as soon as possible.

If the risk of suicide in a patient seen in primary care is high, particularly where depression is complicated by other mental health problems, referral to secondary psychiatric services should be considered. In many areas there are crisis teams which can respond quickly and flexibly to patients’ needs and can arrange appropriate psychiatric support and treatment.

Many clinicians will make informal agreements with patients about what they should do if they feel unsafe or things deteriorate. More formal signed agreements are not recommended as there is a lack of evidence regarding their efficacy, and their legal status in the event of a suicide is unclear. Regular and pro-active follow-up is highly recommended.

Clinicians seeing suicidal patients should consider access to peer support and supervision. When a clinician experiences the death of a patient by suicide they should seek support and advice to help cope with this.