1. The document discusses suicide risk assessment and prevention. It provides an overview of statistical data on suicide rates in the UK, outlines high risk groups, and reviews the Department of Health's suicide prevention strategy. 2. Risk factors for suicide include mood disorders, substance abuse, previous suicide attempts, and easy access to lethal means. A thorough risk assessment involves exploring suicidal thoughts and plans through open and closed questioning. 3. Ongoing support and follow-up are important for managing risk, as risk is dynamic and requires regular reassessment. Early identification and treatment of depression can help prevent suicide.

1. Suicide:
Risk Assessment and Prevention
Dr Imran Waheed
Consultant Psychiatrist

2. Overview
• Context
• Statistical update
• DoH Suicide Prevention Strategy
• Risk factors
• Risk assessment and management

7. Coroner’s Inquest Media Coverage
“Her GP Dr Ryley accepted that when he saw her on 24th
March, a month before her death, he had considered only her
problems of tiredness and getting to school late and had not
asked her about depression.”
“He was concerned her problem could be due to iron deficiency
or low thyroid level and, as she was a vegetarian, he treated her
accordingly, he said.”
“Asked by the coroner if he felt there had been a missed
opportunity to help her, given her suicide bid at Beachey Head,
Dr Ryley said "Certainly, in retrospect. I agree I would have
looked to enquire closely about mood and depression but I
didn't on that occasion.””

8. Statistical Update
• 4,215 suicides recorded in 2010.
• 3 year average for 2008-10 was 7.9 suicides per
100,000 general population, 17.9 % lower than in
1998-2000.
• Most substantial decreases seen towards the
beginning of this period and data show a very
slight increase in deaths from suicide in more
recent years.
• West Midlands: 2007  245 & 2010  450

9. Statistical Update
• Majority in adult males – 4 times more M than F in 25-29
• Rate is now highest for middle age men – slight increase
• 1 % of population have suicidal thoughts per week
• Between a quarter and a half of those committing suicide
have previously carried out a non-fatal act
• Average estimated cost per completed suicide is £1.67m
• Challenge is that suicide is rare event, prediction has very
low specificity (so lots of false positives)

14. Mental Health Patient Suicide
• About 1100 suicides by people in contact
with mental health service in previous 12
months
• About 70-80 psychiatric inpatients die
annually by suicide
• Highest risk: 14 days post-discharge (‘7 day
follow up’)

15. Patient suicide frequency by diagnosis

18. Primary care and suicide
• List size of 1000 – would take 8 years of
consultations before a GP will consult with a
patient who will shortly thereafter commit suicide
• About 90% of those in contact with MH services
will see GP in year preceding suicide, and about
45% in the month preceding suicide
• Mean of 8 consultations with GP in year preceding
death
• Is there a role for suicide prevention in primary
care?

19. DoH Suicide Prevention Strategy
• Published in September 2012
1. Reduce risk in key high risk groups
2. Tailor approaches to improve MH in specific groups
3. Reduce access to the means of suicide
4. Better information and support to those bereaved or
affected by suicide
5. Support the media in delivering sensitive approaches to
suicide and suicidal behaviour
6. Support research, data collection and monitoring

20. High risk groups
1. Young and middle-aged men
2. People in the care of mental health services, including
inpatients
3. People with a history of self-harm
4. People in contact with the criminal justice system
5. Specific occupational groups, such as doctors, nurses,
veterinary workers, farmers and agricultural workers.

21. Suicide Prevention Strategy
• “Those who work with men in different settings, especially
primary care, need to be particularly alert to the signs of
suicidal behaviour.”
• “Accessible, high-quality mental health services are
fundamental to reducing the suicide risk in people of all ages
with mental health problems.”
• “Emergency departments and primary care have important
roles in the care of people who self-harm, with a focus on
good communication and follow-up.”
• “Depression is one of the most important risk factors for
suicide. The early identification and prompt, effective
treatment of depression has a major role to play in
preventing suicide across the whole population.”

22. Primary Care
• “GPs have a key role in the care of people who self-harm.
Good communication between secondary and primary care
is vital, as many people who present at emergency
departments following an episode of self-harm consult their
GP soon afterwards.”
• “Work undertaken by the London School of Economics has
shown that suicide prevention education for GPs can have an
impact as a population level intervention to prevent suicide.”
[ASIST course costs about £200 per GP]

23. Evidence base issues
• Medication - only lithium and clozapine have good
evidence for reducing suicide
• Medication/hospitalisation have good face validity for
being helpful, but limited evidence of ‘anti-suicidal’ effect
• Medication/hospitalisation are not without risks
• Treatment with medication can give access to means – a
third of those who commit suicide and are in contact with
MH services in last 12 months self poison with
psychotropic medication
• Side effects such as akathisia increase suicide risk
• Hospitalisation – 30 per cent of community suicides in 3
months post-discharge

24. Risk factors for suicide
Biopsychosocial Risk Factors
•Mood disorders, schizophrenia, anxiety disorders and
certain personality disorders
•Alcohol and other substance use disorders
•Hopelessness/helplessness
•Impulsive and/or aggressive tendencies
•History of trauma or abuse
•Some major physical illnesses
•Previous suicide attempt
•Family history of suicide

25. Risk factors for suicide
Environmental Risk Factors
•Job or financial loss
•Relationship or social loss
•Easy access to lethal means
•Local clusters of suicide that have a
contagious influence

26. Risk factors for suicide
Sociocultural Risk Factors
•Lack of social support and sense of isolation
•Stigma associated with help-seeking behaviour
•Barriers to accessing health care, especially
mental health and substance abuse treatment
•Certain cultural and religious beliefs (for
instance, the belief that suicide is a noble
resolution of a personal dilemma)
•Exposure to, including through the media, and
influence of others who have died by suicide

27. Assessment
• “Asking a patient about suicide increases
the increase risk of suicide” – T/F?
• “Those who talk about suicide do not
commit suicide” – T/F?
• Use graded questions – open and closed
• Explore suicidal ideas – is there a plan?
• What are the means?

28. Assess seriousness
• Intent
• Planned vs. impulsive
• Final acts
• Attempts made to prevent discovery
• How discovered and how brought to medical
attention?
• Use graded questions – open and closed
• Explore suicidal ideas – is there a plan?
• What are the means? (e.g. guns – greater risk)
• How do they feel now?

29. Vignette 1
• Sarah is a 22 year old girl who presents to
A&E having taken 15 paracetamol and ½ a
bottle of vodka. She had a fight with her
boyfriend earlier in the evening. She used
whatever she could find in the house and
called an ambulance when she felt sick. She
had wanted to end things at the time, but
now regrets her actions.

30. Please make your selection...
1. HIGH RISK - Admit
2. Home with Home
Treatment Team
3. Home with secondary care
follow up
4. Home with primary
care/GP follow up
5. Home with no follow up

31. Vignette 2
• Jennifer is a 43 year old divorced, unemployed
mother of 2. She has been depressed for 6 months
and was recently discharged from hospital. She
was found by a neighbour in a newly bought car
in the garage, with the motor running, and
brought to A&E. She had sent her children away
for the weekend and had parked her own car in
front of the garage hoping no one would discover
her. She is bitterly disappointed to have failed to
end her life.

32. Please make your selection...
1. HIGH RISK - Admit
2. Home with Home Treatment
Team
3. Home with secondary care
follow up
4. Home with primary care/GP
follow up
5. Home with no follow up

33. Key messages
• Suicide is major cause of death and major public
health issue
• Risk assessment is an important intervention
• Risk is dynamic and needs regular reassessment
• Early identification and treatment of depression is
important
• Good relationships between primary and
secondary care essential

34. Fighting stigma - a final thought
“Killing oneself is, anyway, a misnomer. We don't kill
ourselves. We are simply defeated by the long, hard
struggle to stay alive. When somebody dies after a
long illness, people are apt to say, with a note of
approval, "He fought so hard." And they are inclined
to think, about a suicide, that no fight was involved,
that somebody simply gave up. This is quite wrong.”
Sally Brampton, Shoot The Damn Dog: A Memoir Of Depression