Suicide Risk Assessment – OSCE guide

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The ability to carry out a suicide risk assessment is an important skill that is often assessed in the OSCE setting. It’s particularly important to have a systematic approach to ensure you don’t miss any key information. This guide provides a framework to perform a comprehensive suicidal risk assessment in an OSCE setting.

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Opening the consultation

Wash your hands and don PPE if appropriate.

It’s important to try and establish rapport with the patient early in the consultation to allow you to perform an accurate assessment of their mental health.

Introduce yourself and explain why you are reviewing the patient: “Dr Y from A&E has asked me to see you. My name is Dr Smith and I’m a psychiatrist. I’m here to talk about the events that have led you to be admitted to hospital.” 

Explain that some of the questions you ask may be difficult to answer and reassure the patient that what they tell you will be kept confidential (unless there is a risk to another person e.g. a child at home).

“Anything that’s said here today will be confidential unless I feel another person is potentially at risk. In that case, I would need to share some information. I appreciate that some questions may be difficult to answer – if there’s anything you don’t want to answer right now, we can come back to it another time. Does that all sound ok?”

The purpose of a suicide risk assessment is to:

• Establish the patient’s intent
• Assess the seriousness and perceived seriousness of their attempt
• Assess how they feel about the attempt at the time of assessment

Covering these points will allow you to make an adequate assessment of risk.

In order to try and establish intent, it can be useful to start off with the day in question and obtain a narrative/autobiographical timeline of what happened. It’s best to start with open questions, and then later use closed questions for clarification.

“Tell me about what happened”

“What happened next?”

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The current episode of self-harm

Although the exact details of the method of self-harm can differ significantly (e.g. overdose/cutting/burning/attempted hanging), there are key questions and themes that need to be covered in all scenarios to assess suicide risk.

Key questions to ask about the current episode of self-harm

It’s best to think about this in terms of before, during, and after…

Before

Was there a precipitant?

• Examples may include an argument with a spouse or a recent bereavement.
• You may establish psychological, physical or social problems here, but you also need to screen for these later.

Was the self-harm planned, or impulsive?

Did the patient carry out any final acts?

• Write a suicide note
• Leaving a will
• Terminating contracts (e.g. mobile phone, gas and electricity)

Were any precautions taken against discovery?

• Closing curtains
• Locking doors
• Waiting until they knew everyone would be out of the house and not be back for several hours
• Going somewhere very remote

Was alcohol used?

• Ask about the amount and type used
• Ask about previous alcohol use

During

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 end their life?

What did they do straight after the self-harm?

After

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 the patient were to feel like this again, what might they do differently?

What does the patient think might prevent them from doing this again in the future?

Does the patient feel there is anything to live for? (i.e. protective factors)

Will the patient accept treatment?

Specific questions to ask about overdose

What medication or medications did the patient take?

Where did the patient get the medication from?

How much of the medication did the patient take?

What did the patient take the medication with?

What did the patient think that amount of medication would do?

What made the patient decide to take the medication/how long had they been thinking about taking an overdose for?

What did the patient do after taking the medication?

How did the patient get to the hospital?

Specific questions to ask about cutting

Where are the cuts?

How many cuts are there?

How deep are the cuts?

How did the patient feel whilst they were cutting?

How did the patient feel when they saw blood?

What was the patient hoping the cutting would do?

Screen for other mental health disorders which increase the risk of suicide

Depression

Anhedonia: “Do you feel that you no longer enjoy activities that you previously used to?”

Low mood: “How has your mood been recently?”

Fatigue: “What have your energy levels been like recently?”

Psychosis

Thought insertion: “Are the thoughts to harm ever not your own?”

Auditory hallucinations: “Do you ever feel like there are voices that you can hear telling you to harm yourself, that no one else can hear?” “How do you know these are other peoples voices and not your own worries in your head?”

Anorexia

“How would you describe your eating habits?”

“Do you feel you’re eating enough at the moment?”

“What’s your appetite like at the moment?”

“Have you lost weight recently?”

“Are you satisfied with your current weight?”

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Previous episodes of self-harm

Has the patient ever carried out self-harm in the past?

What methods of self-harm were involved?

Did they get any help from their support network or other agencies as a result of their self-harm?

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Past psychiatric history

Does the patient have any psychiatric diagnoses?

Has the patient had any previous admissions to a psychiatric hospital?

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Past medical history

It is important to ask about a patient’s past medical history as this may be relevant to their current episode of self-harm (e.g. bleeding disorder/liver dysfunction).

Chronic pain and chronic illness are also risk factors for suicide.

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Drug history

It’s important to take a thorough drug history as this may be relevant to the current episode of self-harm (e.g. anticoagulants/overdose/interactions).

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Family history

Have any of the patient’s family members ever attempted or completed suicide?

Are there any psychiatric conditions present in close family members?

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Social history

Taking a thorough social history allows identification of social risk factors for suicide.

Living situation

Who does the patient live with?

Where does the patient live?

Does the patient have a good support network?

Is the patient able to manage all their activities of daily living independently?

If the patient has children you also need to consider if the children are being neglected and if the patient has thoughts of harm towards the children.

Note: if you do elicit risks then it is important to do something about it (e.g. if there is a child safeguarding concern this needs to be shared with a senior nurse or your consultant to allow the safeguarding concerns to be addressed).

Occupation

What job does the patient have?

If none, ask if coping financially?

Does the patient have any debt?

Alcohol

Particularly important to ask about if used during the episode of self-harm.

Does the patient drink alcohol?

How much does the patient drink in an average week?

What is the pattern of drinking? (e.g. every day vs binge drinking)

Recreational drugs

Does the patient use recreational drugs?

What drugs does the patient use?

How often and how much of the drugs does the patient use?

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Closing the consultation

Thank the patient for taking the time to speak with you.

Tell the patient how you see their difficulties (now).

In most cases, you will have a conversation to agree on a management plan. In some cases, however, this may not be appropriate.

Dispose of PPE appropriately and wash your hands.

If the patient is not suicidal and you intend to send them home with no follow-up

If a patient is felt to be low risk, you may be discharging them home with no follow up with mental health services. In these cases, it’s essential to formulate a safety plan with the patient and also signpost to appropriate agencies.

Safety plan

Seek the support of their family and friends (clarify who they have already told ).

Recognise stressors and address them where possible.

Avoid harmful alcohol use when stressed.

Ask the patient who they could tell if they felt like this again.

Suggest that if the patient feels like this again, they can seek help from a number of places including:

• Personal support network
• GP
• Local support line (e.g. Samaritans)
• A&E
• Local mental health services that see people who self-refer (provide them with the number)

Signpost the patient to appropriate agencies

Signpost the patient to agencies which may be able to address some of their sources of stress/risk factors:

• GP
• Housing services
• Citizen’s Advice Bureau
• Alcohol and drugs services
• Domestic violence services
• Counselling services

If the patient requires support from a mental health team

Some patients may require support from the local mental health team. Have a discussion about whether the patient could manage safely at home with the support of an intensive home treatment team or will accept voluntary admission to a psychiatric hospital.

If the patient is unsafe to send home

For some patients, it may be clear that they are at high risk of completing suicide or further self-harm and lack insight. In these cases, a Mental Health Act assessment will need to be carried out.

Factors that increase suicide risk

Demographics

• Male
• Older
• Widowed/separated/single
• Living alone/social isolation
• Low income/unemployed
• Certain occupation (e.g. doctor, farmer)
• Family history of suicide

Diagnoses

• A previous suicide attempt (risk x 40)
• Severe depression (risk x 20)
• Anorexia (risk x 25)
• Haemodialysis (risk x 14)
• Recreational opiate use/dependence (risk x 14)
• Alcohol dependence (risk x 6)

The act itself

• The patient carried out final acts (e.g. writing a will)
• The patient has researched methods and prepared for the act (e.g. stockpiling tablets)
• The patient perceived the act to have a high lethality
• The patient took precautions against being found
• The patient used a violent method of suicide (e.g. firearms, jumping from a height)
• The patient’s attempt is discovered by chance
• The patient resists/tries to evade medical intervention
• The patient downplays the seriousness of the attempt

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