The ability to carry out a suicidal risk assessment is an important skill that is often assessed in the OSCE setting. It’s important to have a systematic approach to ensure you don’t miss any key information. The guide below provides a framework to perform a comprehensive suicidal risk assessment in an exam setting.
Initiating the consultation
It’s key to try to establish rapport with the patient early to allow you to perform an accurate assessment of their mental health.
Introduce yourself and explain why you are seeing the patient
“Dr Y from A&E has asked me to see you. I am Dr Smith, and I’m a psychiatrist, I’m here to talk about the events that have led you to being admitted to hospital”
The patient may also appreciate at this stage an acknowledgement that what you want to talk about with them can sometimes be difficult, and confidential.
“Anything that’s said here today will, of course, be confidential* and 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. However, having this talk will help us to help you as much as we can. Does that all sound ok?“
*be confidential — “but if a child’s safety is at risk, I may need to share this information.”
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?”
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 suicidal 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…
Was there a precipitant? (e.g. argument with spouse/recent bereavement)
- You may establish psychological, physical or social problems here, but you also need to screen for these later.
Was it 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 (amount/type/previous use)
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?
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?
Specific questions to ask about overdose
What medication or medications did you take?
Where did you get the medication from?
How much of the medication did you take?
What did you take the medication with?
What did you think that amount of medication would do?
What made you decide to take the medication/how long have you been thinking about taking an overdose for?
What did you do after taking the medication?
How did you get to hospital?
Specific questions to ask about cutting
Where are the cuts?
Number of cuts?
How deep are the cuts?
Can you describe how you felt whilst cutting?
How did you feel when you saw your blood?
What were you hoping the cutting would do?
Screen for other mental health disorders which increase the risk of suicide
- Check for the cardinal symptoms
- Low mood
- Are the thoughts to harm ever not your own?
- Do you ever feel like there are voices that you can hear telling you to harm yourself, that no one else can hear?
- If YES: how does the patient know these are voices and not their own worries in their head?
Alcohol dependency (particularly if used during self-harm episode)
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 gain any help as a result of their self-harm?
Past psychiatric history
Does the patient have any psychiatric diagnoses?
Any previous admissions to psychiatric hospitals?
Past medical history
It would be 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.
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).
Have any of the patient’s family members ever attempted or completed suicide?
Are there any psychiatric conditions present in close family members?
Very important for checking epidemiological risk factors.
- 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:
- Are they being neglected?
- Do they witness the episodes?
- Does the patient have 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 these need to be shared with a senior nurse or your consultant, and the safeguarding concerns addressed or plan put in place.
- What job does the patient have?
- If none, ask if coping financially? Any debt?
- Does the patient drink alcohol?
- How much does the patient drink in an average week?
- Ask about the pattern of drinking (e.g. every day vs binge drinking)
- Does the patient use recreational drugs?
- What drugs does the patient use?
- How often and how much of the drugs does the patient use?
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.
If the patient is not suicidal and you intend to send them home with no follow-up
For patients who are not suicidal who you intend to send home, you may be sending them home with no follow up from mental health services
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?
- Suggest they:
- Use their support network
- See a GP
- Phone local support line (e.g. Samaritans)
- Present to A&E (before taking overdose)
- Contact local mental health services that see people who self-refer (provide them with the number)
Signpost to appropriate agencies
- Housing services
- Citizen’s Advice Bureau
- Alcohol and Drugs services
- Domestic Violence Services
- Counselling services
If the patient requires support of the mental health team
For some patients, you may decide they require the support of the mental health team. Have a discussion about whether the patient can keep safe at home with the support of the Intensive Home Treatment Team or will accept voluntary admission to a psychiatric hospital.
If the patient is unsafe to send home
For a few, it may be clear that they are mentally unwell, at high risk of completing suicide or further self-harm but lack insight, capacity or simply refuse to come into hospital. For these patients, you would be requesting a Mental Health Act assessment. This can take some time to set up and explaining to the patient that you are concerned and will be taking advice from your senior doctor to ask that they see them.
Factors that increase suicide risk
- Living alone/social isolation
- Low income/unemployed
- Certain occupation e.g. doctor, farmer
- Family history of suicide
- Previous attempt increases risk x 40
- Severe depression x 20
- Anorexia x 25
- Haemodialysis x 14
- Recreational opiate use/dependence x 14
- Alcohol dependence x 6
The act itself
- Final acts e.g. writing a will
- 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