Suicidal thoughts and self harm thoughts

Suicidal thoughts are thoughts of ending one's own life, ranging from passive wishes to be dead to active plans with intent. Self harm thoughts are thoughts of deliberately injuring oneself, with or without intent to die. Both are a medical emergency until risk is defined.

Definitions

• Passive suicidal ideation: wish to be dead or not to wake, without a method or intent.
• Active suicidal ideation: thoughts of killing oneself, with or without a plan.
• Suicidal intent: the person intends to act on the thought. A plan includes method, time and place. Preparatory behaviour includes obtaining means, writing notes, giving away possessions and rehearsal.
• Suicide attempt: a self injurious act with some intent to die. Interrupted and aborted attempts are included.
• Nonsuicidal self injury: deliberate self inflicted damage (cutting, burning, hitting) without intent to die, to relieve distress. It is a strong marker of later suicide attempts.
• Suicide: death caused by self directed injurious behaviour with intent to die.

Epidemiology. About 700000 people die by suicide each year worldwide, and suicide is a leading cause of death in people aged 15 to 29 years. Attempts outnumber deaths by 20 to 30 times. Men die by suicide about 2 to 4 times as often as women, and women attempt more often. Around 8 in 10 people who die have contact with health services in the preceding year, and about half have contact in the month before death. Most people who think of suicide do not act, and asking about suicide does not plant the idea.

Risk factors (static and dynamic)

• Previous attempt (the strongest single predictor) and previous self harm.
• Mental disorders: major depression, bipolar disorder, schizophrenia, borderline and antisocial personality disorder, posttraumatic stress disorder, anxiety, eating disorders, and substance use disorders (especially alcohol).
• Recent discharge from psychiatric admission (highest risk in the first week to 3 months).
• Hopelessness, agitation, severe insomnia, psychotic symptoms (including command hallucinations), and impulsivity.
• Recent loss, relationship breakdown, bereavement, legal or financial problems, job loss, bullying, abuse, discrimination and migration or conflict.
• Chronic illness, chronic pain, new serious diagnosis, cancer, neurological disease, HIV, and disability.
• Access to lethal means: firearms, medicines, pesticides, heights, ligature points, rail lines.
• Family history of suicide, social isolation, older age, male sex, being gay, lesbian, bisexual or transgender in hostile settings, and certain occupations (doctors, farmers, police, military, veterinarians).
• Early weeks of an antidepressant in people under 25 years (small increase in suicidal thoughts).

Protective factors. Family and social connection, children in the home, help seeking, reasons for living, faith, engagement in care, problem solving skills, and restricted access to means. They reduce risk but never exclude it.

Key distinctions. Chronic low level passive ideation in a stable person differs from new active ideation with a plan. Thoughts relieved after a crisis settle may recur. Nonsuicidal self injury and suicidal behaviour often coexist, so ask about intent each time. Apparent sudden calm after severe distress can signal a decision to act.

History (ask directly, without judgement, in private, with open and then specific questions)

• Ideation: "Have you been having thoughts of ending your life?" Frequency, duration, intensity, controllability, and whether present now.
• Plan and intent: method, time and place, preparations (obtaining means, notes, farewells, financial arrangements), rehearsal, and whether the person intends to act, with reasons that would stop them.
• Past behaviour: previous attempts (method, intent, medical harm, rescue), self harm, and family or friends who died by suicide.
• Current mood and mental state: depression, hopelessness, agitation, panic, insomnia, anhedonia, psychotic symptoms, command hallucinations, guilt, shame, and mania or mixed features.
• Substances: alcohol (a strong short term risk factor, with intoxication increasing impulsivity), drugs, and prescribed sedatives.
• Triggers: loss, conflict, bereavement, shame, bullying, abuse, violence, legal problems, financial strain, physical illness and pain, and anniversaries.
• Means: access to firearms, stockpiled medicines, pesticides, and other lethal means at home or work, and willingness to restrict them.
• Protective factors: relationships, children, pets, reasons for living, future plans, engagement with care, and help seeking.
• Medical history: chronic illness, pain, cancer, neurological disease, sleep, and pregnancy or postpartum status.
• Drugs: recent starts or changes (antidepressants, antiepileptics, isotretinoin, montelukast, levetiracetam, mefloquine, efavirenz, interferon, corticosteroids, varenicline, hormonal agents), and supply of potentially lethal medicines.
• Collateral from family, carers, police and records, with consent when possible (or in line with local law when the patient lacks capacity or risk is high).
• Capacity, legal status, and safeguarding for dependants.

Examination

• General appearance, signs of self harm (cuts, burns, ligature marks), grooming, intoxication, injury, and signs of overdose (drowsiness, pupils, respiratory rate).
• Vital signs, temperature, oxygen saturation, and glucose in any person who has taken a substance or medicine.
• Mental state: mood, affect, agitation, speech, thought content (guilt, hopelessness, worthlessness, nihilism), delusions, hallucinations, orientation, insight, and judgement.
• Physical examination directed by symptoms, including neurological examination and signs of intoxication or withdrawal.
• Structured tools as an adjunct to clinical judgement: the Columbia Suicide Severity Rating Scale (screener of 6 questions covering wish to be dead, active ideation, method, intent, plan and behaviour in the past 3 months), the Ask Suicide-Screening Questions (4 questions, used in emergency settings in patients aged 8 years and over), the PHQ-9 question on thoughts of death, and the Beck Scale for Suicide Ideation. No tool predicts suicide, and low scores do not exclude risk.

Red flags (high acute risk)

• Active ideation with a specific plan, intent to act, preparation, or a recent attempt, particularly with a violent or highly lethal method.
• Access to a lethal method with intent to use it, or refusal to give up the means.
• Command hallucinations to kill oneself, psychotic depression, or catatonia.
• Severe agitation, panic, insomnia, or mixed affective state.
• Intoxication with alcohol or drugs together with suicidal thoughts.
• Hopelessness with recent major loss, shame, public humiliation or a new serious diagnosis.
• Discharge from psychiatric admission within the previous 3 months.
• Recent self harm with medical danger, an unusual calm after distress, or farewell behaviour (giving away belongings, settling affairs).
• Perinatal period with suicidal thoughts (postpartum psychosis), or thoughts of harming a child or others (homicide followed by suicide).
• Older adult with depression, medical illness and isolation, who is male, widowed, or recently bereaved.
• Adolescents or young adults with bullying, abuse, substance misuse, self harm, or a recent suicide in the peer group.
• Refusal of help, no reasons for living, or inability to engage in a safety plan.

Special groups

• Children and adolescents: take all statements seriously. Interview the young person alone and the parents separately, assess bullying, abuse, online harm, substance use, sexuality and gender distress, and safeguarding. Use age specific doses.
• Pregnancy and postpartum: assess for depression and psychosis, infant safety and obstetric complications. Suicide is a leading cause of maternal death in the first year after birth.
• Older adults: depression often presents with somatic complaints, and risk is high with illness, pain, isolation and bereavement.
• Medical illness: cancer, chronic obstructive pulmonary disease, epilepsy, spinal cord injury, HIV and chronic pain are associated with raised risk.
• People with psychosis, substance use disorders and personality disorder: chronic raised risk with episodic peaks.
• Region specific: pesticide self poisoning is a major cause of death in rural low and middle income settings, firearms in some settings, and stigma and legal barriers (criminalisation of attempted suicide) reduce help seeking.

Psychiatric conditions underlying suicidal and self harm thoughts

• Major depressive disorder, including psychotic depression and melancholia.
• Bipolar disorder (depressive and mixed episodes).
• Schizophrenia and schizoaffective disorder.
• Posttraumatic stress disorder and acute stress reaction.
• Anxiety disorders and panic disorder.
• Borderline and other personality disorders.
• Eating disorders.
• Alcohol use disorder and other substance use disorders.
• Adjustment disorder and prolonged grief disorder.
• Obsessive compulsive disorder and body dysmorphic disorder.
• Autism spectrum disorder and attention deficit hyperactivity disorder.
• Catatonia and delirium.

Medical and neurological contributors

• Chronic pain, cancer, and terminal illness.
• Epilepsy, stroke, Huntington disease, Parkinson disease, multiple sclerosis, traumatic brain injury and dementia.
• Hypothyroidism, hyperthyroidism, Cushing syndrome and Addison disease.
• HIV, neurosyphilis and other CNS infection.
• Systemic lupus erythematosus.
• Sleep apnoea and insomnia.
• Delirium (hypoactive and agitated).
• Perinatal conditions (postpartum depression and psychosis).

Drug induced and toxic

• Antidepressants in the first weeks (young people), corticosteroids, isotretinoin, levetiracetam, montelukast, efavirenz, mefloquine, interferon, varenicline, benzodiazepines and opioids.
• Alcohol and drug intoxication and withdrawal.
• Anabolic steroid use and withdrawal.

Behaviours that resemble or overlap

• Nonsuicidal self injury for emotional regulation.
• Accidental overdose and risk taking behaviour.
• Medically assisted dying requests and refusal of life sustaining treatment, which are assessed for depression and capacity.
• Cultural or religious martyrdom, and coercion by others.
• Factitious self harm and malingering (rare, and never assumed).

Step 1. Safety and medical stability. Make the patient safe and observe continuously if risk is high or intent unclear. Assess airway, breathing and circulation, and treat intoxication, overdose or injury first. Remove means and hazards (belts, cords, sharp items) in the department.

Step 2. Clinical risk formulation. Combine the history, the mental state, static and dynamic risk factors, protective factors, access to means, and the context into a statement of acute risk (low, moderate or high) and chronic risk, with the reasons. Use a structured tool (Columbia Suicide Severity Rating Scale) for consistency, and repeat when circumstances change. Do not use risk scales to decide who should be admitted, because they have poor positive predictive value.

Step 3. Diagnose the underlying disorder. Screen for major depression (PHQ-9), bipolar disorder (past elevated episodes), psychosis, posttraumatic stress disorder, anxiety, alcohol (AUDIT-C), drugs, eating disorders, personality disorder, cognitive impairment and delirium.

Step 4. Tests

• Capillary glucose, oxygen saturation, temperature, and 12 lead ECG for any overdose or when the substance is unknown.
• Paracetamol and salicylate concentrations (taken at 4 hours or more after ingestion) in all overdoses, because early symptoms are absent, and other drug levels when relevant (lithium, digoxin, antiepileptics).
• Full blood count, urea, creatinine, electrolytes, liver tests, calcium, creatine kinase, coagulation, blood gas, and lactate directed by the ingestion.
• Alcohol level, urine and blood drug screen.
• Pregnancy test.
• Thyroid stimulating hormone, vitamin B12 and folate, HIV and syphilis serology when risk or neuropsychiatric features exist.
• CT head for head injury or altered consciousness; chest radiograph for aspiration.
• Toxicology and poisons service advice for unknown or multiple ingestions.

Step 5. Interpretation. A high acute risk requires continuous observation and urgent specialist assessment. Moderate risk requires a written safety plan, means restriction, and arranged follow up within 24 to 72 hours. Low risk allows outpatient care with a safety plan and defined contacts. Reassess on any change in circumstances, and treat intoxication before judging risk, since risk can fall or rise as intoxication clears.

Limits. Risk cannot be predicted at individual level. Patients may deny intent. A fixed risk label should not become a reason to withhold care. Responsibility is shared between clinician, patient and system, and documentation of the reasoning is essential.

Immediate

• Create a calm, private, safe environment. Stay with the patient, listen, and acknowledge pain without arguing, judging or minimising. Ask about thoughts of suicide directly.
• If risk is high: do not leave the patient alone, provide one to one observation within arm's length, remove means and hazards, and arrange urgent mental health assessment. Use mental health legislation when the patient lacks capacity or refuses necessary treatment and risk is high.
• Treat medical emergencies first: airway, oxygen, intravenous access, glucose, ECG and monitoring. Consult toxicology for overdose.
• Treat agitation with de-escalation, and if medicines are needed, lorazepam 1 to 2 mg orally or intramuscularly, or olanzapine 5 to 10 mg orally, with monitoring.
• Notify and involve carers with consent (or without consent when risk is high and local law allows).

Common poisonings (general principles, with toxicology advice)

• Paracetamol: start acetylcysteine in the intravenous regimen when the 4 hour (or later) concentration is over the treatment line, when the time of ingestion is unknown or staggered, when an ingestion of 150 mg/kg or more (or 12 g or more) is reported and levels are delayed, or when liver injury is present. The 21 hour regimen is 150 mg/kg in 200 mL of 5% glucose over 1 hour, then 50 mg/kg in 500 mL over 4 hours, then 100 mg/kg in 1000 mL over 16 hours (watch for anaphylactoid reactions, slow the infusion and give an antihistamine; dose for weight to a maximum of 110 kg). Continue until the paracetamol level is undetectable, the INR is under 1.3 (or has fallen), ALT is falling, and the patient is well. Oral activated charcoal 50 g within 1 hour of a large ingestion in a patient with a protected airway.
• Salicylates: activated charcoal 50 g, intravenous sodium bicarbonate 1.5 mL/kg of 8.4% (about 100 mL in a 70 kg adult) over 3 hours or 1 to 2 mmol/kg to keep urine pH at 7.5 to 8.5 and serum pH under 7.55, potassium replacement, and haemodialysis for severe poisoning (levels over 7.2 mmol/L or 100 mg/dL, altered mental state, pulmonary oedema, or kidney failure).
• Opioids: naloxone 0.4 to 2 mg intravenously (or 0.8 to 2 mg intramuscularly or intranasally 4 mg), repeated every 2 to 3 minutes, then an infusion at two thirds of the reversal dose each hour if long acting opioids were taken. Monitor for at least 4 to 6 hours after the last dose (longer with long acting preparations).
• Benzodiazepines: supportive care and airway management. Flumazenil is avoided in mixed overdoses and dependence.
• Tricyclic antidepressants: ECG (QRS over 100 ms), sodium bicarbonate 1 to 2 mmol/kg intravenously for QRS widening or ventricular arrhythmia, and seizure treatment with benzodiazepines.
• Organophosphate pesticides: airway protection, atropine 1 to 3 mg intravenously doubled every 5 minutes until secretions dry, and pralidoxime under specialist advice.
• Paraquat and other pesticides, corrosives, hanging, carbon monoxide and firearm injuries: emergency resuscitation, early specialist toxicology and surgical care.
• Lithium: intravenous 0.9% sodium chloride, level monitoring, and haemodialysis for severe toxicity.
• Observe patients after overdose until medically fit, and do not discharge before psychosocial assessment.

Safety planning and means restriction (for every patient with suicidal thoughts)

• Safety plan (written, with the patient): personal warning signs, internal coping strategies, people and places that provide distraction, people to ask for help, professionals and crisis numbers, and steps to make the environment safe.
• Lethal means counselling: ask about firearms, stockpiled medicines, pesticides and other means, ask family to hold or remove them, lock them away, and limit the quantity of medicines dispensed (for example, a 1 to 2 week supply, or blister packs, and lower toxicity drugs). Avoid prescribing tricyclic antidepressants, large amounts of paracetamol or opioids, or high dose benzodiazepines to high risk patients.
• Follow up contact within 24 to 72 hours, then regularly in the first 3 months, by telephone, text or visit. Brief contact interventions reduce repeat attempts.
• Involve family and carers, and provide crisis numbers and local emergency services.

Treatment of the underlying disorder

• Major depression: psychological therapy, and sertraline 50 mg orally once daily (25 mg for the first week if anxious) increased every 1 to 2 weeks to 50 to 200 mg, maximum 200 mg, or escitalopram 10 mg daily (maximum 20 mg; 10 mg over 65 years), with weekly review in people under 25 years for the first month. Mirtazapine 15 mg at night when insomnia is marked. Antidepressants are not withheld because of suicidal thoughts, and the quantity supplied is limited.
• Severe, psychotic or refractory depression with high suicide risk: electroconvulsive therapy (rapid response, effective), or antidepressant with an antipsychotic. Ketamine 0.5 mg/kg intravenously over 40 minutes, or esketamine nasal spray 56 mg then 84 mg twice weekly for 4 weeks, can reduce suicidal thoughts within hours to days (specialist, monitored, short term effect; evidence limited for preventing suicide).
• Bipolar disorder and recurrent depression: lithium, taken long term (serum level 0.6 to 0.8 mmol/L at 12 hours, with kidney, thyroid and calcium monitoring), reduces suicide and attempts. Lithium is dangerous in overdose, so limit supply and monitor levels.
• Schizophrenia: clozapine, started at 12.5 mg once or twice on day 1 and titrated to 300 to 450 mg daily over 2 to 3 weeks (maximum 900 mg), with blood count monitoring (weekly for 18 weeks, then fortnightly to 1 year, then monthly), reduces suicidal behaviour in treatment resistant disease. Treat postpsychotic depression.
• Posttraumatic stress disorder, anxiety and panic: trauma focused therapy and SSRIs.
• Insomnia and agitation: treat promptly with cognitive behavioural therapy for insomnia, and short term sedation.
• Borderline personality disorder and recurrent self harm: dialectical behaviour therapy (weekly individual and group skills for at least 6 months), mentalisation based therapy, and short term crisis plans. Avoid long term benzodiazepines and polypharmacy.
• Alcohol and substance use disorders: brief intervention, withdrawal management (chlordiazepoxide 15 to 30 mg orally every 6 hours reducing over 5 to 7 days, with thiamine), relapse prevention, and addiction services.
• Specific suicide focused psychological treatments: cognitive behavioural therapy for suicide prevention (10 sessions), the Collaborative Assessment and Management of Suicidality, safety planning intervention with follow up calls, and problem solving therapy.
• Chronic pain and medical illness: treat pain and optimise care.
• Self harm without intent to die: assess the function, teach emotion regulation, substitute with nonharmful strategies, wound care (clean, close with tissue adhesive or sutures, and treat tetanus status), and psychological therapy. Do not use sedatives as a routine.

Special populations

• Pregnancy and postpartum: sertraline is preferred. Urgent specialist care, ideally to a mother and baby unit, for severe depression, psychosis or thoughts of harming the infant.
• Children and adolescents: family based therapy, cognitive behavioural therapy, dialectical behaviour therapy for adolescents, and fluoxetine 10 mg daily for 1 week then 20 mg (maximum 60 mg) when drugs are needed. Remove means at home (locked medicines and firearms), and involve school and safeguarding services.
• Older adults: treat depression actively, address isolation, pain and bereavement, restrict medicines, and consider electroconvulsive therapy.
• Kidney and liver impairment: start low for antidepressants, avoid lithium in kidney impairment, and use caution with paracetamol.
• Medical illness: treat pain and mood, and involve palliative care when suffering is related to terminal illness.

Disposition

• High acute risk: inpatient admission (voluntary or under mental health legislation) or continuous observation until assessed, with a clear plan.
• Moderate risk: admission is considered if the patient lacks supports, cannot engage in a safety plan, is intoxicated, or has access to means. Otherwise intensive community care (crisis resolution, home treatment) with daily to 72 hour contact.
• Low risk: outpatient care with a safety plan, means restriction, and appointment within 1 to 2 weeks.
• Do not discharge intoxicated patients with suicidal ideation until sober and reassessed.
• Discharge from hospital with a follow up contact within 24 to 72 hours, and a face to face review within 7 days.

Monitoring. Reassess suicidal thoughts at every contact. Measure with PHQ-9 and Columbia Suicide Severity Rating Scale. Review adherence, adverse effects, supply of medicines, alcohol and drugs, safety plan use, and social changes. Heightened vigilance in the first weeks of a new antidepressant, after discharge, at anniversaries and after losses.

Referral and escalation. Emergency psychiatric assessment for active ideation with plan or intent, recent attempt, psychosis, or severe depression. Child and adolescent mental health services for under 18 years. Crisis teams, community mental health teams, and addiction services. Toxicology and critical care for overdose. Social work and safeguarding. Postvention support for families after a suicide. Admission criteria.

Imminent risk of suicide or serious self harm, active plan with intent, psychosis or severe depression with suicidal thoughts, medical admission for overdose or injury, and inability to keep safe in the community.

Discharge and follow up. Written safety plan and crisis contacts, means restriction completed, a limited supply of medicines, and arranged follow up within 24 to 72 hours. Safety net advice: call emergency services or return at once for intent to act, a plan, new self harm, command hallucinations, loss of the ability to keep safe, intoxication with suicidal thoughts, or any sudden worsening.