Suicide

Suicide is the act of intentionally ending one's own life. It is the culmination of a spectrum of suicidal phenomena, and is a major, largely preventable cause of death globally and across all age groups.

The spectrum runs from passive ideation (thoughts that life is not worth living, without active intent or plan) through active ideation (specific thoughts of ending one's life, with varying intent and planning) to suicide attempt and completed suicide.

Systematic, direct risk assessment with prompt, appropriate intervention is a core clinical skill in virtually every area of practice, not only psychiatry. Individuals at risk frequently present to general medical, emergency and primary care settings.

Epidemiology and risk factors

• Suicide risk is substantially elevated with an underlying psychiatric condition: depressive disorders, bipolar disorder (mixed feature and depressive episodes carry particular risk), certain personality disorders, and substance use disorders.
• Suicide occurs across the full spectrum of mental health presentations, including in individuals with no diagnosed psychiatric condition, particularly in acute psychosocial crisis.
• Well established risk factors include prior suicide attempt (one of the strongest predictors of future completed suicide), significant psychosocial stressors (relationship breakdown, financial difficulty, significant loss), chronic pain or significant physical illness, social isolation, access to lethal means and a family history of suicide.
• Demographic factors include male sex, older age and certain occupational groups. Men have a substantially higher rate of completed suicide despite a lower rate of attempts than women, reflecting differences in method lethality.
• Explore protective factors as part of full assessment: strong social support, engagement with mental health treatment, religious or cultural beliefs discouraging suicide, and responsibility toward dependent children or other family members.
• Protective factors inform risk stratification and identify sources of support to incorporate into safety planning.

• Suicidal ideation may be passive: a wish to not wake up, or a feeling that life is not worth living, without active intent.
• It may be active: specific intent to end one's life, potentially with a plan. In more concerning presentations there is preparatory behaviour, such as acquiring means or completing final acts like writing a note or giving away possessions.
• The presence and characteristics of any plan and intent are critical elements of risk assessment.
• Warning signs of acute, elevated risk include explicit statements of suicidal intent. Always take these seriously and never dismiss them as attention seeking.
• A sudden, unexplained improvement in mood after a period of significant depression may reflect relief or resolve after a decision to act. This pattern is important but not universal.
• Other warning signs: giving away significant possessions, writing a will or making other final arrangements, and increasing withdrawal from social contact and previously valued activities or relationships.
• Presentation may be direct, with explicit disclosure of suicidal thoughts or a recent attempt. It is frequently indirect, with an ostensibly unrelated physical symptom, or with a family member or other concerned party raising the concern.
• Clinicians in all specialties should therefore keep a low threshold for direct enquiry where any relevant clinical or contextual concern is present.
• Non-suicidal self injury differs from suicidal behaviour in intent: it typically serves emotional regulation or coping rather than a wish to end life.
• It is nonetheless an important marker of significant distress and is associated with elevated subsequent suicide risk. Assess it carefully and sensitively rather than dismissing it as unrelated to suicide risk.

• Direct, explicit, non-judgmental enquiry about suicidal thoughts is the essential foundation of risk assessment.
• Clear evidence shows that asking directly about suicide does not increase risk or "plant the idea". This should overcome any clinician hesitancy, because failing to ask carries far greater risk of missing a significant, actionable risk.
• Full risk assessment systematically explores:
  • suicidal ideation (passive versus active, frequency, intensity)
  • any plan, including the method under consideration and its accessibility and lethality
  • intent, the degree to which the individual wishes to act on their thoughts
  • any preparatory behaviour
  • the broader constellation of risk and protective factors
• Ask directly about access to lethal means, including firearms, stockpiled medication or other means relevant to the individual's circumstances and any expressed plan.
• Assessment of a recent suicide attempt should explore the method used and its medical lethality, the degree of planning, and whether the individual took steps to avoid discovery or ensured discovery.
• Also explore the individual's current feelings about the attempt. Regret at having survived is an important marker of continued, significant risk.
• Structured risk assessment tools may support and inform, but should never replace, full, individualised clinical judgment.
• Any structured tool has recognised limitations in predicting individual risk, and none is precise enough to be the sole basis for clinical decisions.

• Active, current suicidal ideation with intent and an accessible, specific plan is a psychiatric emergency requiring immediate action.
• Ensure immediate physical safety. This may require removing or restricting access to an identified means, and in some circumstances not leaving the individual alone pending further assessment.
• Arrange urgent psychiatric assessment. Consider informal admission or, where necessary and in accordance with local mental health legislation, involuntary admission where risk is sufficiently high and cannot be managed in the community.
• Removing or restricting access to lethal means is a specific, evidence based, highly effective intervention. Substantial evidence shows that restricting access to a specific means (prominently firearms and stockpiled medication) reduces subsequent suicide risk.
• Many suicide attempts are impulsive, so a delay or barrier between suicidal urge and a highly lethal method matters, even where the individual could in principle identify an alternative method.
• Safety planning is developed collaboratively with the individual. It is a structured, individualised plan identifying warning signs of an emerging crisis, independent coping strategies, sources of social support and distraction, professional and crisis service contacts, and steps to restrict access to identified lethal means.
• Safety planning is an evidence based intervention for individuals at risk who do not need immediate hospitalisation.
• Treat any underlying psychiatric condition (depression, bipolar disorder, substance use disorder, or other diagnosis) as an essential component of longer term risk reduction.
• Offer psychological therapy that targets suicidal thoughts and behaviour. Options include dialectical behaviour therapy, particularly where recurrent self harm or suicidal behaviour occurs with significant emotional dysregulation, and cognitive behavioural therapy adapted for suicide prevention.
• Lithium maintenance treatment has established evidence for reducing suicide risk in patients with bipolar disorder and recurrent major depressive disorder. See bipolar disorder.
• Provide structured follow up and monitoring. Be particularly vigilant, with closer follow up, in the days and weeks after any psychiatric hospital discharge and after any suicide attempt. Suicide risk is substantially elevated in the immediate post-discharge period.
• Ensure clear communication and coordination between all involved clinical services. Where appropriate and with consent, involve family members or other close, trusted contacts in ongoing support and monitoring.
• After a completed suicide, provide postvention support for surviving family members, close contacts and, where relevant, involved clinical staff. Review the case in a structured way to identify learning for future practice.
• Postvention is an important but frequently underemphasised component of a system wide approach to suicide.