SUICIDAL BEHAVIOUR

Suicidal behaviour is an emergency and requires immediate attention. It is an attempted conscious act of
self-destruction, which the individual concerned views as the best solution. It is usually associated with feelings of
hopelessness, helplessness and conflicts between survival and death.

Self-harm is a broader term referring to intentional poisoning or self-inflicted harm, which may or may not have
an intent of fatal outcome.

Causes/risk factors

  • Physical illness e.g. HIV/AIDS, head injury, malignancies, body disfigurement, chronic pain
  • Psychiatric disorders e.g. depression, chronic psychosis, dementia, alcohol and substance use disorders, personality disorders, epilepsy

Risk is high in the following cases:

  • Patient >45 years old
  • Alcohol and substance use
  • History of suicide attempts
  • Family history of suicide
  • History of recent loss or disappointment
  • Current mental illness e.g. depression, psychosis
  • Evidence of violent behaviour or previous psychiatric admission

Risk may be low if patient is

  • <45 years old
  • Married or in stable interpersonal relationships
  • Employed
  • In good physical health

Clinical features

Patients can present in one of the following situations:

  • A current suicide attempt or self harm
  • A situation of imminent risk of suicidal attempt or self harm: Current thoughts or plans of suicide/self harm or history of thoughts or plans of suicide/self harm in the last 1 month, or acts of self harm/suicide attempts in the last 1 years plus
    • Person is agitated, violent, emotionally distressed or uncommunicative and socially isolated, hopeless
  • A situation of no imminent risk but
    • Thoughts or plans of suicide/self harm in the last 1 month or acts of self/harm/suicide attempt in the last one year in person not acutely distressed

Investigations

  • Complete medical, social and family history
  • Ask the patient about suicidal or self harm thoughts/plans/ acts and reasons for it
    • Asking about self harm or suicide does not increase the risk of those acts. On the contrary, it may help the patient to feel understood and considered. First try to establish a good relationship with the patient before asking
  • Always assess risk of suicide and self harm in patient
    • With any other mental illness (depression, mania, psychosis, alcohol and substance abuse, dementia,
      behavioural or development disorders)
    • Chronic pain, severe emotional distress

Management


If acute suicidal behaviour/act of self harm or imminent risk

  • Admit the patient and treat any medical complications (bleeding, poisoning etc)
  • Keep in a secure and supportive environment
    • Do not leave patient alone
    • Remove any means of self harm
  • Continuous monitoring
  • Offer/activate psychosocial support
  • Consult mental health specialist
  • Treat any medical and mental condition present

If no imminent risk

  • Offer/activate psychosocial support
  • Refer to mental health specialist for further assessment
  • Establish regular follow up
Note
  • Suicide is less frequent in children and adolescents, but there is increased risk if there is disturbed family
    background (e.g. death of parents, divorce), use of alcohol and other drugs of abuse, physical illness, psychiatric disorder

Prevention

  • Identify and manage risk factors
  • Screening and early identification of patients at risk
  • Ensure good psychosocial support
  • Restrict access to means of self-harm
  • Develop policies to reduce harmful use of alcohol