Chapter 13 Risk of suicide
Although the risk of violence has seemed to generate more interest within mental health settings over the last few decades, the risk of suicide is one which general mental health clinicians are much more likely to have to deal with on a regular basis. The links between suicide and mental illness are much closer than those between violence and mental illness. It is a given that mental health clinicians should have a solid grounding in the assessment and management of suicide risk. Although there is no substitute for the experience gained from time spent assessing and managing suicidal patients, the assessment skills can be taught and there is a large body of knowledge available in this area.
Although suicide is a relatively rare event, it is a devastating event for those close to the person who died. The low base rate of suicide makes it difficult to predict such a tragedy. Suicide is generally, although not always, associated with mental illness and ‘effective treatment can reduce or abolish the risk of suicide in those cases’.1
Assessment
The assessment of suicide risk is similar to the assessment of other risks and includes a need for:
• a good rapport with the patient
• sensitivity, but also a willingness to ask difficult questions in order to be able to deliver good treatment.
Many junior clinicians (and some senior) are reluctant to ask patients too many questions about their suicidal intent, usually out of a mistaken concern that they will upset the patient. It is vitally important to remember that there is no evidence that assessing suicidality increases the risk in any way whatsoever. In practice, the process of catharsis is often healing and will reduce the risk in some instances. Once sufficient rapport has been established, clinicians should not avoid asking questions in as much detail as is necessary to fully assess the risk.
Assessment of suicide risk as an outpatient is essentially an exploration of the risk factors but, for an inpatient, there are a few added complications that need to be borne in mind. For inpatients, the assessment of risk should be repeated at clearly defined intervals. There should be agreement within the treatment team that as far as possible, the same clinician or clinicians should be responsible for reassessing the risk. For some inpatients, if the risk is assessed too frequently, the patient can become irritated with the process and may begin to withhold information. Finding the balance between sufficiently frequent assessments and not overdoing it can be difficult. Being mindful of times of increased risk, such as improving from a psychomotor retarded depression, shift changes, or at the time of discharge from hospital is important. It is also important to bear in mind that for some patients, the objective signs of improvement can in reality be an indication that the patient has attained some peace of mind by having finally decided how and when to complete the suicidal act. Once again, good and thorough assessment can help. Occasionally, staff on a ward may find a particular patient difficult and find themselves unwittingly creating the same sense of alienation that the patient experienced in their own home (malignant alienation2,3). This is highly dangerous and there should be processes set up to reduce the likelihood of this happening.
Relying on intuition or using the phrase ‘I have a gut feeling that they are suicidal’ is poor practice and should be avoided.
