Suicide Risk: Managing Suicidality

Text adapted from "Assessment and management of suicide risk" in Psychiatry in primary care by Marilyn A. Craven and Paul S. Links,  (CAMH, 2019). 

All people who are suicidal are ambivalent—wanting to die and wanting  to live. Keep in mind that suicidality is a fluid state and can change dramatically in the space of a few hours.

Managing suicidality should focus on various areas:

• Optimize the safety of the person—take steps to have firearms or large amounts of medication removed from the home. If no reliable family member is available or willing to help with this, call local police to assist.
• Communicate concern, caring and support.
• Intervene wherever possible to decrease modifiable risk factors.
• Identify and optimize protective factors.
• Identify coping strategies (e.g., distraction) and self-soothing behaviours (e.g., listening to music, going for a walk).
• Identify people or resources the patient can turn to. Provide a phone number for a local crisis service. Ask the patient’s permission to involve family or friends in the safety plan.
• Remove access to means of suicide.
• Provide immediate symptomatic relief for insomnia, agitation, anxiety.
• Treat identified psychiatric disorders (see Table 2 about managing suicidality in specific psychiatric diagnoses).
• Offer hope of a positive treatment outcome.
• Identify patients who require urgent or emergent consultation.
• Follow up with an ongoing management plan.
• Document the management plan clearly.

Your personal safety is equally important. If a suicidal patient is threatening in any way, remove yourself and others from the situation, and call 911.

Managing the patient with a suicide plan and high intent

If your patient has a plan and tells you that he or she has a strong intent to follow through, or if the plan is highly lethal (e.g., firearm), further questioning is probably not warranted. The patient should be transferred immediately to the nearest emergency room. Document your risk assessment and the steps you are taking to transfer the patient.

Managing the patient with low intent but serious risk factors

If your patient denies a plan, or has low intent to follow through in the short term, but has one or more serious risk factors, request an urgent psychiatric consultation (within 24 to 48 hours). You should also take the following steps:

• Wherever possible (with the patient’s agreement), get corroborative history from family, friends or co-workers to confirm your assessment of risk.
• Remove lethal weapons and medications from the home. Have a responsible family member or friend call you to report that this has been done. If you have reason to doubt that the weapons or medications have been removed, involve the police. Document your actions to reduce the patient’s access to means.
• Ensure that the patient and family know how to reach you and what to  do if suicidal thoughts worsen. Make sure the family knows about crisis services that are available around the clock.
• Provide symptomatic relief (e.g., small quantities of benzodiazepine for agitation or insomnia; prescribe a high enough dose to be effective).
• See the patient the next day to reassess, and then see the patient frequently (as dictated by level of suicidal intent) until psychiatric consultation takes place or the patient’s suicide risk returns to baseline.
• Clearly document your risk assessment, safety plan and management plan in the patient’s chart.
  
  

Table 2 Managing suicidality in specific psychiatric diagnoses