10.5 Assessing the risk of suicide and self-harm
Assessing the risk of suicide is perhaps the most important part of risk assessment. Suicide is an act that cannot be reversed. You cannot do anything for the person once they are dead. The main strategies for suicide, therefore, emphasise effective prevention by identifying and treating people early when they are at risk of committing suicide.
The need to assess the risk arises in two situations:
- when someone has indications of significant mental illness, such as depression or alcohol abuse
- after someone has tried to end their life in the past.
In both these situations, there are some common risk indicators, for example being jobless, of lower educational status and being in either a younger or an older age group. These are discussed in more detail in Study Session 18. The risk of suicide has to be considered to some extent in all cases of mental illness, particularly those priority conditions listed in Box 10.1. The main risk indicators for someone with mental illness are shown in Box. 10.3.
Box 10.3 Suicide risk indicators in people with mental illness
- Suicidal thoughts: if a person tells you they are thinking about suicide, you should take this very seriously; about 66% of those who commit suicide have previously told someone about their intention.
- Severity of mental illness: the more severe the illness, the higher the risk of suicide. Someone young with a severe mental illness like psychosis, may be at increased risk if they have developed awareness about how ill they are; this is particularly the case if they also develop depressive symptoms (Study Session 12).
- Substance misuse: the risk increases when the person also misuses substances like alcohol and khat.
- Social isolation and lack of support: for example, when someone does not have family to care for them, is single, and/or jobless. Marriage reinforced by children is thought to be a protective factor in relation to the risk of suicide.
History of suicide attempts or self-harm: the risk is increased if there have been previous attempts.
The terms ‘self-harm’ and ‘suicide attempt’ are used here interchangeably.
When someone has already attempted suicide, their risk of suicide is about 100 times higher than that in the general population. This risk is particularly high in the first year after the original attempt. It is therefore crucial that you closely monitor the risk of suicide after an attempt has been made. Be open with the patient, asking about the risk as a matter of fact.
Most people who self-harm do not intend to kill themselves or end their life. In low-income countries like Ethiopia, many die even when they don’t intend to do so. This is because the methods they use to self-harm are dangerous. For example, certain poisons, such as pesticides used by farmers, are fatal if swallowed unless the person gets immediate medical help – which is not available in most rural communities.
In Ethiopia, up to 20% of individuals self-harming may end up dying. This figure is about 1% in high-income countries. It is therefore important to identify people who self-harm. Box 10.4 lists some factors that indicate a risk for serious self-harm. Establishing the intent of the person when they self-harmed (whether they were intending to die, or self-harming to indicate their mental distress), gives you a good clue about future risk. If there are indicators of a serious intent to end their life, the risk of successful suicide in the future is high.
Box 10.4 Risk indicators for life-threatening self-harm
- Preparation for self-harm: someone who has taken time to plan, considered the consequences of their actions, said goodbye to people or taken precautions to avoid being discovered by others represents a much higher risk than a person who self-harms without much thinking about it (i.e. self-harm as an ‘impulsive’ act).
- Seriousness of the method used to self-harm: violent methods such as hanging, stabbing or throwing oneself into deep water are considered serious and indicate higher risk.
- Current mental illness: at least 60% of people who self-harm have some form of mental illness.
- Factors that reduce self-control: the use of alcohol or other drugs, or having an impulsive personality, reduce self-control and increase the risk of serious self-harm.
- Presence of ongoing ‘real life’ difficulties: marital problems, financial problems, difficulties at work, or other problems in daily life increase the risk of self-harm.
Note that the factors described in Box 10.3 are also important.
10.4.1 The main risks in mental illness