Suicide

Overview – Suicide

Suicide is a leading cause of preventable death worldwide and a critical focus within psychiatry and general medical practice. It requires urgent attention due to its strong association with psychiatric disorders, substance use, psychosocial stressors, and chronic medical illnesses. Effective suicide prevention hinges on routine screening, risk stratification, and timely intervention, especially in high-risk groups.

This guide outlines key elements of suicide risk assessment, clinical features, and management strategies relevant for final-year medical students and frontline clinicians.

Screening for Suicide

• All patients should be screened, regardless of presenting complaint.
• Opening question: “Have you had any thoughts of wanting to harm or kill yourself?”

Suicidal Ideation

• Passive Ideation: Wishes they were dead, but no plan
  • E.g. “I wouldn’t mind if a car hit me”
• Active Ideation: Thoughts of killing oneself
  • E.g. “I think about ending my life”

Suicide Risk Assessment

• Plan: “Do you have a plan for ending your life?”
• Intent: “Do you think you would carry it out?”
• Previous Attempts: Particularly within the past 12 months

Probing Current Ideation

• Onset & frequency
• Coping strategies
• Suicidal intention
• Perceived lethality
• Access to means
• Chosen time/place
• Triggers/worsening factors
• Protective factors: Family, pets, religion, therapeutic relationships
• Final arrangements: Suicide note, will, gift-giving
• Practiced/aborted attempts
• Ambivalence: Ask gently if a part of them still wants to live

Suicide Attempt Assessment

• Setting: Public vs. isolated
• Planning: Impulsive vs premeditated
• Substance use during attempt
• Method of seeking help: Self vs. others
• Delay in ED arrival
• Expectations of lethality
• Reaction to survival: Relief vs. disappointment

Common Clinical Presentations

• Hopelessness
• Anhedonia
• Insomnia
• Severe anxiety or panic attacks
• Poor concentration
• Psychomotor agitation

Risk Factors – ‘SADPERSONS’ Mnemonic

• S – Sex (male)
• A – Age > 60 years
• D – Depression
• P – Previous suicide attempt
• E – Ethanol abuse
• R – Rational thinking loss (psychosis, hopelessness)
• S – Suicide in family
• O – Organised plan
• N – No spouse or social support
• S – Serious illness or chronic pain

Management of Suicidal Patients

High Risk

• Active suicidal ideation + plan + intent
• Access to lethal means
• Recent psychosocial stressors
• May require:
  • Involuntary admission under mental health legislation
  • Close monitoring (never left alone)
  • Removal of dangerous items

Lower Risk

• No plan or intent
• Discuss protective factors
• Create a safety plan:
  • Agreement not to self-harm
  • Avoid alcohol or drug triggers
  • Schedule prompt follow-up
  • Contingency steps:
    • Contact healthcare provider
    • Call a crisis line
    • Present to ED if condition worsens

Suicide with Comorbid Psychiatric Disorders

• Depression:
  • May require SSRIs/SNRIs
  • Consider hospitalisation if severe
• Alcohol misuse:
  • Thiamine replacement
  • May need supervised withdrawal with benzodiazepines
• Schizophrenia/Psychosis:
  • Consider urgent hospitalisation for safety and treatment

Summary – Suicide

Suicide is a medical emergency requiring structured screening, accurate risk assessment, and rapid response, especially in high-risk individuals. Final-year medical students should be confident in recognising warning signs, evaluating risk, and implementing safety plans or hospitalisation where needed. For a broader context, see our Psychiatry & Mental Health Overview page.