Connecting with People Emotional Resilience and Suicide Awareness Training Comprises A
Details of what led up to current suicide attempt/self-harm:
Any precipitating factors that day? (e.g. Argument, alcohol, received bad news )
What has been difficult in the last few weeks/months? (e.g. Debts, relationship breakdown, depression, domestic violence or other problems, deteriorating physical illness)
Date of last self-harm/suicide attempt?
Method used:
What taken/done
Perceived lethality of method chosen and perceived possible rescue/treatment
Important:*methods which imply high intent e.g. hanging, jumping off bridgeetc.
Perceived lethality for other methods
*Is there a high extent of planning and preparation signifying high suicide intent?
Such as: will, affairs in order, a suicide note, texts, internet search re methods etc?
Was this out of character e.g. impulsive
(ask informant if available)
Did they secure the means specifically for the suicide attempt/self-harm?
*High self-report suicide intent: Attempts not to be discovered, high perceived lethality.
What were they thinking at the moment of self-harm/suicidal act?
Any boundaries in place to ensure safety or possibility of rescue?e.g. someone close by, informed someone, did not use all available means, depth of cut, number, size and position of cuts etc.
Beware as proposed method can easily change from a low lethality method to a high lethality method
*Availability of lethal means and have steps been taken to ‘disarm’ or remove the method
Area 2: Mental State Examination & Current suicidal thoughts
Any symptoms of a mental illness?
Depression or psychosis?
Symptoms of depression:
Low mood, sleep & appetite changes, low motivation, lack of ability to enjoy life, feeling negative and pessimistic, difficulty seeing a future, not usual self
Symptoms of psychosis (see below)
NICE Depression Guidelines 2 screening Questions:
During the last month, have you often been bothered by:
– feeling down, depressed or hopeless?
– having little interest or pleasure in doing things?
Mental State Examination
Appearance &behaviour?
(Such as:Agitated, restless, withdrawn, distractible, pacing, unable to stay seated, trying to leave, good self-care, unkempt, tremulous, sweaty)
Mood? Include RANGE of emotions (normal/flat, labile) and TYPE of emotions (sad, elated, irritable, suspicious, perplexed)
Objective (your assessment):
Subjective (patient’s self-report):
Current suicidal thoughts &attitude to suicide attempt/self-harm?
*Do they regret surviving their suicide attempt?
Any psychotic features:Screen for undiagnosed psychotic illness:‘Have you had any unusual experiences recently that you find hard to explain?’
‘Do you think that you have been experiencing things that other people do not seem to experience such as feeling, hearing or seeing things that no one else does?’
If ‘yes’ Illicit any details
Symptoms of psychosis if screen positive or in history
Behaviours & emotions documented above (e.g. Perplexed, distractible, suspicious)
Perceptions (Hearing voices, seeing things)
Delusions (Believes things, such as being hunted or controlled or having special powers, that do not fit available evidence or culture)
Insight?
Area 3: Risk Factors and Warning signs indicated by *
Indicate when a patient requires urgent specialist advice/input:
* Regret surviving and/or well-formed suicidal plans and preparationsrecent worsening with distress Use of suicide promoting websites.
*Hopelessness:especially if only able to see a brief future, ‘nothing to live for’, guilt, ‘I’m a burden’
*Psychotic phenomena,especially if distressing:persecutory & nihilistic delusions; command hallucinations perceived as omnipotent
*Pain/chronic medical illness
*Perception of lack of social support:no confidants;Major relationship instability; Recently bereaved
*Sense of ‘entrapment’Do they feel ‘overwhelmed’ by their problems?
*Recent or current disinhibiting factors
i.e. intoxication; substance use may make them more likely to act on suicidal thoughts / N.B. See Connecting with People risk factor table for additional information
Demographic risks
Male ,younger men and very elderly (but recent ↑ men aged 35-55)
Marital status: separated > divorced > widowed > single > married; Unemployment
Population level risk Factors
Lack of Social Capital: Social isolation and living alone;
Institutionalisation e.g. prison; recently leaving armed forces
Abusive relationships (past/current) e.g. childhood abuse, domestic violence
Access to lethal means:e.g. Firearms; dentists, doctors (esp. anaesthetists); suicide ‘hot spots’
Past Psychiatric History:
Previous self-harm especially if of a high suicide intent, Current treatment for a mental disorder by GP or mental health services/mental health diagnosis/ recentdischargefrom general / psychiatrichospital
Family history:
Bereaved by suicide: relative (also close friend, co-worker)
Family History mental illness, particularly alcoholism and Bipolar Affective Disorder
Substance abuse: drugs &/or alcohol
Especially if: High level of dependency, Long history of drinking
Binge drinking, depressed mood, poor physical health
Area 4: Protective factors & suicide mitigation
Protective Factors
Do they have any emotional support?
Do they have any supportive confidants?
Ability to consider other alternatives to self/harm or suicide?
Have they managed to resist acting on previous suicidal thoughts – how?
Clinical Summary
Clinical impression of immediate suicide risk
Refer to Cole-King Classification for additional info
Clinical Suicide Mitigation plan and Safety plan for ED
To help patient to resist acting on their suicidal thoughts whilst waiting for review. Include all available support
If staying in ED for assessment
Ensure patient in a safe environment, aware of waiting time named nurse.
When leaving ED please ensure:
Has patient received ‘on the Edge: Helping you through it’ and/or ‘Feeling overwhelmed and staying safe’ leaflets?
Who will support them?
Details of follow up appointment?
Connecting with People Emotional Resilience and Suicide Awareness training comprises a series of peer reviewed and independently evaluated 2 hour modules, ideally suited to CPD and in-house training sessions. Participants will be able to develop a compassionate approach suitable for a demanding and time-pressured environment. At the end of the modules participants will be able to use the clinical resources to enhance their assessment and response to a suicidal patient. They will be able to undertake a safe triage and referral if appropriate, reduce their patients’ distress, and collaboratively create a safety plan to increase their patients’ resilience to suicidal thoughts (
4 Area assessment for patients with suicidal thoughts or following self-harm presenting to ED Copyright © A Cole-King & S Wadman Connecting with People, H Hughes,J Bethel, M Dennis, J Butler & A John 2011