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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

10.2 Suicide

There is a lack of evidence for the routine screening of patients using a screening instrument (C). GPs should be alert for higher-risk individuals and the possibility of suicide in these patients. There is evidence that detecting and treating depression has a role in suicide prevention.44,45 For example, the incidence of suicide has decreased in older men and women in association with exposure to antidepressants.31,46

Table 10.2.1. Suicide: Identifying risk
Who is at risk?What should be done?How often?
Average risk
General population47, 48 No routine screening for suicide (III, C) N/A
Increased risk
Attempted suicide is a higher risk in the following factors31, 44, 48, 49:
  • mental illness, especially mood disorders, and alcohol and drug abuse
  • previous suicide attempts or deliberate self-harm
  • male
  • young people and older people
  • those with a recent loss or other adverse event
  • patients with a family history of attempted or completed suicide
  • Aboriginal and Torres Strait Islander peoples 50
  • widowed 51
  • living alone or in prison 35
  • chronic and terminal medical illness
  • in the 12 months following discharge from a psychiatric hospital
  • women experiencing intimate partner violence
  • lesbian, gay and bisexual people
Be aware of risk factors for suicide (III, C) Opportunistically
Table 10.2.2. Tests to detect suicide risk
TestTechnique
Evaluate the risk of suicide in the presence of risk factors Assessment of risk involves enquiring into the extent of the person’s suicidal thinking and intent, including the following: 41
  • Suicidal thinking – If suicidal thinking is present, how frequent and persistent is it?
  • Plan – If the person has a plan, how detailed and realistic is it?
  • Lethality – What method has the person chosen and how lethal is it?
  • Means – Does the person have the means to carry out the method?
  • Past history – Has the person ever planned or attempted suicide?
  • Suicide of family member or peer – Has someone close to the person attempted or completed suicide?
Consideration should also be given to:
  • risk and protective factors
  • mental state – hopelessness, despair, psychosis, agitation, shame, anger, guilt, impulsivity
  • substance use – current misuse of alcohol or other drugs
  • strengths and supports – availability, willingness and capacity of supports
For all patients with suicidal ideation, enquiry should be made regarding preparatory actions (eg obtaining a weapon, making a plan, putting affairs in order, giving away prized possessions, preparing a suicide note)
Screening for psychological distress in young people The HE2ADS3 tool has questions that can assist in assessing suicide risk. 40

For example:
  • Sometimes when people feel really down, they feel like hurting or even killing themselves. Have you ever felt that way?
  • Have you ever deliberately harmed or injured yourself (eg cutting, burning or putting yourself in unsafe situations, such as unsafe sex)?
  • Do you feel sad or down more than usual? How long have you felt that way?
  • Have you lost interest in things you usually like?
  • On a scale of 1 to 10, with 1 being the worst you feel and 10 being really great and positive, how would you rate your mood today?

References

  1. Siu AL, US Preventive Services Task Force. Screening for depression in adults, US Preventive Services Task Force recommendation statement. JAMA 2016;315(4):380–87.
  2. King M, Semlyen J, Tai SS, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry 2008;8:70.
  3. McDermott B, Baigent M, Chanen A, et al. Clinical practice guidelines: Depression in adolescents and young adults. Hawthorn, Vic: beyondblue, 2010.
  4. Arroll B, Goodyear-Smith F, Kerse N, Fishman T. Effect of the addition of a ‘help’ question to two screening questions on specificity for diagnosis of depression in general practice: Diagnostic validity study. BMJ 2005;331(7521):884.
  5. Austin MP, Highet N, the Guidelines Expert Advisory Committee. Clinical practice guidelines for depression and related disorders – anxiety, bipolar disorder and puerperal psychosis – in the perinatal period. A guideline for primary care health professionals. Hawthorn, Vic: beyondblue, 2011.
  6. Gaynes B N, West SL, Ford CA, Frame P, Klein J, Lohr KN. Screening for suicide risk in adults: A summary of the evidence for the US Preventive Services Task Force. Ann Intern Med 2004;140(10):822–35.
  7. Goldney RD. Suicide prevention: A pragmatic review of recent studies. Crisis 2005;26(3):128–40.
  8. Hall W, Mant A, Mitchell PB, Rendle VA, Hickie IB. Association between antidepressant prescribing and suicide in Australia, 1991–2000 trend analysis. BMJ 2003;326(7397):1008–12.
  9. Goldney RD. Suicide prevention. Oxford, UK: Oxford University Press, 2008.
  10. LeFevre ML, US Preventive Services Task Force. Screening for suicide risk in adolescents, adults, and older adults in primary care: US Preventive Services Task Force recommendation statement. Ann Intern Med 2014;160(10):719–26.
  11. US Preventive Services Task Force. The guide to clinical preventive services 2014: Recommendations of the US Preventive Services Task Force. Rockville, MD: US Preventive Task Force. 2014. Available at www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/index.html [Accessed 1 November 2015].
  12. Large MM, Nielssen OB. Suicide in Australia: Meta-analysis of rates and methods of suicide between 1988 and 2007. Med J Aust 2010;192(8):432–37.
  13. World Health Organization, Department of Reproductive Health and Research London School of Hygiene and Tropical Medicine, South African Medical Research Council. Global and regional estimates of violence against women. Prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: WHO, 2013.
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