Suicidal Ideation and Intent

Assessment

Rapport and trust

  • Maintain and communicate hope

  • Identify and explore ambivalence

Explain the limits of confidentiality

  • “What you say is confidential unless I believe that you are at serious risk of harm to yourself, harm to otherwise or harm from others”

Understand the limitations of assessment

  • No absolute predictor of suicide

  • Risk fluctuates

Consider asking about suicidal thoughts

  • Previous attempt

  • Self-harm

  • Mental illness

  • The recent loss of a friend or relative to suicide

  • Chronic ill health or pain

  • Major psychosocial stressor

  • Socially isolated

  • Recent discharge from psychiatric care

Ask questions to establish the presence of ideation

  • Thought of hurting yourself?

  • Thought of life not worth living?

Determine the degree of risk

  • Current circumstances and stresors

    • Mental health diagnosis

    • Severity of symptoms

    • Current and past mental health Rx

  • Psychosocial situation

  • Substance use

  • Physical wellbeing

    • Pain

    • Sleep

    • Appetite

  • Available social supports

Risk factors

  • Modifiable

    • Suicidal thoughts, plans, and access to means

    • Feelings of hopelessness, guilt, burden

    • Mental illness

    • Alcohol and substance use

    • Psychosocial pressures

  • Enduring

    • PRevious attempts

    • History of trauma

    • Chronic ill health

    • Male

    • Family history of suicide

    • Rural or remote

    • ATSI

    • Gender identity

Protective factors

  • Aspects of life that provide meaning

  • Sense of purpose

  • Connection with others

    • Family, friends, colleague, pets

  • Family cohesion, peer groups, sense of belonging, willingness to seek help

Plan and intent

  • How often think about suicide

  • Do you have a plan

  • Have you thought through the steps

  • Have you made preparations

    • Note, arranging affairs, measures to prevent discovery

  • How detailed is the plan

    • How lethal the intent

    • Acess to means

Previous ideation and attempts

  • What brought you to this point

  • What was your plan

  • What stopped you from acting

  • Did you seek help

  • How did you survive

Access to means

  • Firearms

Corroborate history

  • Family, partner, friends

Risk assessment

  • Not safe to leave general practice unless accompanied by a mental health practitioner, ambulance officer, or police

  • Safe to leave general practice in the company of responsible adults but requiring assessment within a few hours

  • Safe to leave but requiring assessment within 7 days

  • Safe to leave but requiring non-acute mental health assessment

Management

  1. Consider enacting a schedule under the Mental Health Act 2007 if

    • Delusions, hallucinations, serious thought disorder, severe mood disturbance, or sustained irrational behaviors

    • Mentally ill or mentally disordered

  2. Base decisions on immediate safety

    • Not safe to leave

      • Phone 000

    • Safe with adult

      • ED

    • Safe but review 7 days

      • Local mental health line

    • Safe but review non-urgent

      • Arrange mental health line, psychologist, others

  3. Protective factors

    • Ask about aspects of their life that provide meaning, a sense of purpose, connecting with others, neighbors, pets, family, friends

    • Family cohesions, peer groups, sense of belonging, willingness to seek help

  4. Support and minimise distress

  5. Collaboratively develop a safety plan with the patient, involving family and friends, and ensure that the patient and their support people: 

    Safety plan

    A safety plan:

    • is a tool to actively engage a patient in considering and identifying ways to keep themselves safe.

    • includes a collaboratively written list of coping strategies, including both internal and external sources of support.

    • can be used before or during a suicidal crisis.

    • should be regularly reviewed and updated, reflecting what has and has not worked.

    • is best developed with the patient genuinely engaged in its development, and when the strategies reflect realistic options.

    Consider using the following to develop a safety plan:

    When completing the safety plan, include the following under professional support as appropriate:

    • In an emergency always phone 000 (or present to an emergency department)

    • Lifeline: 13‑11‑14 (24 hours, 7 days)

    • 13YARN: 13‑92‑76 (24 hours, 7 days, crisis support for Aboriginal and Torres Strait Islander patients) 

    • Suicide Call Back Service: 1300‑659‑467 (24 hours, 7 days)

    • MensLine Australia: 1300‑78‑99‑78 (24 hours, 7 days)

    • Kids Helpline: 1800‑55‑1800 (24 hours, 7 days)

  6. Review or start treatment for any underlying mental health problem or modifiable suicide risk factors.

  7. If the patient is on regular medication, consider arranging staged supply with the patient’s pharmacist if indicated.

  8. Consider recommending websites and/or e-mental health services to support self-management. See Patient Information.

  9. Arrange follow-up.

    Follow‑up

    • Make another appointment.

    • Arrange for practice nurse or general practitioner to phone.

    • Referral to appropriate agencies.

  10. Reassess if circumstances change, as suicide risk can fluctuate over time.

  11. Consider offering aftercare postvention support to family, friends, and clinicians for bereavement following suicide.

Resources for patients

Suicide and Self-harm – Black Dog Institute

Mental Health Outpatient and Community Services

Translated resources

Reference