Definitions for the Levels of Evidence (1++ to 4) and Grades of Recommendation (A to D, and Good Practice Points [GPP]) are given at the end of the Major Recommendations field.
Risk Factors
D Anyone who talks about suicide needs to be taken seriously. People who die by suicide have often expressed suicidal thoughts or displayed warning signs to families or health professionals.
GPP All people who report self-harm or suicidal intent should be treated as being in a state of potential emergency until clinicians are convinced otherwise.
Establishing a Therapeutic Alliance
GPP A key component to working with anyone who presents in a state of distress following a suicide attempt or expressing suicidal ideation is the conscious attempt to establish rapport with that person. This facilitates their disclosure of information and may serve as a protective factor by encouraging a sense of hopefulness and connectedness.
The Challenge of Working with People who Self-harm or Attempt Suicide
GPP All clinicians who work with people who self-harm or are suicidal should be in regular clinical supervision to mitigate the negative impact that this work can have both on them and on the quality of their work with suicidal people.
Involving Whanau/Family Support People of the Suicidal Person
GPP Whenever possible clinicians should involve whanau/family/support people/carers of the suicidal person when working with that person. This is equally true for the assessment component, crisis management, and subsequent treatment. At any time families can give information to the clinician without it compromising the person's privacy.
GPP If a person who is considered acutely suicidal declines involvement of others, the clinician may override that refusal in the interest of keeping the person safe.
Assessment of Suicide Risk
D Anyone who seeks assistance from an emergency department following an act of deliberate self-harm, irrespective of intent, or who is expressing suicidal ideation, should be further evaluated by a suitably trained mental health clinician.
GPP Culturally appropriate services should be involved with assessment, crisis management, and service liaison where possible, and if agreed to by the suicidal person.
GPP A suicide assessment should be conducted in a separate interview room that allows the person privacy when disclosing sensitive material.
GPP There is no evidence to suggest that directly asking about the presence of suicidal ideation or intent creates the risk of suicide in people who have not had suicidal thoughts or worsens the risk in those who have. It is more likely that a calm and matter-of-fact approach discussion of suicidality may allow people to disclose their previously "taboo" thoughts.
Assessment of Suicidality by Emergency Departments
Triage
GPP No person who has attempted deliberate self-harm or who is expressing suicidal ideation should be categorised to triage category 5 (i.e., waiting beyond one hour to be seen by a doctor).
General Assessment Principles
C Case notes should be augmented with structured assessments.
C Training in suicide assessments should be provided to all appropriate staff.
Medical Clearance
D Emergency department staff are encouraged to use the triage protocol described (see page 12 in the original guideline document) and the Rapid Assessment of Patients in Distress (RAPID) assessment tool (Appendix 1 in the original guideline document) to assess the urgency of need for mental health referral and security measures.
GPP Clinicians should maintain a high index of suspicion when a person arrives following an overdose. People will often under-report quantities consumed.
Sedation
C Acute sedation with medication may be necessary if the person shows violent or agitated behaviour or symptoms of psychosis. Consider prescribing an antipsychotic (such as haloperidol) or a short- to medium-term benzodiazepine (such as lorazepam which has a short half-life, or clonazepam which is presently the only intra-muscular benzodiazepine available). A full assessment must then be resumed.
A Haloperidol is contraindicated where the person is depressed or has central nervous system (CNS) depression due to drugs or alcohol.
GPP Haloperidol can cause painful dystonic reactions for some people, particularly among people who have never taken an antipsychotic before. In such cases, the co-prescription of an anticholinergic agent (such as benztropine) is advised. The newer antipsychotic medications have not yet been formally evaluated for use in this setting.
GPP Benzodiazepines should only be used for sedation as a short-term measure. They must be administered under supervision.
GPP Check for allergic reactions to some sedating drugs. Ask the person or obtain file notes.
GPP If a person has been sedated and then needs to be transported to another place for assessment, medical support must be provided during transit. The accompanying clinician needs to be aware of potential medical complications of sedation (e.g., respiratory arrest following intravenous benzodiazepine use).
Assessment of Intoxicated People
GPP People who present to emergency departments with suicidal ideation or following a suicide attempt whilst intoxicated should be provided with a safe environment until they are sober. Assessment should focus on their immediate risk (whilst they are still intoxicated). Enduring risk cannot be judged until the person is sober.
GPP People at risk of suicide should be strongly advised to stop using alcohol or illicit drugs due to their potential disinhibiting effects. Whanau/family members should also be told of this.
Referral to Mental Health Services
GPP Mental health services should at least be contacted (or existing management plan consulted) by the assessing emergency department clinician whenever suicidal ideation, intent, or a suicide attempt or self-harm is present.
Detailed Suicide Assessment/Assessment by Mental Health Services
Key Components of a Psychiatric/Psychosocial Assessment
B When conducting an assessment of suicide risk always be mindful of the presence of concomitant mental illness, particularly the following diagnoses, which are associated with increased risk.
- Major depression - acute risk factors: severe anhedonia, insomnia, anxiety, substance abuse.
- Substance abuse - acute risk factors: comorbid depression, recent interpersonal loss or disruption.
- Schizophrenia - acute risk factors: age <40, chronicity of illness with frequent exacerbations, awareness of deterioration and poor prognosis, depression.
- Borderline Personality Disorder or Antisocial Personality Disorder - acute risk factors: comorbid Axis I disorders, particularly depression.
Use of Screening Measures
B The Beck Hopelessness Scale has the best generic application for screening for suicide risk amongst adults, adolescents, inpatients, outpatients, and people seeking assistance from emergency departments.
Formulating Risk
GPP Mental state and suicidal ideation can fluctuate considerably over time. Any person at risk should be re-assessed regularly, particularly if their circumstances have changed.
Crisis/Initial Management
D The presence of a "safety contract" does not in any way guarantee the person's actual safety. There is no evidence that it acts as a deterrent to suicide.
Management as an Outpatient
A Providing people with "green cards" (24-hour access to a crisis team) is a useful but insufficient treatment strategy, and other interventions should also be provided.
The Decision to Hospitalise
D The following people with suicidal ideation should be admitted when:
- they are acutely suicidal
- medical management of an attempt is required
- they require more intensive psychiatric management
- the establishment of a treatment alliance and crisis intervention fails and the person remains acutely suicidal
D When no suitable caregivers/support people are available, respite care options may be considered as an alternative to admission.
A In order to reduce the person's risk of suicide, admission should be for more than 4 days.
C For a chronically suicidal person short admissions (1- 4 days) may be appropriate.
GPP If the person is not admitted, appropriate arrangements must be made for timely follow-up with the relevant health provider (e.g., care manager, therapist) within 24 hours.
GPP The reasons for not admitting must be clearly documented in the person's file.
Management as an Inpatient
GPP People assessed as being at high risk of suicide should be under close supervision. (See Appendix 6 in the original guideline for guidelines for supervision.)
GPP The level of support and observation should reflect the person's changing suicide risk.
C Inpatient unit staff need to be vigilant, particularly when the person is not well-known and for the first week after admission.
D Treatment (both psychopharmacological and psychological) of underlying mental illnesses should be initiated as early as possible.
Discharge Planning
A Follow-up should occur in the first week post-discharge, as this is the highest risk time for a person discharged from hospital. This should happen even if the person fails to attend their outpatient appointment.
D If the person does not attend their follow-up appointment and is believed to still have a significant risk of suicide, the clinician must make efforts to contact that person immediately to assess their risk of suicide or self-harm.
GPP The discharge plan should be developed in consultation with the person and their key support people (including whanau/family if appropriate) and clinicians.
GPP Before leaving the hospital the person should have a clear understanding of discharge arrangements that have been made and a written copy with information about medication, treatment plans, and key contacts to call, if needed.
GPP If appropriate, the person's whanau/family or nominated next-of-kin should be informed of the person's risk, told of their next appointment, and invited to attend. They should also be involved in discharge planning processes.
GPP The continuing care provider/team must get at least a verbal report prior to discharge. They should also be included in any discharge planning meetings/decision-making processes.
GPP The person's general practitioner should also get a full copy of the discharge plan, including any medication recommendations. If the general practitioner is the sole care provider, he/she should receive this prior to the person's discharge from hospital.
Intervention/Treatment Strategies
A Follow-up by the same therapist across inpatient and outpatient settings results in people at risk of suicide being more likely to agree to take medication and to attend appointments.
Prescribing Issues
C Clinicians should be cautious when prescribing benzodiazepines (both acutely and in the medium-term), especially if the person may also be suffering from depression or have risk factors for suicide.
C Clinicians need to monitor suicide risk closely irrespective of the antidepressant/drug used. This is essential both to rule out any paradoxical increase in suicidality and also to ensure that risk does not increase as the treatment begins to work, relieving the motor symptoms and lack of drive first, but not the mood related symptoms.
GPP In general, if a person is suspected of being at risk of suicide, appropriate medications should be prescribed and dispensed in dosages and quantities that are less likely to be lethal in overdose or in combination with other drugs or alcohol.
Assessment and Crisis Management with Special Populations
Children and Adolescents
D The assessment of suicidal young people should be carried out by a clinician who is skilled in interviewing and working with children and adolescents whenever possible.
D Self-harm among children is rare and should be treated very seriously.
GPP Risk assessments should draw on information from multiple sources, including the young person, their teachers/guidance counselors, parents etc.
The Elderly
GPP Any elderly person who is expressing suicidal ideation or has presented following an attempt should be treated very seriously. The clinician should consider whether the symptoms could be related to self-neglect or reflect a passive death wish.
GPP Clinicians should treat symptoms of depression in an older person assertively. If depression and/or suicidality is suspected, physical causal factors need to be ruled out.
GPP Assessments should also draw on information from relatives or friends who can comment on whether the person is different from "their usual self."
Maori
GPP Assessment of Maori people requires consideration of their cultural context and meaning associated with their identity as Maori. Specialist Maori input is important when cultural issues or issues of identity arise among tangata whaiora. Maori people who are suicidal should be offered the input of specialist Maori mental health workers.
GPP People's preference should be sought and respected for involving whanau or support of others in assessment and developing a treatment/management plan.
Pacific Peoples
GPP Assessment of Pacific peoples requires consideration of their Pacific cultural contexts and beliefs. Specialist Pacific input is important when cultural issues or issues of breaches of protocol are present among Pacific peoples. Pacific peoples who are suicidal should be offered the input of specialist Pacific mental health workers.
GPP Pacific peoples' preference should be sought and respected for involving family or support of others (e.g., church leaders, traditional healers) in assessment and developing a treatment/management plan.
GPP Language barriers may be an issue for some Pacific peoples. Care must be taken in ensuring confidentiality when interpreters are used due to the small size of Pacific communities and the shame associated with suicide and attempted suicide among Pacific peoples.
People of Indian Descent
GPP Indian people come from many diverse cultures, and assessment should acknowledge their specific cultural contexts and beliefs.
GPP Indian people consider family roles and obligations of primary importance, and assessment should acknowledge their needs within the context of their family.
GPP Problem-solving, psycho-education, and the use of trusted intermediaries can help counter some of the shame or "loss of face" associated with mental illness.
Asian Populations
GPP Cultural values and beliefs vary depending on the person's subculture and degree of acculturation to Western values. Even if the person identifies themselves as a New Zealander, it is still important to check the cultural values of their family and significant others, as a gap in views can be a source of stress.
GPP Language barriers may be an issue for some Asian people. Care must be taken in ensuring confidentiality when interpreters are used due to the small size of Asian communities.
GPP When working with someone from an Asian community the clinician should consult culturally appropriate services to assist in intervening in helpful ways.
Refugee Groups
GPP Refugees are most likely to have been victims of some level of trauma. They may be distrustful of official agencies and health systems. Clinicians need to proceed respectfully and carefully, explaining the intention behind any action and potential consequences for the person. Clinicians should not push for accounts of past trauma experiences, and may need to focus more on the "here and now."
GPP If an interpreter is needed, care must be taken over confidentiality issues as many of the communities are small and people may know each other.
GPP Serious consideration should be given to referring refugees with mental health difficulties to specialist agencies such as Refugees as Survivors.
Assessment and Management of Chronically Suicidal People
C Detailed management plans that list both chronic and acute symptoms should be developed with the person. This assists clinicians in determining whether a person is presenting with new/greater risk than their ongoing risk. All services working with this person should have a copy of these plans, and they should be regularly reviewed and updated.
C Emergency departments should always contact mental health services (even if only by phone) when a chronically suicidal person presents. Care must be taken not to downplay the seriousness of attempts.
D When a person who is well-known to the service arrives at the emergency department, it is crucial that their file is obtained, their management plan consulted, and ideally their case manager or therapist contacted in case they are now suffering from additional stressors or a significant change in their mental illness(es).
D Inpatient admission or referral to high support services (such as crisis respite) may be necessary when the person's suicidality is exacerbated by an acute life stressor, or if they also develop an Axis I disorder.
Definitions:
Levels of Evidence
1++
High quality meta-analyses/systematic reviews of randomised controlled clinical trials (RCTs), or RCTs with a very low risk of bias
1+
Well-conducted meta-analyses/systematic reviews, or RCTs with a low risk of bias
1-
Meta-analyses/systematic reviews, or RCTs with a high risk of bias
2++
High quality systematic reviews of case-control or cohort studies
High quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+
Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-
Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3
Non-analytic studies (e.g., case reports). Case series
4
Expert opinion
Qualitative material was systematically appraised for quality, but was not ascribed a level of evidence.
Grades of Recommendations
A
At least one meta-analysis, systematic review, or randomised, controlled clinical trial (RCT) rated 1++ and directly applicable to the target population
or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B
A body of evidence consisting principally of studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results
or
Extrapolated evidence from studies rated as 1++, or 1+
C
A body of evidence consisting principally of studies rated as 2+, directly applicable to the target population, and demonstrating overall consistency of results
or
Extrapolated evidence from studies rated as 2++
D
Evidence level 3 or 4
or
Extrapolated evidence from studies rated as 2+
Additionally, Good Practice Points are recommended as the best practice based on the clinical experience of the guideline development team.
