BMJ: A series of unfortunate events


I have had an educational piece published in the BMJ today.  You can read it free of charge in the published form here.   It took me an exceptionally long time to write.


Endgames case report: “A series of unfortunate events”

Stephen Ginn, psychiatry core training year 3
Ladywell Unit, Lewisham Hospital, London SE13 6LH

A 24 year old man presented to the accident and emergency department because he had been planning to take an overdose, but had decided instead to seek help from mental health services. He had intended to take the contents of several blister packs of paracetamol, together with alcohol. He had been having suicidal thoughts for a week but they had become particularly pronounced over the past two days.

His recent history was one of a “series of unfortunate events” that had left him feeling desperate. Four months ago his flatmate stole money from him, which meant that he was unable to repay several loans. His debtors had started to threaten him and he had been forced to move to a different city and leave his job. He had become socially isolated, and continuing financial difficulties had resulted in poor relations with his new landlord. Just before his presentation he had been awaiting a cheque for housing benefit. However, this had not arrived, and he described this as “the last straw.” He reported feelings of hopelessness and thoughts of “what’s the point?”

He had no history of suicide attempts, self harm, or suicidal thoughts. Five years previously, however, he was admitted twice to a psychiatric ward with psychotic symptoms associated with the use of cannabis. Currently there is no evidence of psychosis, and no relevant medical history. He came to hospital on his own, but a friend provided a collateral history on the telephone. The patient says that if he goes home he is worried that he will take the large amount of paracetamol tablets that await him there.


1 How would you assess his risk of suicide?
2 How would you manage this patient?
3 What are the general principles of suicide prevention?


1 How would you assess his risk of suicide?

Short answer:
The likelihood of future suicide should be estimated during an unhurried and sympathetic interview by establishing the motivation for, and circumstances of, the suicidal ideas or act in question, as well as the presence of known risk factors. It is useful to obtain a collateral history from a friend or relative if possible. The three most important risk factors for future suicide are current suicidal intent, history of suicide attempts, and presence of a psychiatric disorder. Once you have inquired after risk factors and have an understanding of the patient’s circumstances you should be able to form an opinion on the patient’s suicide risk.

Long answer:
A suicide risk assessment is normally performed in hospital by psychiatric trainees or psychiatric liaison nurses, although knowledge of risk assessment with suicidal ideation is useful for doctors working in all specialties. This answer is written from the perspective of a psychiatric trainee conducting an assessment in hospital, but assessments elsewhere and under other circumstances follow the same principles.

Before assessing a patient you should establish his or her state of physical health and, if appropriate, level of intoxication. The appropriateness of assessing a patient who is physically unwell, or compromised through drug or alcohol use, is often a cause of friction between psychiatric and non-psychiatric professionals. It may be wise not to see patients who are acutely physically unwell until they have improved, because their physical health may be a more pressing concern and may prevent a satisfactory assessment. However, if the patient is physically stable, then their physical problems need not be a barrier. Although it may not be safe to wait until someone is no longer intoxicated before they are seen, an assessment of mental state performed under these circumstances should ideally be repeated.

When assessing a patient for suicide risk your main task is to gather information that will help you decide whether a future suicide attempt is likely. The first major area to cover in the assessment is the context in which the patient’s suicidal act took place and the motivation behind it. This involves a detailed review of events leading up to the act, the act itself, and the circumstances under which the patient came to hospital. Life events typically precede suicidal acts, with disruption of a relationship with a partner being particularly common.1 The features of the circumstances surrounding the act provide an indication of seriousness and hence chance of it being repeated. The tableGo lists features of an attempt that suggest high and low risk of repetition.

Once the circumstances surrounding a suicidal act have been established, specific risk factors for future suicide must be explored.

The main risk factors indicating continued high risk are:

  • A statement of continued intent. Although clinicians may be reluctant to ask such a blunt question, patients are often surprisingly open about their current state of mind.
  • History of previous suicidal behaviour. Many people who complete suicide have made a previous attempt, and a history of self harm or suicide attempts is present in at least 40% of cases.3 You will need to ask details about previous attempts, such as whether hospital admission was necessary?
  • Presence of a psychiatric disorder. About 90% of people who have completed suicide have a psychiatric disorder at the time of death.3 Affective disorder carries the highest risk of suicide, followed by substance misuse (especially alcohol), and schizophrenia; comorbidity greatly increases risk.3 A key factor linking depression to suicidal acts is hopelessness or pessimism about the future, and this should be included in the history taking.4

To establish the presence of a psychiatric disorder an assessor should inquire after the common symptoms of psychiatric disease, any contact with mental health services, and whether any psychiatric drugs are being prescribed. Clinical descriptions and diagnostic guidelines for mental and behavioural disorders are found in ICD-10 (International Classification of Diseases, 10th revision).5

Once these three main risk factors have been dealt with, further risk factors associated with suicide are:2

Age 25-54 years

  • Male sex
  • Unemployed or retired
  • Poor physical health
  • Separated, divorced, or widowed
  • Living alone
  • Lower socioeconomic class
  • Criminal record
  • History of violence.

Scales are available to help assess the risk factors for suicide, such as the Beck suicidal intent scale6 and the SAD PERSONS scale,7 which has a mnemonic that is easily remembered.

Other areas that must be covered during an assessment include the patient’s medical history, medications, and family history of medical or psychiatric disease. A suicide attempt can be a response to stress learnt by example, and a family history of suicide increases the risk at least twofold, independently of family psychiatric history.8 Personal history should also be sought and include schooling, accommodation, personal relationships, and employment.

It can be useful to talk to a friend or relative to gain a collateral history. When taking such a history, the assessor must remember to respect the patient’s confidentiality. Collateral history is especially valuable if the patient is deliberately trying to mask his or her mental state and seems to be telling you what he or she thinks you want to hear rather than how they actually feel. It is also necessary to evaluate the degree of support available to the patient should they return home. If the patient’s suicide attempt seems to be as a result of a situation at home to which they are proposing to return, this would obviously be of concern.

If in doubt about a patient’s level of risk it is wise to consult a more experienced colleague.

2 How would you manage this patient?

Short answer:
It may be possible to discharge patients who are thought to be at low risk to the care of their general practitioner for follow-up, whereas those with moderate risk will probably need an urgent appointment with a community mental health team or involvement of a home treatment team. Patients thought to be at high risk may need hospital admission and possible assessment under appropriate mental health legislation. Follow-up services will consider whether further interventions—for example, psychotherapy and pharmacotherapy—are appropriate. This patient was thought to be at moderate risk because of continuing suicidal intent and access to lethal drugs. He was admitted informally to a psychiatric inpatient unit.

Long answer:
It is important to make thorough notes on your consultation. Although this is true for any patient encounter, it is even more important here because your record serves as potentially valuable material for future risk assessments should the patient attempt suicide again. The steps taken to protect the patient should also be documented.

Suicidal acts occur for a variety of reasons, and often the primary aim is not death but some other outcome, such as demonstrating distress to other people or seeking change in their behaviour.9 Therefore, the needs of individual patients will vary widely. If you have asked about the risk factors above and have an understanding of the context of the suicidal act then you will have formed an opinion as to a patient’s suicide risk. Any patient with a concerning level of perceived suicide risk will, for a time, need supervision and restriction of access to lethal means. Your assessment will establish to what level and for how long these restrictions should be enacted.

If you think that a patient’s suicide risk is low and you are assured that they have good support in the community, they can be discharged from hospital and followed up by their general practitioner or community mental health team, to whom a copy of your assessment should be sent. A patient discharged home should be advised to attend appropriate services, such as the accident and emergency department, if they or their family are concerned in the future.

You may feel that the suicide risk is moderate. This might be the case for patients who say that they have no continuing suicidal ideation, but in whom you have identified several risk factors for a further attempt. In this situation, although it may be appropriate to discharge the patient from hospital, the local community mental health team should be urgently informed so that they can provide follow-up. Some psychiatric home treatment teams will be willing to see patients at this level of risk.

For any patient you discharge who has had recent suicidal thoughts or has performed suicidal acts you must be convinced that the environment to which they are discharged will be safe and supervised by friends or relatives whom you judge to be reliable, who wish to care for the patient, and who understand their responsibilities.

An example of a patient who is at high suicide risk would be someone who continues to have suicidal intent, has made several previous attempts, and has a psychiatric disorder. Hospital admission is appropriate for such patients. If they refuse the offer of an informal (non-compulsory) hospital admission, you may wish to recommend that they are detained under the relevant mental health legislation.

After their assessment it is the responsibility of the assessing doctor to be confident that, before the end of their shift, the appropriate follow-up services will be provided with all the information that is needed.

3 What are the general principles of suicide prevention?

Short answer:
Two broad approaches to reducing the total number of suicides exist. The first is to take steps at a population level; an example of this is to sell paracetamol in smaller size packs. The second involves targeted strategies, such as evidence based treatments, aimed at high risk groups about whom healthcare professionals should be aware.

Long answer:
The two main approaches for reducing the number of suicides in the population are: preventive strategies that can be applied to the population as a whole and those that are targeted towards high risk groups.

Population strategies10 11:

Improving the ability of primary care doctors to recognise and treat depression and other psychiatric disorders has been shown to be valuable because studies have reported that 16-40% of people who die by suicide have visited a family doctor in the week before their death.12

School based programmes aimed at improving psychological wellbeing could contribute to suicide prevention in young people by increasing knowledge of psychological symptoms and help seeking behaviour.

Gatekeepers are community members, such as clergy, whose contact with potentially vulnerable populations provides an opportunity for them to help identify at risk individuals and then direct them towards appropriate assessment and treatment.

Suicide screening aims to identify people at risk and direct them towards treatment.

Public education campaigns have been aimed at improving understanding of the causes and risk factors for suicidal behaviour and reducing the stigmatisation of mental illness and suicide, with the aim of improving the recognition of suicidal risk and increasing help seeking.

Restricting the availability of the means by which people commit suicide, such as installing safety barriers on bridges, saves lives. Substitution of one method for another can happen, but studies indicate that many people have a preference for a given method.13

The media can help educate the public about suicide, but it can exacerbate matters by glamorising suicide. Restrictions on reporting and codes of conduct can help lower suicide rates.

Strategies applicable to high suicide risk groups10 11:

Some people are at particular risk of suicide, and healthcare professionals should provide these people with treatments that reduce the risk of suicide attempts. Patient groups at particular risk of suicide include people with psychiatric disorders—those who have just been admitted or just been discharged from psychiatric hospital in particular; elderly people; high risk occupational groups, such as medical practitioners, pharmacists, farmers, and vets; and prisoners. Major risk factors for suicide in prisoners are previous attempts, recent suicidal ideation, being in a single cell, presence of a psychiatric disorder, and a history of alcohol problems.

Psychiatric disorders should be treated in high risk patients, and pharmacotherapy and psychotherapy are key treatments. Because of the chronic and recurrent nature of mental illness, and the difficulties in engaging patients with treatment, the best possible acute and long term psychiatric care needs to be available.

Even with near perfect care and risk assessment, and despite the best efforts of friends and professionals, suicide is not something that can be entirely predicted or prevented.

Patient outcome

Our patient was judged to be of moderate-high risk of future suicide. He had been having suicidal thoughts for some time and had a method in mind. If he had been discharged he would have returned to an unresolved stressful social situation with continued access to lethal methods. Particular risk factors for repeat suicide were a possible diagnosis of depression and statement of continued intent. Other risk factors were male sex, social isolation, and unemployment. His friend confirmed his story and said that he had seemed to be low in mood recently.

We thought that there was sufficient cause to warrant an informal inpatient hospital admission. The admission lasted three days, during which time antidepressants were started, his relationship with his landlord improved after the intervention of a social worker, and he denied further suicidal ideation. At the end of his stay he was discharged into the care of a community mental health team.

Further reading

The reader is referred to the relevant NICE guidelines on assessment and management of self harm.14


  1. Cavanagh JTO, Owens DGC, Johnstone EC. Life events in suicide and undetermined death in south-east Scotland: a case-control study using the method of psychological autopsy. Soc Psychiatry Psychiatr Epidemiol 1999;34:645-50.[CrossRef][Web of Science][Medline]
  2. Hawton K, Taylor T. Treatment of suicide attempters and prevention of suicide and attempted suicide. In: Gelder M, Andreasen N, Lopez-Ibor J, Geddes J. New Oxford textbook of psychiatry. 2nd ed. Oxford University Press, 2009:969-78.
  3. Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM. Psychological autopsy studies of suicide: a systematic review. Psychol Med 2003;33:395-405.[CrossRef][Web of Science][Medline]
  4. Beck AT, Steer RA, Kovacs M, Garrison B. Hopelessness and eventual suicide: a 10 year prospective study of patients hospitalised with suicidal ideation. Am J Psychiatry 1985;145:559-63.
  5. WHO. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. 1992.
  6. Beck A, Schuyler D, Herman J. Development of suicidal intent scales. In: Beck A, Resnik H, Letteri DJ. Prediction of suicide. Charles Press, 1974:45-56.
  7. Patterson W, Dohn H, Bird J, Patterson G. Evaluation of suicidal patients: the SAD PERSONS scale. Psychosomatics 1983;24:343-9.[Web of Science][Medline]
  8. Qin P, Agerbo E, Mortensen PB. Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register-based study of all suicides in Denmark, 1981-1997. Am J Psychiatry 2003;160:765-72.[Abstract/Free Full Text]
  9. Hjelmeland H, Hawton K, Nordvik H, Bille-Brahe U, De Leo D, Fekete S, et al. Why people engage in parasuicide: a cross-cultural study of intentions. Suicide Life Threat Behav 2002;32:380-93.[CrossRef][Web of Science][Medline]
  10. Hawton K, van Heeringen K. Suicide. Lancet 2009;373:1372-81.[CrossRef][Web of Science][Medline]
  11. Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al. Suicide prevention strategies. A systematic review. JAMA 2005;294:2064-74.[Abstract/Free Full Text]
  12. Pirkis J, Burgess P. Suicide and recency of health care contacts: a systematic review. Br J Psychiatry 1998;173:462-74.[Abstract/Free Full Text]
  13. Daigle MS. Suicide prevention through means restriction: assessing the risk of substitution: a critical review and synthesis. Accid Anal Prev 2005;37:625-32.[CrossRef][Web of Science][Medline]
  14. National Institute for Health and Clinical Excellence. Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. 2004.

Assisted suicide, Dignitas, Sir Edward Downes

I wrote a post about rational suicide a few weeks ago which attracted a lot of interest, and even spawned a post on another site dedicated to debunking my viewpoint.  This issue and that of physician assisted suicide is rarely far from the headlines and clearly is a subject which excites strongly held opinions.  Most recently conductor Sir Edward Downes and his wife are reported to have died together at the controversial Swiss assisted suicide clinic Dignitas.  For a small organisation it attracts an impressive amount of coverage and its actions may have a substantial influence on future UK legislation.

For many people the discussion of the right to die is a simple one: people should not have to suffer toward the end of their lives and have the right to choose the time and means of their own passing.  This attitude is in line with the increasing emphasis on choice and self determination in our society of which suicide is perhaps the ultimate expression.  There are strong emotions involved and polarized viewpoints, but shouldn’t mean that we shy away from discussion both about philosophical underpinnings as well as more practical aspects.

I am concerned that where assisted dying to become legal in this country doctors would be expected to take a central role and this would sit unhappily with our usual duties.  Psychiatrists would regularly be called up to make difficult assessments about capacity and some of us might find being asked to assist in someone’s death very distressing.  Outside these professional concerns, and more fundamentally, is the message that legalised assisted dying would send out to vulnerable people who are near to the end of their lives.  Elderly people may worry that they are a burden or that their care is costing too much, and with a legal way of reaching a swift resolution may feel a duty to move on.  I cannot see how we could safe guard against this.

Sir Edward was elderly and frail but not terminally ill when he chose to take his life.  Apparently decided that he could not live without his wife and choose to end his life when she was choosing to end hers.  Most discussion about assisted suicide has focused on incurable conditions, which Sir Edward did not have.  Enabling people in similar situations to Sir Edward to take their own lives is disquieting to me.

Addendum 16 July 2009
What I think about Sir Edward Downes’ decision to ‘die with dignity’ Guardian

‘Beat Blue Monday’ and the most miserable day of the year

Someone called Cliff Arnall has come up with a equation for the most depressing day of the year.  It goes like this:

1/8W+(D-d) 3/8xTQ MxNA.

Where W is weather, D is debt – minus the money (d) due on January’s pay day – and T is the time since Christmas.
Q is the period since the failure to quit a bad habit, M stands for general motivational levels and NA is the need to take action and do something about it.

I was rather amused by this the first time I read about it.  The Guardian had an article all about the best songs to listen to on the most miserable day of the year.  But it’s all bollocks, so much so that it is worthy of a diatribe from Bad Scientist writer Ben Goldacre, who appears to be a longtime adversary of Mr Arnall.  The same story was wheeled out in 2005 and 2006
The Samitarians got sucked this time and have launched Beat Blue Monday as a money earning drive, allegedly with Mr Arnall and a PR company taking their cut.

So when is the most depressing day of the year? If we assume that people who commit suicide are a reliable indicator of misery, then these two papers are relevant:

The Office of National Statistics have published a cheerful paper entitled Mortality from suicide and drug-related poisoning by day of the week in England and Wales, 1993–2002 An increased proportion of suicides occurred on Mondays, while the single day on which the largest number of suicides occurred was 1st January 2000, a Saturday.  The increased numbers of deaths would on a Monday and especially on 1st January would suggest a theory that people are more suicidal with the move into a new time period.

More light is shed by another interesting article which considers the frequency of suicide by day, day of the week, month, and lunar phase by studying suicide occurrence among residents of Sacramento County, CA, during the period from 1925 to 1983. It found suicide occurrence varying substantially by time of day, with the fewest suicide deaths occurred during the early morning hours. Suicides occurred most frequently on Monday for both males and females and for most age groups. Furthermore, variation by month followed no consistent pattern by gender, age, years of the study. Suicide occurrence did not vary by lunar phase.

There aren’t so many werewolves after all.