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Clinical Risk Assessment in Psychiatry – Part 3

The management of deliberate self-harm and suicide risk in community settings and on discharge from hospital — psychosocial assessment, disorder-specific risk factors, safety planning, and follow-up arrangements.

Risk Assessment Series: Part 1 (Risk Factors & Formulation) • Part 2 (A&E Management & Consent) • Part 3 (Community Management)

This section should be read in conjunction with Part 1 and Part 2 of the Clinical Risk Assessment in Psychiatry series.

As outlined in Parts 1 and 2, having assessed the patient — whether in A&E or in a community setting — and identified those at moderate or serious risk of further self-harm, the next step is to ensure appropriate specialist assessment and management. Such patients should be seen by a specialist nurse or psychiatrist, who may arrange admission to a psychiatric unit for further evaluation of mental state, social circumstances, and treatment.

In fact, it is always easier to manage patients once you have identified them clearly for specialist psychiatric assessment and probable admission. Sometimes the patient may require admission under the appropriate section of the Mental Health Act, which the psychiatric team will arrange.

Rarely, you may need to hold a patient who is already an inpatient on a general hospital ward but who refuses to stay and, in your opinion, needs further psychiatric evaluation. You can do this under Section 5(2) of the Mental Health Act 1983 for a maximum of 72 hours. This provision allows the responsible clinician or their nominated deputy to detain an informal inpatient to prevent them from leaving until a proper MHA assessment can be arranged. You may need the help of nursing and/or security staff to keep the patient on the ward until the psychiatric team arrives. Very rarely, you may need to notify the police about a patient who has left A&E without psychiatric assessment and whose safety you are seriously concerned about.

Disorder-Specific Risk Factors

The following paragraphs highlight the key risk factors in specific psychiatric presentations. Be aware of these when deciding when to seek urgent psychiatric help.

Major Depression

In cases of major depression, assess for:

  • Recent changes in living arrangements leading to increased isolation and self-neglect
  • Feelings of hopelessness — the belief that nothing will ever improve
  • Excessive guilt and self-blame (which may reach delusional intensity in psychotic depression)
  • Alcohol misuse (which increases impulsivity and lowers the threshold for acting on suicidal thoughts)
  • Active suicidal intent and any specific plan
  • Lack of social support
  • Recent anniversary of a significant loss
  • Inadequate or recently changed pharmacological treatment (be especially vigilant in the first weeks of starting an antidepressant, when energy and motivation may improve before mood does — a period of increased risk)

Schizophrenia

In cases of schizophrenia, be aware of the following factors that increase the risk of suicide:

  • Recently diagnosed young male with high premorbid functioning (who may acutely appreciate the implications of the diagnosis)
  • Recent discharge from a psychiatric unit — the highest risk period is the two weeks immediately following discharge
  • Current or past history of depression (depression is the strongest predictor of suicide in schizophrenia)
  • Non-compliance with prescribed psychiatric treatment, particularly antipsychotic medication
  • Social isolation and lack of meaningful daytime activity
  • Active suicidal intent, particularly if driven by command hallucinations
  • Substance misuse as a comorbidity

Older Persons

In older patients, suicide is more likely to be premeditated, use more lethal methods, and less likely to be communicated in advance. Key risk factors include:

  • Male gender
  • Single, separated, or widowed status
  • History of depression and suicidal intent
  • Recent significant changes in living arrangements (e.g. moving into a care home, loss of independence)
  • Comorbid physical illness, particularly involving chronic pain, loss of mobility, or terminal diagnosis
  • Bereavement — particularly the loss of a spouse or close companion
  • Social isolation

Psychosocial Assessment of the Patient Without Mental Disorder

The next step considers the management of a patient who has been brought to A&E following an episode of deliberate self-harm and who is not found to be suffering from major depression, schizophrenia, or other mental disorders.

The examining clinician should first assess:

  1. The patient's capacity to consent to further assessment and treatment
  2. What treatment can and cannot be given without the patient's consent in these circumstances (see Part 2 for the principles of consent and capacity)

The patient should then be medically examined, investigated, treated accordingly, and considered to be physically fit for a psychosocial assessment. Before undertaking the psychosocial assessment, it is helpful to have the contact details of the following services readily available to assist in management:

  1. Local social services and housing department
  2. Crisis Assessment Team (Crisis Resolution and Home Treatment Team)
  3. Voluntary services — including the Samaritans (116 123), Campaign Against Living Miserably (CALM), and local crisis support lines
  4. Community-based resources including day hospitals, day centres, walk-in clinics, and primary care mental health services

Psychosocial Assessment: Key Areas to Explore

The following information should be obtained from the patient and/or a family member or friend, with the patient's consent:

  • The patient's intention at the time of self-harm — what did they hope would happen?
  • How they feel about it now — do they regret surviving, or are they relieved?
  • Who can help and support the patient immediately after discharge, and what arrangements should be made for essential support in any future crisis over the next three months
  • Employment status — are they working? Off sick? At risk of redundancy?
  • Current financial problems, if any
  • Details of debts or ongoing financial pressures
  • Accommodation issues — is housing secure?
  • Any eviction notices due to non-payment of rent or for other reasons
  • Relationship problems — separation, domestic violence, coercive control
  • Children — their current physical and mental health; any safeguarding concerns
  • Pregnancy — wanted or unwanted
  • Issues with substance use, petty crime, or antisocial behaviour
  • Any pending court cases
  • Driving offences and pending fines
  • Fear of losing custody of children
  • Fear of imprisonment
  • Estrangement from extended family members
  • Loneliness and inability to cope with current social and financial circumstances

An episode of self-harm is often the only available coping mechanism for a person under overwhelming psychosocial pressure — poor socioeconomic conditions, relationship difficulties, and a limited or absent social support network. Such patients may also have difficulties with organisational skills, problem-solving, anger management, and emotional regulation. Recognition of these difficulties should inform the referral pathway and the management plan.

Prerequisites for Safe Discharge

Before planning to discharge a patient from A&E or from hospital following deliberate self-harm, make sure that you have:

  • Excluded any treatable underlying physical or mental health disorders
  • Confirmed that the crisis that precipitated the self-harm has abated and that the patient is no longer expressing active suicidal intent

The following must be completed in almost all cases of deliberate self-harm prior to discharge:

  • A responsible adult has been contacted who will assume responsibility for the patient's immediate safety and general welfare
  • The patient's GP has been notified and the relevant details communicated, with advice to see the patient within 72 hours
  • The patient has been referred to appropriate services where needed — such as social services, housing support, or relationship support
  • Community-based psychiatric services have been arranged to see the patient as soon as possible — ideally within 72 hours — if clinically indicated
  • An outpatient appointment with a psychiatrist has been arranged by the Community Psychiatric Services, if appropriate

Information to Provide on Discharge

As the patient leaves the hospital, ensure that you — and their accompanying responsible adult — have been given the following:

  • Your own contact details (for any other health professional who may need further information about the patient's management)
  • Appointment time and date with the GP, if you have been able to arrange this
  • Contact details of social services, housing department, or other support agencies where relevant
  • Details of the Crisis Assessment Team appointment, if one has been arranged
  • Emergency helpline numbers — Samaritans (116 123, available 24 hours), local crisis line, and 999 for life-threatening emergencies
  • Clear written instructions about what to do and who to contact if the patient experiences a further crisis before their next appointment

Ideally, each A&E department should have an agreed, written protocol for the step-by-step management of deliberate self-harm that incorporates most of the above. Where such a protocol exists, it should be followed consistently. Where it does not, the approach outlined here provides a sound clinical framework.

Safety Planning

A safety plan is a collaborative, personalised document developed with the patient before discharge. It is increasingly recommended in NHS NICE guidelines (NG225, 2022) as best practice for patients following self-harm. A safety plan typically includes:

  • Early warning signs that a crisis may be developing
  • Coping strategies the patient can use independently
  • Social contacts (family or friends) the patient can turn to
  • Professional contacts and emergency services
  • Reasons for living that the patient has identified themselves
  • Steps to reduce access to means of self-harm (e.g. removing medications from the home, asking a trusted person to hold onto them)

Safety plans are not a guarantee against future self-harm, but evidence suggests they improve engagement with services and reduce the frequency of self-harm when developed collaboratively.

Frequently Asked Questions

What is Section 5(2) of the Mental Health Act and how do I use it?

Section 5(2) of the MHA 1983 is the "doctor's holding power." It allows the responsible clinician (or their nominated deputy) to detain a patient who is already admitted as an informal (voluntary) inpatient for up to 72 hours, in order to allow a full MHA assessment to take place. Key points: it can only be applied to patients who are already admitted to a hospital ward — it cannot be used in A&E or a community setting; it can only be applied by the responsible clinician or a nominated deputy (it cannot be delegated to any doctor); as soon as Section 5(2) is applied, you must contact the on-call psychiatric team immediately to arrange a formal MHA assessment; and Section 5(2) cannot be renewed — once it expires, the patient must either be assessed under Section 2 or 3, or allowed to leave.

Why is the period immediately after discharge from a psychiatric unit a high-risk period?

The two to four weeks immediately following discharge from inpatient psychiatric care represent one of the highest-risk periods for suicide. Several factors contribute: the patient may still be in the early stages of recovery from an acute episode; the transition from a highly structured, supportive inpatient environment to an often much less supported community setting can be profoundly destabilising; the intensity of follow-up in the community is typically lower; and medications may not yet be optimally effective. The NHS Long Term Plan and NICE guidelines both emphasise the importance of structured follow-up within 72 hours of discharge (now a CQUIN standard for acute psychiatric admissions) and intensive support from Crisis Resolution and Home Treatment Teams during the early post-discharge period.

What is a safety plan and how does it differ from a crisis plan?

A safety plan is a brief, personalised written document co-produced with the patient to help them manage a suicidal crisis if it arises. It outlines warning signs, coping strategies, social contacts, professional contacts, and means restriction. A crisis plan is a broader document (often part of the Care Programme Approach) that describes the patient's mental health history, what signs indicate they are becoming unwell, what interventions have worked in the past, who to contact in a crisis, and what to do if the patient's condition deteriorates. Safety plans are targeted specifically at suicide risk; crisis plans cover a wider range of deterioration. Both are considered best practice in NICE guidance (NG225, 2022) for patients following self-harm.

What is means restriction and why is it recommended?

Means restriction refers to reducing the availability of, or access to, the methods a person might use to harm themselves. Evidence from suicide prevention research demonstrates that means restriction is one of the most effective suicide prevention strategies — many suicidal crises are relatively brief, and if the intended means is unavailable, the crisis may pass without a fatality. In practice this involves: limiting the quantity of medications prescribed at one time; asking a trusted person to hold medications on behalf of the patient; removal or safe storage of firearms and other weapons; fitting safety barriers at high-risk locations; and reducing access to toxic substances. In clinical practice, means restriction should be discussed as part of every safety plan for patients at significant risk.

How do I communicate with a patient's GP after an A&E attendance for self-harm?

Communication with the GP is essential and should happen as promptly as possible — ideally on the same day as the presentation. It should include: the date and nature of the presentation; the risk assessment findings and risk category; the mental state at the time of assessment; the management provided in A&E; the follow-up arrangements made; and clear guidance about what further action the GP is being asked to take (e.g. review within 72 hours, prescription changes, referral to IAPT). If available, send a full written discharge summary. If the patient has not consented to GP contact, document this and explain why contact was still made if you judged that the risk to the patient's life outweighed the duty of confidentiality.

What voluntary and crisis support services should I know about for patients in crisis?

Key services include: Samaritans (116 123 — available 24 hours a day, 365 days a year; also available by email at jo@samaritans.org); CALM (Campaign Against Living Miserably) — 0800 58 58 58, open 5pm to midnight; Shout (85258 by text — 24/7 crisis text service); Papyrus (HOPELINE UK — 0800 068 4141, for young people under 35); the local NHS Crisis Resolution and Home Treatment Team; and local MIND or Rethink Mental Illness branches. Clinicians should be familiar with what is available in their local area. Having this information to hand — either on a wallet card or in the clinical system — makes it much easier to provide during a time-pressured clinical encounter.

For an ST3 interview — how do you structure a safe discharge for a patient following deliberate self-harm?

A model answer would cover: (1) confirming medical fitness for discharge; (2) completing a formal risk assessment including MSE, suicidal ideation, intent and plan, precipitating factors, protective factors, and social circumstances; (3) ensuring the crisis has resolved or is adequately contained; (4) ensuring a responsible adult is available to support the patient; (5) completing a safety plan collaboratively with the patient; (6) making referrals to appropriate services (Crisis Team, CMHT, GP, social services); (7) notifying the GP with a clear summary of the assessment and plan; (8) providing the patient and their responsible adult with written information about what to do and who to contact in a further crisis; and (9) documenting all of the above clearly in the clinical record. Demonstrating understanding of how suicide risk fluctuates — and why robust follow-up in the 72 hours and two weeks after discharge is critical — shows clinical maturity.

References

  1. Gelder M, Harrison P, Cowen P. Shorter Oxford Textbook of Psychiatry (6th ed). Oxford University Press, 2010.
  2. Semple D, Smyth R. Oxford Handbook of Psychiatry (4th ed). Oxford University Press, 2019.
  3. NICE. Self-harm: Assessment, Management and Preventing Recurrence (NG225). NICE, 2022.
  4. NICE. Self-harm in Over 8s: Short-term Management and Prevention of Recurrence (CG16). NICE, 2004.
  5. National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH). Annual Report, 2023. University of Manchester.
  6. Mental Health Act 1983 (as amended by the Mental Health Act 2007), Section 5(2). legislation.gov.uk.
  7. NHS England. The NHS Long Term Plan. NHS England, 2019.
  8. Stanley B, Brown GK. Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioural Practice. 2012;19(2):256–263.
  9. Appleby L, et al. Preventing suicide in England: a technical report on the implementation of the National Suicide Prevention Strategy. University of Manchester, 2017.
  10. Beautrais AL. Risk factors for serious suicide attempts among youths aged 13 through 24 years. Journal of the American Academy of Child and Adolescent Psychiatry. 2000;39(10):1277–1284.