Deliberate self-harm and suicide risk assessment in the ED

Principles. The disciplined response is medical clearance and toxicological treatment first, the psychosocial and suicide-risk assessment second, the disposition third. This patient has a paracetamol level above the treatment line and is clinically intoxicated — both demand action before any psychiatric assessment. The bedside glucose is checked (mandatory in any behavioural or self-harm presentation), a venous gas screens for acidosis, and a 12-lead ECG is performed.^[1]

(i) Immediate medical management. Treat the paracetamol overdose as a medical emergency. Start N-acetylcysteine 150 mg/kg IV over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours (the 21-hour regimen) because the 4-hour level is above the treatment line.^[6] Check a baseline INR, ALT, creatinine and venous lactate; a paracetamol level above the line with any sign of hepatotoxicity is managed jointly with the toxicology or medical team. Activated charcoal is not given: she is drowsy with an unprotected airway, and by the time the 4-hour level returns the early window has passed — airway protection takes priority.^[7] Admit for the full N-acetylcysteine regimen and medical observation; the psychiatric assessment is deferred until the treatment is underway and she is stable.^[1]

(ii) Timing of the psychosocial assessment. The assessment is NOT performed now. She is clinically intoxicated — the history, the stated intent, the capacity assessment and the risk stratification are all unreliable while intoxicated, and an underestimate made through alcohol is a recurring cause of death. She is observed under the doctrine of necessity (and, if the criteria are met, the Mental Health Act) until sober, with the means of further harm removed and one-to-one observation as needed. Once she is stable, sober and able to give a reliable account, a trained clinician — the mental-health liaison team where available — undertakes the psychosocial assessment, with collateral from her partner, her family and her general practitioner.^[5]

(iii) Components of the structured suicide-risk assessment. The history of the act (events, intent at the time versus now, planning, rehearsal, precautions against discovery, last-minute rescue, role of alcohol, lethality of method); the ideation (presence, frequency, intensity, duration — passive versus active); the plan (specificity, lethality, preparation); the intent (the stated determination to die, distinguished from ambivalence); the access to means (a stockpile at home, firearms); the protective factors and reasons for living (family, children, faith, future orientation, engagement with services); the psychiatric history (prior attempts, known illness, current treatment, recent psychiatric discharge); the precipitant (loss, conflict, legal or financial crisis); and the mental state examination, with explicit attention to depression, hopelessness and psychosis.^[2][3]

(iv) Risk tiers and disposition. High risk — a plan plus means plus intent, or a near-lethal attempt, or active intent on reassessment: psychiatric admission, voluntary if she accepts and involuntary under the Mental Health Act if she refuses and meets the criteria, with one-to-one observation and removal of means. Moderate risk — active ideation with a plan but ambivalent intent, or a recent attempt without current intent, in a patient who can engage: crisis-resolution and home-treatment team review within 24 hours, a written safety plan, means restriction and carer involvement; a brief voluntary admission is considered where ambivalence, isolation or access to means cannot be managed safely at home. Low risk — passive ideation, no plan, no intent, strong protective factors, willing to engage: discharge with a written safety plan, GP follow-up within 7 days, crisis-line numbers, means restriction, and the family or carer informed. SAD PERSONS (Sex, Age, Depression, Previous attempt, Ethanol, Rational thinking loss, Separated, Organised plan, No social support, Sickness) is a ten-item clinical aid with modest predictive value — a score of 5 or more is high risk — and never replaces the structured assessment.^[2][4]

(v) Legal authority to detain. Two frameworks apply. Capacity is assessed on the four-stage test (understand, retain, weigh, communicate) and is presumed, decision-specific and time-specific; capacity is unreliable while intoxicated. If she lacks capacity and faces serious harm, treatment proceeds under the doctrine of necessity. If she has a mental illness of a nature or degree that warrants hospital treatment and her health or safety is at risk and she cannot or will not consent, the Mental Health Act authorises detention — in New South Wales the Schedule 1 certificate of an authorised medical practitioner under the Mental Health Act 2007, in England a Section 2 (assessment, 28 days) or Section 4 (emergency, 72 hours) of the Mental Health Act 1983 (as amended 2007) or Section 5(2) (72-hour doctor's holding power).^[1]