Deliberate self-harm and suicide risk assessment

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Target exams

Red flags

• Medical clearance before psychosocial assessment — the patient who dies of untreated paracetamol hepatotoxicity while awaiting the mental-health team has been failed at the first step; the paracetamol level, the salicylate level, the ECG for tricyclic widening and the glucose come before the risk assessment
• Never assess the intoxicated patient — the history, the intent and the capacity assessment are unreliable while intoxicated; observe under the doctrine of necessity until sober, then reassess risk
• A prior suicide attempt is among the strongest predictors of future completed suicide — every self-harm presentation is taken seriously, including the chronic repeater and the single-tablet overdose
• The elderly and the high-lethality single attempter default to admission — high-lethality methods, low physiological reserve, physical illness and social isolation make the first episode in an older person a high-risk presentation
• Suicide risk is dynamic, not a single score — reassess whenever the situation changes, remove access to means before discharge, and never discharge a patient with active intent and a plan without a written safety plan and arranged psychiatric follow-up
• The weeks after a psychiatric discharge are a high-risk window — a recently discharged patient presenting again is treated as an emergency until a full reassessment proves otherwise