Assessment of suicide risk in people with depression

 
Assessment of suicide risk in people with depression
Clinical Guide

Assessment
of suicide risk
in people with
depression

The guide was developed by the University
of Oxford’s Centre for Suicide Research to
assist clinical staff in talking about suicide
and assessing suicide risk with people
who are depressed.

                                                 © Centre for Suicide Research,
                                                   Department of Psychiatry,
                                                   University of Oxford.
Assessment of suicide risk in people with depression
Clinical Guide: Assessment of suicide risk in people with depression                                            2

Introduction                                                           Contents
This guide is intended for a range of healthcare
professionals, including:                                              1   About this guide                3

General practitioners and other primary care staff                     2   Explaining suicide              4

Mental health workers                                                  3   Risk factors                    5
Counsellors
                                                                       4   How to assess someone           6
IAPT (Increasing Access to Psychological                                   who may be at risk of suicide
Therapies) therapists
                                                                       5   Involvement of others           8
Accident and Emergency Department staff
Support workers                                                        6   Managing risk                   8

                                                                       7 	Frequently asked questions      10
This guide is primarily about assessing risk in adults.                    and common myths
However, the principles can be applied to younger                          about suicide
people (although the issues relating to consent
may differ).                                                           8 	Resources                       12

The guide may also be useful for reviewing care of                     9	Risk assessment                  14
people, including through Significant Event Analyses.                     summary of key points

                                                                       10 Useful contacts                  15

                                                                       11 References                       16
Clinical Guide: Assessment of suicide risk in people with depression                                                                                                      3

1
About this guide
How was this guide produced?                                           Clinicians working in a range of settings will       Suicide of a patient can also have a profound
This guide was informed by the findings of a                           encounter depressed people who may be                effect on professionals involved in their care.
systematic review of risk factors for suicide                          at risk. For example, approximately 50% of           Following a suicide they may be helping
in people with depression1. It was also                                those who take their own lives will have seen        support the people bereaved by the death,
developed with input from experts in primary                           a general practitioner in the three months           dealing with official requirements (e.g.
care and secondary care.                                               before death; 40% in the month beforehand;           response to the coroner and other agencies),
                                                                       and around 20% in the week before death 5 .          and at the same time trying to cope with their
Why is this guide needed?                                              Primary care staff are therefore in a particularly   own emotional responses.
Suicide is a major health issue and suicide                            important position in the detection and
prevention is a government priority. In the                            management of those at risk of suicide. Also,
UK there are nearly 6000 suicide deaths                                approximately a quarter will have been in            Approximately 90% of
per year 2 , and nearly 500 further suicides in
Ireland 3 . Approximately three-quarters of
                                                                       contact with mental health services in the year
                                                                       before death 6 .
                                                                                                                            people dying by suicide
these occur in men, in whom suicide is the                                                                                  have a psychiatric disorder.
most frequent cause of death in those under                            While most clinicians outside of psychiatric
35 years of age. The most common method of                             specialties will only experience a few suicides
suicide is hanging, followed by self-poisoning.                        during their career, it is crucial that they are
                                                                       vigilant for people who may be at risk. It is
Approximately 90% of people dying by suicide                           important to recognise that the effects of
have a psychiatric disorder 4 , although this                          suicide on families can be devastating.
may not have been recognised or treated.
Depression is the most common disorder,
found in at least 60% of cases. This may be
complicated by other mental health issues,
especially alcohol misuse and personality
disorders.
Clinical Guide: Assessment of suicide risk in people with depression                                                                                   4

2
Explaining suicide
Suicide can result from a                          Suicide pathway model7
range of factors, including,
for example, psychiatric
disorder, negative life events,                     Family history,           Psychological   Exposure to      Availability of             Outcome
psychological factors, alcohol                      genetic &                 factors (e.g    self-harm/       method
                                                    biological                pessimism,      suicide
and drug misuse, family                             factors                   aggression,
history of suicide, physical                                                  impulsivity)
illness, exposure to suicidal
behaviour of others, and                                                                                                 Method likely
access to methods of self-                                                                                               to be lethal
harm. In any individual case                                                                                                               Suicide
multiple factors are usually
involved.                                          Psychiatric              Psychological        Thoughts of
                                                   disorder                 distress             self-harm/
                                                                            Hoplessness          suicide
                                                                                                                                           Self-harm

                                                                                                                         Method unlikely
                                                                                                                         to be lethal

                                                     Negative life
                                                     events
                                                     & social
                                                     problems
Clinical Guide: Assessment of suicide risk in people with depression                                                                                               5

3
Risk factors
No one is immune to suicide. People with
                                                                               Risk factors                   Other risk                       Possible
depression are at particular risk for suicide,
                                                                                 specific                    factors for                      protective
especially when factors shown in the table are
                                                                              to depression                 consideration                       factors
present 1 . Previous self-harm (i.e. intentional self-
poisoning or self-injury, regardless of degree of
suicidal intent) is a particularly strong risk factor.                 – Family history of           – Family history of suicide   – Social support.
Also, a number of other risk factors for suicide                         mental disorder.               or self-harm.
                                                                                                                                     – Religious belief.
have been identified and should be considered
                                                                       – History of previous         – Physical illness
when assessing depressed individuals. It should be                                                                                   – Being responsible
                                                                         suicide attempts (this         (especially when this
noted that family history of suicide or self-harm is                                                                                    for children (especially
                                                                         includes self-harm).           is recently diagnosed,
particularly important. There are also some factors                                                                                     young children).
                                                                                                        chronic and/or painful).
which may offer some degree of protection                              – Severe depression.
against suicide.                                                                                      – Exposure to suicidal
                                                                       – Anxiety.
                                                                                                        behaviour of others,
                                                                       – Feelings of hopelessness.     either directly or via
                                                                       – Personality disorder.         the media.

                                                                       – Alcohol abuse and/or        – Recent discharge from
                                                                         drug abuse.                    psychiatric inpatient
                                                                                                        care.
                                                                       – Male gender.
                                                                                                      – Access to potentially
                                                                                                        lethal means of self-
                                                                                                        harm/suicide.
Clinical Guide: Assessment of suicide risk in people with depression                                                                                        6

4
How to assess someone who may be at risk
The interview setting                                                  Asking about suicidal ideas
Assessment should take place in a quiet room                           Some patients will introduce the topic            There is no definitive way to
where the chances of being disturbed are
minimised. Ideally you should meet with the
                                                                       without prompting, while others may be too
                                                                       embarrassed or ashamed to admit they
                                                                                                                         approach enquiring about
patient alone but also see their family/carers/                        may have been having thoughts of suicide.         suicide but it is essential that
friends, together or alone, as appropriate.                            However the topic is raised, careful and          this is assessed in anyone
In general, open questioning is advisable                              sensitive questioning is essential. It should
although it may become necessary to use                                be possible to broach suicidal thoughts in        who is depressed.
more closed questions as the consultation                              the context of other questions about mood
progresses and for purposes of clarification.                          symptoms or link this into exploration of
There is no definitive way to approach                                 negative thoughts (e.g. “It must be difficult
enquiring about suicide but it is essential that                       to feel that way – is there ever a time when
this is assessed in anyone who is depressed.                           it feels so difficult that you’ve thought about
                                                                       death or even that you might be better off
There may be circumstances under which                                 dead?”). Another approach is to reflect back
assessment is conducted by telephone. This                             to the patient your observations of their non-
will clearly place limitations on the assessment                       verbal communication (e.g. “You seem very
procedure (e.g. access to non-verbal                                   down to me”. “Sometimes when people are
communication). However the principles of                              very low in mood they have thoughts that life
assessment are the same. Where feasible, a                             is not worth living: have you been troubled by
face-to-face assessment is recommended.                                thoughts like this?”).
Clinical Guide: Assessment of suicide risk in people with depression                                                                                                       7

4
How to assess someone who may be at risk
You may want to ask about a number of                                  – Do they have the means for a suicidal act         Sometimes patients with few risk factors may
topics, starting with more general questions                             (do they have access to pills, insecticide,        nevertheless make the clinician feel uneasy
and gradually focusing on more direct                                    firearms…)?                                        about their safety. The clinician should not
ones, depending on the patient’s answers.                                                                                   ignore these feelings when assessing risk,
This must be done with respect, sympathy                               – Is there any available support                    even though they may not be quantifiable.
and sensitivity. It may be possible to raise                             (family, friends, carers…)?
the topic when the patient talks about
negative feelings or depressive symptoms. It                           There is increasing evidence that visual             It is important to pay heed to
is important not to overreact even if there is
reason for concern. Areas that you may want
                                                                       imagery can strongly influence behaviour.
                                                                       Therefore it is worth asking whether a person
                                                                                                                            non-verbal cues and intuitive
to explore include:                                                    has any images about suicide (e.g. “If you           feelings about a person’s
                                                                       think about suicide, do you have a particular        level of risk.
– Are they feeling hopeless, or that life is not                      mental picture of what this might involve?”).
   worth living?                                                       While assessment of risk factors for suicide in
                                                                       people with depression and more generally
– Have they made plans to end their life?                              (see sections 6 and 7) can inform evaluation
                                                                       of risk, it is also important for the clinicians
– Have they told anyone about it?                                      to pay heed to non-verbal clues and their
                                                                       intuitive feelings about a person’s level of risk.
– Have they carried out any acts in
   anticipation of death (e.g. putting
   their affairs in order).
Clinical Guide: Assessment of suicide risk in people with depression                                                                  8

5                                                                      6
Involvement of others                                                  Managing risk
Where practical, and with consent, it is recommended                   When a patient is at risk of suicide this information should
that clinicians inform and involve family, friends or other            be recorded clearly in the patient’s notes. Where the
identified people in the patient’s support network, where              clinician is working as part of a team it is important to
this seems appropriate. This is particularly important                 share awareness of risk with other team members. Out-
where risk is thought to be high.                                      of-hours emergency services need to be able to access
                                                                       information about risk easily.
Family and social cohesion can help protect against
suicide. It is often useful to share your concerns about               It is advisable to be open and honest with patients about
suicide risk, since family, friends and carers may be                  your concerns regarding the risk of suicide and to arrange
unaware of the danger and can frequently offer support                 timely follow-up contact in order to monitor their mental
and observation. They can also help by reducing access                 state and current circumstances.
to lethal means, for example by holding supplies of
medication and hence lowering the risk of overdose.                    Patients should be informed how best to contact you
                                                                       in between appointments should an emergency arise.
If the person is not competent to give consent 8, the                  You should encourage them to let you know if they feel
clinician should act in the patient’s best interests. This is likely   worse or the urge to act upon their suicidal thoughts
to involve consultation with family, friends or carers 9.              increases. Patients should also be given details of who to
                                                                       contact out of hours when you are not available. Where
                                                                       appropriate, reception or administrative staff may need
                                                                       to be alerted that a patient should be prioritized if they
                                                                       make contact.
Clinical Guide: Assessment of suicide risk in people with depression                                                                                                      9

6
Managing risk
It is important to assess whether patients                             Active treatment of any underlying depressive         Regular and pro-active follow-up is highly
have the potential means for a suicide                                 illness is a key feature in the management of         recommended.
attempt and, if necessary, to act on this: for                         a suicidal patient and should be instigated as
example, only prescribing limited supplies of                          soon as possible.                                     Clinicians seeing suicidal patients should
medication that might be taken in overdose                                                                                   consider access to peer support and
and encouraging family members, friends or                             If the risk of suicide in a patient seen in primary   supervision. When a clinician experiences the
carers to dispose of stockpiled medication.                            care is high, particularly where depression           death of a patient by suicide they should seek
Medicines that are particularly dangerous in                           is complicated by other mental health                 support and advice to help cope with this.
overdosage include tricyclic antidepressants,                          problems, referral to secondary psychiatric
especially dosulepin, paracetamol and                                  services should be considered. In many areas
opiate analgesics. Restricting access to other                         there are crisis teams which can respond
lethal means (e.g. shotguns) should also                               quickly and flexibly to patients’ needs and           Active treatment of any
be considered.                                                         can arrange appropriate psychiatric support
                                                                       and treatment.
                                                                                                                             underlying depressive
Some internet sites can be a helpful source                                                                                  illness is a key feature in
of support for patients, but there are also
pro-suicide websites and those which advise
                                                                       Many clinicians will make informal
                                                                       agreements with patients about what
                                                                                                                             the management of a
about lethal means. Patients should be asked                           they should do if they feel unsafe or things          suicidal patient.
if they have been accessing internet sites                             deteriorate. More formal signed agreements
and, if so, which ones.                                                are not recommended as there is a lack of
                                                                       evidence regarding their efficacy, and their
Suicide and self-harm can be contagious.                               legal status in the event of a suicide is unclear.
It is worth enquiring about exposure to such
behaviours, including in family, friends and in
the media, and the patient’s reactions to this.
Clinical Guide: Assessment of suicide risk in people with depression                                                                                                    10

7
Frequently asked questions & common myths
Does enquiry about suicidal thoughts                                   Are there any rating scales I can                   When should I ask about suicide?
increase a patient’s risk?                                             use to quantify risk?                               All patients with depression should be
No. There is no evidence that patients                                 There are many rating scales which attempt          asked about possible thoughts of self-harm
are suggestible in this way. In reality many                           to quantify risk but none are particularly useful   or suicide. As already noted, there is no
patients are relieved to be able to talk about                         in an individual context. They tend not to take     evidence to suggest that asking someone
suicidal thoughts.                                                     account of the circumstances in which a             about their suicidal thoughts will give them
                                                                       person may be experiencing suicidal ideation        “ideas”, or that it will provoke suicidal
Do antidepressants increase the                                        and are reliant upon self-report.                   behaviour. When this is best asked will vary
risk of suicide?                                                                                                           from patient to patient (see section 4: Asking
The risk of increasing suicidal thoughts and                           They should therefore be used with caution          about suicidal ideas).
gestures following commencement of an                                  and only as an adjunct to a clinical assessment.
antidepressant has received considerable                               Some measures of level of depression are useful
media coverage. The current consensus is                               (e.g. PHQ-9, Beck Depression Inventory), some
that there may be a slightly increased risk                            of which include items on hopelessness and          There is no evidence that
among those under the age of 25, where
closer monitoring is required. However, the
                                                                       suicidality. Such a measure is best used at each
                                                                       patient visit in order to help monitor progress
                                                                                                                           enquiry about suicidal
active treatment of depression is associated                           (the patient might be asked to complete this in     thoughts increases a
with an overall decrease in risk. The most                             advance or in the waiting room).                    person’s risk.
successful way of reducing suicide risk is to
treat the underlying depressive illness, and to
monitor patients carefully, especially during
the early phase of treatment.
Clinical Guide: Assessment of suicide risk in people with depression                                                                                    11

7
Frequently asked questions & common myths
The patient doesn’t want me to inform their                            The patient is always expressing suicidal
family, friends or carers that they have had                           ideation. When should I worry?                       Sharing your concerns with
suicidal thoughts. What should I do?
This is a difficult situation as family, friends and
                                                                       Chronic suicidal ideation most commonly
                                                                       occurs in people with long-term/severe
                                                                                                                            the patient in an empathic
carers play an important role in helping to                            depression or personality disorders. This group      manner will allow them to
support depressed individuals and in keeping                           of people is at higher risk of suicide in the long   feel listened to and allow you
them safe. It is always worth exploring why the                        term. While it can be difficult to distinguish
patient is reluctant for others to be informed                         circumstances when ideation may transform            to both agree a plan to try
as you may be able to address some of their                            into action it is important to try identify any      and keep them safe.
concerns. Offering to be present when they                             factors that may significantly destabilise
inform close ones can be helpful. Unless there                         the situation - for example, a relationship
is imminent risk you cannot breach patient                             breakdown, loss of a key attachment figure,
confidentiality so ultimately you may have                             alcohol and/or drug misuse, or physical illness.
to respect their wishes.
                                                                       Should I tell the patient that I am
                                                                       concerned they are at risk?
                                                                       In general a collaborative approach is
                                                                       advisable. Sharing your concerns with the
                                                                       patient in an empathic manner will allow
                                                                       them to feel listened to and allow you to
                                                                       both agree a plan to try and keep them
                                                                       safe. If psychosis is a prominent feature of the
                                                                       presentation this may be more difficult and
                                                                       may require urgent psychiatric care.
Clinical Guide: Assessment of suicide risk in people with depression                                                                                                    12

8
Resources
Sources of help for patients, family, friends and carers

General                                                                CALM (Campaign Against Living Miserably)          Healthtalkonline: bereavement due to suicide
                                                                       A website which offers support for distressed     A website which explores themes around
Samaritans Tel: 08457 90 90 90
                                                                       people, especially young men                      bereavement, with illustrative interviews
http://www.samaritans.org
                                                                       http://www.thecalmzone.net/what-is-calm/          with bereaved people
NHS 111 Tel: 111                                                                                                         http://www.healthtalkonline.org/Dying_and_
                                                                       Papyrus
http://www.nhs.uk/111                                                                                                    bereavement/Bereavement_due_to_suicide
                                                                       Support for young people with suicidal thoughts
NHS Choices: depression                                                http://www.papyrus-uk.org/support/for-you         Self-help books
http://www.nhs.uk/conditions/depression
                                                                       For relatives, friends and carers                 Gilbert, P. (2009). Overcoming depression:
NHS Choices: suicide                                                                                                     A guide to recovery with a complete self-help
                                                                       Mind: how to support someone who is suicidal
http://www.nhs.uk/conditions/suicide                                                                                     programme. London: Robinson.
                                                                       http://www.mind.org.uk/help/medical_and_
Royal College of Psychiatrists: Depression                             alternative_care/how_to_help_someone_             Veale, D., & Willson, R. (2007). Manage your
http://www.rcpsych.ac.uk/                                              who_is_suicidal                                   mood: How to use behavioural activation
mentalhealthinfoforall/problems/depression.                                                                              techniques to overcome depression.
                                                                       Papyrus
aspx                                                                                                                     London: Robinson.
                                                                       Support for parents
Therapeutic                                                            http://www.papyrus-uk.org/support/for-parents     Westbrook, D. (2005). Managing depression.
Mind: how to cope with suicidal feelings                                                                                 Oxford: OCTC Warneford Hospital.
                                                                       Bereavement by suicide
http://www.mind.org.uk/help/diagnoses_                                                                                   Williams, J. M. G. (2007). The mindful way
                                                                       Help is at hand
and_conditions/suicidal_feelings                                                                                         through depression: Freeing yourself from
                                                                       A resource for people bereaved by suicide
Beyond Blue: depression                                                                                                  chronic unhappiness. New York: Guilford Press.
                                                                       and other sudden, traumatic death. Can be
http://www.beyondblue.org.au/index.                                    downloaded from:                                  Butler, G., & Hope, R. A. (1995). Managing
aspx?link_id=89                                                        http://www.dh.gov.uk/prod_consum_dh/              your mind: The mental fitness guide.
Healthtalkonline: depression                                           groups/dh_digitalassets/@dh/@en/@ps/              Oxford: Oxford University Press.
A website which explored themes around                                 documents/digitalasset/dh_116064.pdf
depression, with illustrative interviews
http://www.healthtalkonline.org/mental_
health/Depression
Clinical Guide: Assessment of suicide risk in people with depression                                                                                                   13

8
Resources
Information for professionals

NICE guidance on management of                                         National suicide prevention strategies           NICE guidance on management of self-harm
depression
                                                                       Preventing suicide in England: a cross-          Self-harm: The short-term physical and
Depression: the NICE guideline on the                                  government outcomes strategy to save             psychological management and secondary
treatment and management of depression in                              lives (2012)                                     prevention of self-harm in primary and
adults (updated edition)                                               http://www.dh.gov.uk/en/Consultations/           secondary care
http://www.nice.org.uk/CG90                                            Liveconsultations/DH_128065                      http://www.nice.org.uk/CG16
Depression in children and young people:                               Talk to me: A national action plan to reduce     Self-harm: The NICE guideline on longer-term
identification and management in primary,                              suicide and self harm in Wales 2008-2013         management
community and secondary care                                           http://www.wales.gov.uk/splash?orig=/            http://www.nice.org.uk/CG133
http://www.nice.org.uk/CG28                                            consultations/healthsocialcare/talktome
                                                                                                                        Further reading
Practical guidance for professionals                                   Choose life: National strategy and action plan
                                                                                                                        Kutcher, S. P., & Chehil, S. (2007). Suicide
                                                                       to prevent suicide in Scotland
Mind: Supporting people with depression                                                                                 risk management: A manual for health
                                                                       http://www.chooselife.net/
and anxiety.                                                                                                            professionals. Malden, Mass: Blackwell.
A guide for practice nurses                                            Protect Life: a shared vision. The Northern
http://www.mind.org.uk/assets/0001/4765/                               Ireland Suicide Prevention Strategy and
MIND_ProCEED_Training_Pack.pdf                                         Action Plan (2012- March 2014)
                                                                       http://www.dhsspsni.gov.uk/
                                                                       phnisuicidepreventionstrategy_action_
                                                                       plan-3.pdf
                                                                       Reach out: Irish National Strategy for Action
                                                                       on Suicide Prevention 2005-2014
                                                                       http://www.nosp.ie/reach_out.pdf
Clinical Guide: Assessment of suicide risk in people with depression                                                                                            14

9
Risk assessment summary of key points
All patients with depression should be assessed for possible
risk of self-harm or suicide.
Risk factors for suicide identified through research studies are:

                                                                                                  In assessing patients’ current suicide potential, the
         Risk factors                             Other risk                     Possible
                                                                                                  following questions can be explored:
           specific                              factors for                    protective
        to depression                           consideration                     factors         – A
                                                                                                     re they feeling hopeless, or that life is not worth living?
                                                                                                  – H
                                                                                                     ave they made plans to end their life?
– Family history of                   – Family history of suicide    – Social support.         – H
                                                                                                     ave they told anyone about it?
   mental disorder.                      or self-harm.
                                                                       – Religious belief.       – H
                                                                                                     ave they carried out any acts in anticipation of death
– History of previous                 – Physical illness                                          (e.g. putting their affairs in order)?
                                                                       – Being responsible for
   suicide attempts (this                (especially when this
                                                                         children (especially     – D
                                                                                                     o they have the means for a suicidal act (do they
   includes self-harm).                  is recently diagnosed,
                                                                         young children).           have access to pills, insecticide, firearms…)?
                                         chronic and/or painful).
– Severe depression.
                                                                                                  – Is there any available support (family, friends, carers…)?
                                       – Exposure to suicidal
– Anxiety.
                                         behaviour of others,                                     – W
                                                                                                     here practical, and with consent, it is generally a
– Feelings of hopelessness.             either directly or via                                     good idea to inform and involve family members and
                                         the media.                                                 close friends or carers. This is particularly important
– Personality disorder.
                                                                                                    where risk is thought to be high.
– Alcohol abuse and/or                – Recent discharge from
                                         psychiatric inpatient                                    – W
                                                                                                     hen a patient is at risk of suicide this information should
   drug abuse.
                                         care.                                                      be recorded in the patient’s notes. Where the clinician
– Male gender.                                                                                      is working as part of a team it is important to share
                                       – Access to potentially
                                                                                                    awareness of risk with other team members.
                                         lethal means of self-
                                         harm/suicide.                                            – R
                                                                                                     egular and pro-active follow-up is highly
                                                                                                    recommended.
Clinical Guide: Assessment of suicide risk in people with depression                                               15

10
Useful contacts
This page can be printed and given to your patient. You
may wish to add any relevant local telephone numbers.

NHS 111                                                                MIND
Website: http://www.nhs.uk/NHSEngland/                                 Website: http://www.mind.org.uk/
AboutNHSservices/Emergencyandurgentcareservices/                       Email: info@mind.org.uk
Pages/NHS-111.aspx                                                     Telephone: 0300 123 3393.
                                                                       Mind helplines are open Monday to Friday,
Telephone: 111.
                                                                       9.00am to 6.00pm.
Available 24 hours a day, 365 days a year.
Calls are free from landlines and mobile phones.
SAMARITANS                                                               Local numbers/notes
Website: http://www.samaritans.org
Email: jo@samaritans.org
Telephone: 08457 90 90 90.
Available 24 hours a day.
PAPYRUS
Website: http://www.papyrus-uk.org/support/for-you
Telephone: 0800 068 41 41.
The helpline is open every day of the year;
on weekdays from 10am - 5pm
and 7pm - 10pm and during the
weekends from 2pm - 5pm.
Advice for young people who may have suicidal
thoughts, and parents and carers.
Clinical Guide: Assessment of suicide risk in people with depression                                                                                              16

11
    References
1
    Hawton, K., Casañas i Comabella, C., Haw, C. and Saunders, K. (2013)
    Risk factors for suicide in individuals with depression: A systematic review. Journal of
    Affective Disorders, 147, 17-28. This is a review of 19 studies worldwide in which risk factors   This guide was developed at the Centre for
    have been examined.                                                                               Suicide Research at the University of Oxford
2
    Office for National Statistics: Suicides in the United Kingdom, 2012 Registrations               by Professor Keith Hawton, Carolina Casañas i
    www.ons.gov.uk/ons/dcp171778_351100.pdf                                                           Comabella, Dr Kate Saunders and Dr Camilla
3
    National Office for Suicide Prevention, Ireland http://www.nosp.ie/                               Haw, with the following general practitioners: Dr
4
    Lönnqvist, J. (2000). Psychiatric aspects of suicidal behavior: depression.                      Kate Smith, Dr Deborah Waller and Dr Ruth Wilson,
    In: Hawton, K., and van Heeringen, K. (2000). The International Handbook of Suicide               and with the assistance of several other clinicians
    and Attempted Suicide. New York: Wiley.                                                           with a range of professional backgrounds. It has
5
    Pirkis, J. Burgess, P. (1998). Suicide and recency of health care contacts.                      been funded by the Judi Meadows Memorial
    A systematic review. British Journal of Psychiatry, 173, 462-474.
                                                                                                      Fund and Maudsley Charity.
6
    Five-year report of the National Confidential Inquiry into Suicide and Homicide by People with
    Mental Illness (2006) http://www.medicine.manchester.ac.uk/mentalhealth/research/suicide/
    prevention/nci/reports/avoidabledeathsfullreport.pdf
7
    Adapted with permission from: Hawton, K., Saunders, K. E. A. and O’Connor, R. C. (2012).
    Self-harm and suicide in adolescents. Lancet, 379, 2373-2382.
8
    General Medical Council confidentiality guidance (2009)
    http://www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp
9
    Mental Capacity Act http://www.legislation.gov.uk/ukpga/2005/9/contents
                                                                                                      © Centre for Suicide Research, Department of Psychiatry,
                                                                                                        University of Oxford.
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