Suicide Risk Management
1. Principles of Management2
a. Acute medical stabilisation and de-escalation
b. Siting of care and interventions
c. Addressing underlying factors and mental health conditions
d. Safety planning (Paragraph 5)
e. Monitoring and follow-up
2. Acute medical stabilisation and de-escalation
a. Ensure safety for both patients and medical staff. Remove any objects that may pose a danger to patients and staff
b. Assess if the patients are medically stable and provide the necessary treatment
c. Patients who are mentally rational, medically and emotionally stable can be assessed to determine their care and support needs
d. For patients who are medically unstable, emotionally labile and mentally irrational, activate emergency services (995) or refer to the A&E/IMH Emergency Departments for immediate management
e. GPs who encounter acutely severe suicidal patients, who may be at imminent risk to self or pose harm to others, can refer to Table 1 on suggested actions to take7
Table 1. Recommended Actions When Encountering an Acutely Severe Suicidal Patients |
Initial Response |
1. Assess the medical situation and provide immediate emergency resuscitation or initial treatment of injuries (e.g., wound management), while ensuring personal safety. |
Establish Rapport |
2. Thereafter, remain calm and communicate sensitively with the patients to avoid escalating the situation. Empathetically acknowledge the situation and assure the patients of your presence to assist and help.
3. Maintain rapport with the patients while ensuring personal safety. |
Escalation and Conveyance |
4. Professionally and empathetically convey the urgency of the situation to the patients, which is the immediate risk of self-harm or harm to others. Advise the patients to receive urgent psychiatric management.
5. Contact 995 and refer the patients immediately to the nearest A&E for further care. If resources permit and clinically appropriate, non-SCDF ambulances may be activated if the patients can be conveyed timely and safely to A&E or IMH Emergency Departments.
6. Should the patients refuse conveyance by ambulance, assess if alternative modes of conveyance (e.g., private transport accompanied by family members) are clinically appropriate and sufficiently safe for the patients and conveying person(s).
7. If the patients refuse treatment and there are clear medical grounds (e.g., threatened or actual self-harm in the clinic), activate SCDF and/or the police to respond to the situation in the patients' best interests and for public safety.
8. If the patients lack mental capacity at the material time, act in their best interests.
9. Where possible, obtain patients' consent to contact their next of kin. If patients cannot provide consent (e.g., mentally incapacitated) at the material time, the doctor may break confidentiality in their best interests and contact their next of kin to update on their situation and the next course of action. |
Monitoring and Safety Management |
10. Do not leave the patients unattended in the clinic. Ensure they are accompanied by clinic staff in a suitable area in the clinic until they have been conveyed.
11. Remove from the patient's reach objects that could potentially inflict injuries. |
Managing Aggressive Patients |
12. If the patients act physically or verbally threateningly, do not attempt to restrain them. Call the security or the police immediately. |
Managing Patients who Abscond |
13. If the patients leave the clinic abruptly, notify the police. This is in accordance with Section 7 of the Mental Health (Care and Treatment) Act 2008 where in this context, it is the duty of the police to reach out and engage any person, where the police believes that the person may endanger his or her own or any other person's life or personal safety, and the person's conduct is reasonably suspected to be attributable to a mental disorder. |
3. Siting of care and Interventions
a. Refer to Table 4 on siting of care and interventions based on suicide risk.
i. In general, GPs with appropriate training can manage patients identified as Low Risk (Yellow of C-SSRS).
ii.
Not all patients identified as Medium Risk (Orange of C-SSRS) may need urgent assessment by hospital Psychiatrists or referral to the A&E/IMH Emergency Departments. GPs should exercise clinical discretion and assess whether patients can be managed in the community with support. Patients should be closely monitored and referred to hospital psychiatric services if the risk level increases.
iii. In general, all patients identified as
High Risk (Red of C-SSRS) should be
urgently assessed by hospital Psychiatrists or referred to the A&E/IMH Emergency Departments if indicated. In accordance with Section 10 of the Mental Health (Care and Treatment) Act 2008, patients deemed required to receive inpatient psychiatry care may be detained in IMH for further treatment.
4. Addressing underlying factors and mental health conditions
a. Assess and address risk factors for suicide (Table 2).
b. Manage underlying mental health conditions. For patients with MDD, optimise pharmacotherapy and psychosocial intervention
c. Assess and optimise protective factors (Table 3) to reduce the risk of suicide.
5. Safety planning4,5,6
a. Develop safety plans for patients to reduce future suicide risks and increase coping ability
b. The plans should include:
i. Recognising the triggers and signs of impending suicidal crisis (e.g., such as triggers or thoughts)
ii. Planning in advance coping methods to manage future suicidal urges
iii. Identifying individuals or agencies that can be contacted to facilitate patients' safety and reduce suicide behaviour
iv. Keeping the environment safe by removing or restricting lethal means of self-harm/suicide
6. Monitoring and follow-up
a. Monitor patients as clinically indicated during treatment
b. Consider more frequent monitoring in the following circumstances:
i. Patients with greater suicide risk severity
ii. During initial treatment
iii. During medication initiation (especially in the first 3 months) or tapering.
iv. During a relapse of MDD
v. Recent hospitalisation discharge due to suicidal behaviour or underlying psychiatric condition
vi. Emergence or intensification of suicide risk factors
vii. Loss of suicide protective factors
References
1. Practice Guide for Tiered Care Model for Mental Health (Adult) for Service Providers (Tier 2-4).
2. Ng CW, How CH, Ng YP. Depression in primary care: assessing suicide risk. Singapore Med J. 2017 Feb;58(2):72-77. doi: 10.11622/smedj.2017006. PMID: 28210741; PMCID: PMC5311887.
3. National Healthcare Group Polyclinics. Clinical Practice Guidelines: Management of Depression and Anxiety (including suicide management workflow). Last updated Oct 2020.
4. SingHealth Polyclinics (SHP) Clinical Guidebook: MOOD AND ANXIETY DISORDERS CLINICAL CARE PATH. Updated: June 2024
5. Department of Veterans Affairs and Department of Defense. VA/DoD clinical practice guideline for the assessment and management of patients at risk for suicide. 2019.
6. National Institute for Health and Care Excellence. Self-harm: assessment, management and preventing recurrence (NICE NG225). 2022 September 2022.
7. National Health Group Polyclinics Procedure Manual PM-CS-COP-032 Revision 03: Management of Suicidal Patients. Effective 04 Oct 2022.
8. Singapore Statutes Online. Mental Health (Care and Treatment) Act 2008. 2020 Revised Edition. 31 December 2021.
