Suicide prevention in mental health services – Guidelines

Although risk factors cannot identify suicidal individuals with any certainty, they can alert a clinician to take particular care in assessing an individual.

There are a wide range of factors that can influence suicide risk, from mental illness or chronic or physical ill-health issues, to a history of trauma, abusive relationships, or stressful life events such as unemployment, financial and housing instability, relationship breakdown and family violence, bereavement, or a history of suicidal thoughts and self harm.

• Men are three times more likely to die by suicide than women (although women make more suicide attempts).
• There are some groups of people that experience higher rates of suicide due to sustained trauma, racism or discrimination, such as Aboriginal and Torres Strait Islander people and gay, lesbian, bisexual, transgender and intersex people, in particular, trans and gender diverse people.
• People recently discharged from acute psychiatric services are particularly vulnerable, exhibiting a suicide risk 100 to 200 times greater than normal in the month after discharge.
• Adolescents and young people can also face risk factors that may elevate their suicide risk, from mood and anxiety disorders to substance use, bullying, feelings of isolation, or the influence of close friends who have taken their own lives.
• The elderly face unique risks stemming from their declining health, social isolation, recent bereavements and concerns about being a burden to others.

Treatment plans should include written information regarding available community resources (for example, help lines), dates of review appointments, and specific services to contact in a crisis. If the person provides informed consent, family members and supporters should be given a copy of the plan , advised to remove any means of self-harm within the home, and asked to monitor the person’s whereabouts and any sudden changes in their behaviour.

It is vital to involve the person in the preparation of any treatment plan, providing them with both written and verbal information about the nature and purpose of the treatment they are being offered. This can help to alleviate pressure on people who may be incapable of making important healthcare decisions due to their distress. Family and supporters should also be involved in preparation of treatment plans (as appropriate) and with the informed consent of the person.

Careful consideration should be given to the degree of support available to the person and the level of risk. Although people facing acute suicide risk are generally better managed in an inpatient environment, the Mental Health and Wellbeing Act 2022 requires preference to be given to the least restrictive approach to treatment and care. Where appropriate for the level of risk, a home-based treatment plan may be appropriate. Home-based plans require detailed evaluation of the person’s home environment and social supports, to gauge levels of personal support as well as potential stress factors.

In the case of suicidal behaviour, the level of risk will require broader enquiry into a person’s living and family circumstances, as well as other stressors that may be present in the person’s life. Collection of information from the person’s family or other service providers is governed by the Health Records Act 2001 and the Health Privacy Principles, which relate to consent and the need to collect information to prevent or mitigate a serious threat to a person’s life. For more information please see MHW Act 2022 Information Sharing.

The Mental Health and Wellbeing Act 2022 adopts a consent-driven approach to information sharing. As a general rule, consumer consent is required for the sharing of health and personal information, and consumers are able to withdraw this consent at any time.

The Act includes a positive duty for providers to share some or all of a person's health information to family, a carer or a supporter, if a consumer has consented to the sharing of that information, following the consumer's admission or discharge from an inpatient service.

There are some circumstances where the sharing of information be overridden and where health information can be disclosed without consent. For more information please see MHW Act 2022 Information Sharing.

When a person is acutely suicidal or has severe psychiatric illness or inadequate social supports, there is a clear need for inpatient management and close supervision. It is important to remember that inpatient management does not always prevent suicide, which can occur in inpatient settings or during day leave.

Depending on the acuity of risk, the level of supervision may range from management in a high-dependency area to continuous one-to-one observation by a staff member.

The Mental Health and Wellbeing Act 2022 requires that voluntary assessment and treatment is preferred over compulsory approaches wherever possible.

A person subject to an assessment order may only be given treatment for their apparent mental illness if:

• they give informed consent to the treatment (the Act includes specific requirements in relation to informed consent); or
• where the treatment is required as a matter of urgency to prevent serious deterioration in their mental or physical health or serious harm to the person or another person.

If the person is not mentally ill within the meaning of the Act, the clinician should document the clinical basis for their diagnosis, together with the nature of the treatment and care offered, and contact family and friends so that they can provide informed support.

Careful and detailed documentation is particularly critical to keep clinical staff and caregivers informed of the continuing assessment and management of people facing a suicide risk.

The guidelines on Working with the suicidal person offer a series of criteria for planning safe discharge services, including:

• A comprehensive suicide risk assessment has been conducted and an appropriate treatment plan is in place.
• The person is medically stable and has adequate social supports.
• The person has agreed to return to the mental health service if their suicidal intent returns.
• The person, their caregiver and family have been provided with written copies of their treatment plan, including details of any medications, ways to deal with symptoms and distress, dates of follow-up appointments, and contact numbers for times of crisis.
• All attempts have been made to remove potentially lethal means of self-harm.
• Treatment of any underlying psychiatric diagnoses has been arranged.
• Appropriate steps have been taken to address psychosocial precipitating factors.
• GPs, counsellors and other community services have been consulted and are in agreement with the discharge arrangements.
• A written report will be sent to the person’s GP and psychiatrist/psychologist within 72 hours.
• Follow-up with the person will be conducted as soon as possible, ideally within 72 hours.

It is important for clinicians to understand that the risks of suicide or self-harm for Aboriginal people extend beyond an expression of mental or alcohol-related disorder. Social and cultural risk factors such as social cohesion, spirituality, sexual abuse, family violence, racism, removal policies, unemployment and lack of connection to country must always be considered.

Building rapport is especially relevant when interviewing Aboriginal people, for whom personal relationships and community respect are highly valued:

• Interviews should be conducted at a relaxed pace that tolerates periods of silence and allows people to tell their story at their own pace.
• Aboriginal people may be guarded and reticent in a clinical setting, but usually respond well to respectful, non-intrusive approaches.
• Clinicians who take time to find out who a person is as an individual and where they stand in the community will increase their capacity to forge a genuine therapeutic relationship.

Although open dialogue about suicide is encouraged with non-Aboriginal clients, many Aboriginal people prefer to not speak about suicide directly, but rather to focus the conversation on protective factors.

Recommended treatments or interventions should be culturally sensitive to work within the most accessible levels of the person’s social system. Traditional treatments can be considered as viable alternatives, and follow-up referrals should wherever possible be made to Aboriginal health professionals and services.

Indigenous communities will often try to care for people within their community until they become violent, and may not seek help from health services until times of great crisis.