Before, during and after the act, plus static and dynamic risk factors
Expansion
Circumstances of the act
- Before: planning or impulsivity, final acts (a note, a will, giving possessions away), precautions against discovery, whether alcohol or drugs were involved
- During: method and its lethality, the patient’s belief about lethality, which matters more than the actual risk
- After: who found them and how, did they seek help, and how do they feel now about having survived; regret at surviving is a serious feature
Current intent: thoughts, plans, means, and preparatory acts. Escalation from fleeting thoughts to a formulated plan with access to means represents markedly higher risk.
Static risk factors: male sex, older age, previous self-harm (the strongest single predictor), family history of suicide, chronic physical illness or pain.
Dynamic and modifiable factors: depression, psychosis with command hallucinations, alcohol and substance misuse, recent loss, unemployment, debt, relationship breakdown, social isolation, recent discharge from psychiatric care, access to means.
Protective factors: dependent children, social support, engagement with services, religious belief, future plans, and expressed reasons for living.
Risk assessment tools do not predict suicide and should not determine management. The purpose of assessment is to understand the person and to construct a safety plan: removing means, identifying warning signs and coping strategies, naming contacts, and arranging follow-up.
Every presentation with self-harm warrants a psychosocial assessment, regardless of the medical severity, which correlates poorly with intent.