One of the key messages of the RCPysch's recent report, Self-harm and suicide in adults, was that some at-risk patients are not being identified and/or offered the mental health treatment that could have prevented their death.
In its Suicide Statistics Report of December 2019, Samaritans highlighted that there had been a significant increase in suicide in the UK, which appeared to be driven by an increase in the male suicide rate. Suicide fortunately remains uncommon as a proportion of the UK population, but deaths arising from suicide are tragedies that devastate families, friends and communities. These deaths will also have a significant personal impact on those healthcare practitioners who knew and cared for the deceased.
The MDU has recently reviewed GP claims files arising after patient suicides over a 10 year period, which has provided an opportunity to reflect on and learn from these sad cases in order to improve suicide prevention.
Some 90% of patients with mental health problems are cared for entirely within primary care. In the majority of encounters, there will not be cause for concern that a patient with a mental health problem poses a risk to themselves. Notwithstanding this, practitioners do need to remain alert to the fact that a psychiatric diagnosis is a risk factor for suicide.
Mental state examinations
GPs and other allied health professionals working in primary care are often the first point of contact for patients experiencing distress and hopelessness. Assessing an individual patient's suicide risk during a standard consultation can be challenging. Risk assessment tools are available but there is a lack of tools that can accurately predict suicide based on scoring systems alone (ref. RCPsych report).
However, a clinician's careful consideration of risk factors in each individual case is important. Published risk assessment tools are generally based on known risk factors, and hence still have a role in guiding a clinical assessment, although the weight a clinician puts on any one factor will depend on the circumstances.
Performing a mental state examination (MSE) can help to identify the presence and severity of a range of mental health problems and assess the risk a patient poses to themselves and others. As with any examination findings, it is helpful to document the pertinent findings of a MSE.
A common theme among the 14% of claims settled by the MDU in this review was the absence of a documented MSE and risk assessment. A comprehensive MSE observes general appearance, behaviour, speech and affect. It will include any identified disturbance of the form and content of thoughts, perception or cognition. Finally, it will assess the patient's insight. With this information, it is possible to note the assessment of risk a patient may pose to themselves and others at that particular time.
A clinician's careful consideration of risk factors in each individual case is important.
The RCPsych's report includes the following possible red flag warning signs from a mental state examination:
- high degree of emotional pain and negative thoughts including hopelessness
- ideas of guilt – including a sense of being a burden to others
- sense of being trapped/unable to escape and/or a strong sense of shame
- suicidal ideas becoming more frequent or intrusive
- suicidal ideas with a well-formed plan and/or preparation
- expressed intent to act on a suicidal plan
- psychotic phenomena, especially if distressing; persecutory and nihilistic delusions, command hallucinations perceived as omnipotent (pervasive) (ref. RCPsych report).
All of the settled claims in this review arose from an encounter during which there was a change to the patient's medication. Initiating, stopping, switching or changing the dose of psychiatric medication can coincide with a deterioration in a patient's mental state.
While it is difficult to draw a causal link in all cases, a medication review could be a suitable moment to reconsider the diagnosis and psycho-social factors contributing to the patient's situation that might be amenable to other interventions. Practitioners need to continue to be alert to this risk and ensure patients are counselled appropriately, and signposted to relevant support; for example, their local mental health team.
Key learning points
- Don't be afraid to ask a patient about depressive symptoms or suicidal thoughts if you have concerns. A sensitive enquiry might encourage the patient to discuss feelings they otherwise felt unable to express.
- Keep up to date with authoritative guidance in mental health, such as the NICE guidance on self-harm, and mental health services available in your area. Knowing what extra help is on offer can make it easier when trying to arrange referral or crisis help for a patient.
- If you're making an urgent referral in a crisis, track the referral to make sure it is actioned as you intended.
- It's a good idea to document a mental state examination (MSE) and your risk assessment.
Explain patients' options to them clearly, including talking therapies, the risks or side effects of medications and details of crisis team or out-of-hours help.