NSW Health suicide care pathway

Establish a therapeutic relationship

A good alliance between the clinician and the person in the early stages of therapy is vital for therapy success. A positive therapeutic relationship includes:

• trust, care and respect
• agreed goals of care
• collaboration on the care plan and tasks to be undertaken.

Ask directly about suicide

Most people who die by suicide contacted a clinician weeks or months before their death. Many don’t talk about suicidal thoughts and plans unless asked. Asking doesn’t make the situation worse. It is critical to identifying and supporting a person who may be contemplating suicide.

Engage with family and the support network where appropriate

With the person’s consent, contact family members or other people who support them during difficult times. This allows you to explore who can help in assessment and treatment planning and to collaboratively develop an escalation process.

Conduct a comprehensive mental health assessment

This includes information about:

• current life stressors
• the person’s strengths, supports and protective factors
• acute mental or physical illness or substance use.

Ask if the person has thought about hurting themselves and ending their life, even when there are no indications of suicidality.

Consider nature of suicidality and its drivers

Identify factors that contribute to a person’s distress, thoughts about suicide and their capacity to navigate suicidal crises. Explore the severity and frequency of suicidal ideation and check:

• if this has changed over time
• the contextual factors that may be impacting the person.

Gather collateral information

If appropriate, mental health assessments and assessment of suicidality, should include the views of family and carers and information from other health professionals who support the person.

Person-centred suicide prevention formulation comprises

Consider suicide risk factors

Person-centred suicide prevention formulation requires you to learn about what is happening in the person’s life. This helps to identify and address risk factors that can be modified. It also enables the most appropriate and valuable support, treatment and care.

Explore protective factors

Determine the nature of the person’s protective factors and how they can be strengthened.

Identify available resources

Take note of the person’s internal and external resources and what is available to help them cope during times of crisis.

Brief intervention requires an immediate action plan consisting of:

Address access to lethal means

As part of an immediate action plan, minimise the availability of lethal means. Doing this can delay a person’s ability to act on suicidal thoughts until the thoughts subside, or care can be provided.

Provide person, family, carer education

The person, their family and support networks need to be given information relevant to the person’s experiences and the supports available to them. This will empower the person to make informed decisions about their recovery.

Develop a safety plan and review

This includes listing coping strategies and sources of support a person wishes to use when they experience a suicidal crisis. The list may cover:

• exploring warning signs of an impending suicidal crisis
• internal coping strategies
• use of social contacts and social settings
• seeking help from friends and family members
• engaging professional help
• addressing access to lethal means.

Rapid follow up

All people identified as at risk of suicide should be followed up, ideally within 24-48 hours.

Treatment requires a comprehensive care plan consisting of:

Treatment for suicidality and address drivers of suicidality

Include therapies that specifically aim to reduce suicidality. Also include treatments or interventions that address the drivers of the person’s suicidality, for example, isolation.

Examples of treatment include cognitive behaviour therapy for suicide prevention (CBT-SP) collaborative assessment and management of suicidality (CAMS) and dialectical behaviour therapy (DBT-SP).

Address modifiable suicide risk factors

These could include:

• underlying mood
• depression
• psychotic and other mental disorders
• substance misuse
• physical illness
• pain and pain syndromes
• past trauma
• isolation.

These risk factors apply even if there is no direct causal link between the experience and the suicidality for a particular person.

Consider and incorporate social and cultural supports and networks

These assist a person to thrive and have a life they want to live. Promote activities that strengthen recovery and consolidate protective factors. This includes considering factors such as employment, housing, spirituality, cultural connections, and social networks.

Facilitate a warm handover

Combining written referrals with a person-to-person discussion with other service providers enables clinicians to highlight key points and introduce the service to the person.

Assertive follow-up during transition

Proactive contact with a person needs to be maintained during transitions of care to ensure the person connects with the new services or supports. Contacts after discharge provide reminders and encouragement about recovery and the supports available. During follow-up contacts, suicide risk formulations need to be reviewed and supports amended accordingly.

Ensure holistic supports are engaged

Ensuring these supports are activated helps the person to recover. The supports may include assistance with:

• employment
• housing issues
• connecting people with peer-led or social networks.