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Mental Health & Substance Use

Suicidal Behaviour / Self Harm

Suicidal behaviour refers to acts intended to end one's life. Self-harm refers to intentional self-poisoning or injury, which may or may not have fatal intent but indicates significant distress. Both require urgent assessment and management.

Also known as: Suicide Attempt, Self-Inflicted Injury, Parasuicide

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Referral and warning signs

When to refer

URGENT referral to hospital (HC4/H) and mental health specialist consultation needed for: ALL individuals presenting after a suicide attempt or act of self-harm. ANY individual assessed to be at imminent risk (current suicidal ideation with plan/intent). Individuals with non-imminent risk should be referred for specialist mental health assessment and follow-up.

Red flags

  • Expressing clear intent to die with a specific plan
  • Access to lethal means
  • Recent suicide attempt or severe self-harm
  • Severe agitation, hopelessness, or psychosis
  • Command hallucinations telling patient to harm self
  • Strong risk factors present with poor protective factors
  • Sudden calmness or resolution after period of distress (may indicate decision made)

Signs and symptoms

  • Presentation varies:
  • - Current suicide attempt or act of self-harm (e.g., poisoning, cutting, hanging attempt).
  • - Imminent risk: Expressing current suicidal thoughts with a plan and intent; severe agitation, violence, emotional distress; hopelessness; social isolation.
  • - Non-imminent risk with past behaviour/thoughts: History of suicidal thoughts/plans within last month OR self-harm/suicide attempt within last year, but currently not acutely distressed or intending action.
  • Verbal Cues: Talking about wanting to die, feeling hopeless, having no reason to live, being a burden, feeling trapped, unbearable pain.
  • Behavioral Cues: Increased substance use, withdrawing from activities, isolating, sleeping too much/little, visiting/calling people to say goodbye, giving away possessions, aggression, fatigue, searching online for methods.
  • Mood Cues: Depression, anxiety, loss of interest, irritability, humiliation/shame, agitation/anger, sudden sense of calm after period of distress.

Risk factors

  • Psychiatric disorders (MAJOR risk): Depression (esp. severe), Bipolar disorder, Psychosis (schizophrenia), Alcohol/Substance use disorders, Personality disorders (esp. Borderline), Anxiety disorders, Eating disorders, PTSD.
  • Previous suicide attempt (strongest predictor).
  • Family history of suicide or mental illness.
  • Chronic physical illness, chronic pain, disability, terminal illness (e.g., HIV/AIDS, cancer).
  • Recent loss or stressful life event (relationship breakup, job loss, financial crisis, bereavement).
  • History of trauma or abuse (physical, sexual, emotional).
  • Social isolation, lack of support.
  • Access to lethal means (pesticides, firearms).
  • Demographic factors (e.g., older age associated with higher completion risk, though attempts more common in younger).
  • Impulsivity.
  • Hopelessness.

Diagnosis

Clinical assessment

Assessment involves direct questioning about suicidal thoughts, plans, intent, and past behaviour. Asking does NOT increase risk. Establish rapport first. Assess immediate safety and level of risk (imminent vs non-imminent). Identify underlying psychiatric/medical conditions and psychosocial stressors. Assess protective factors (reasons for living, support systems).

Investigations

  • Complete medical, social, family history.
  • Mental state examination, focusing on mood, hopelessness, psychosis, impulsivity.
  • Direct questioning: 'Are you having thoughts of harming yourself?', 'Have you thought about how you would do it (plan)?', 'Do you intend to act on these thoughts?'
  • Assess risk factors and protective factors.
  • Investigate and manage any underlying medical conditions or substance intoxication/withdrawal.
  • No specific lab tests for suicidality itself.

Diagnostic criteria

Assessment of risk level based on presence and severity of suicidal ideation, plan, intent, risk factors, protective factors, and current mental state.

Management

Non-pharmacological management

  • Immediate Management (Acute Attempt / Imminent Risk):
  • - Ensure safety: Admit patient. Provide secure, supportive environment. Remove ALL potential means of self-harm (belts, sharps, medications, ligatures). Do not leave patient alone. Continuous observation (1:1 if necessary).
  • - Treat medical complications: Manage overdose (see Toxicology), treat injuries (bleeding, wounds).
  • - Activate psychosocial support: Involve family/carers (if supportive), social workers.
  • - De-escalation techniques for agitation.
  • - Establish therapeutic alliance.
  • - Develop a safety plan: Coping strategies, identifying triggers, sources of support, emergency contacts.
  • Management (Non-imminent Risk):
  • - Offer psychosocial support.
  • - Develop safety plan.
  • - Establish regular follow-up.
  • - Refer to mental health specialist for comprehensive assessment and treatment planning.
  • Psychotherapy (Longer term): CBT, Dialectical Behavior Therapy (DBT), problem-solving therapy can reduce risk.

Pharmacological treatment

  • Treat Underlying Mental Disorder: Aggressively treat depression, bipolar disorder, psychosis, anxiety, substance use disorder according to specific guidelines (see relevant sections). Effective treatment of underlying condition reduces suicide risk.
  • Medications for acute agitation may be needed (e.g., Benzodiazepines, Antipsychotics) but used cautiously.
  • No specific 'anti-suicide' medication, but Lithium (for bipolar) and Clozapine (for schizophrenia) have evidence for reducing suicide risk in those specific conditions.

Monitoring

Continuous monitoring in acute/imminent risk situations. Regular and frequent follow-up after discharge/initial assessment is crucial. Monitor mental state, suicidal ideation, adherence to treatment, psychosocial situation. Re-assess risk frequently.

Complications

  • Completed suicide
  • Serious injury from attempt (e.g., brain damage from hypoxia, organ damage from poisoning, disability from physical trauma).
  • Psychological trauma for patient and family.
  • Social stigma.
  • Recurrent attempts.

Prevention

  • Early identification and treatment of mental health and substance use disorders.
  • Reducing access to lethal means (secure storage of pesticides/medications/firearms).
  • Responsible media reporting of suicide.
  • School-based awareness and prevention programs.
  • Community support and reducing stigma.
  • Crisis support services (helplines - if available).
  • Training healthcare workers in suicide risk assessment and management.
  • Follow-up care for individuals who have attempted suicide.

Patient education

  • Validate the patient's distress while conveying hope for improvement.
  • Explain that suicidal thoughts are often related to treatable mental health conditions.
  • Discuss the safety plan and importance of using it.
  • Emphasize importance of follow-up and treatment adherence.
  • Involve family/support system (with patient consent) in safety planning and support.
  • Provide contact information for crisis support if available.

Uganda-specific notes

Suicide risk assessment should be part of routine mental health evaluation. Common methods in Uganda may include pesticide ingestion, hanging. Stigma is high. Access to mental health specialists and crisis support is limited. Focus on immediate safety, treating underlying conditions (medical and psychiatric), involving family/community support, and ensuring follow-up.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 9, Section 9.2.2.2

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