An early study found that in a sample of 134 people who had ended their life, over two-thirds (69%) had communicated suicidal thoughts and 41% had specifically stated they intended to end their lives (Robins et al 1959). Sixty per cent had communicated suicidal thoughts to a spouse and 50% to a relative. In a study of 60 deaths by suicide in Wisconsin, half had informed their spouses or another close relative of their suicide intent, but only 18% had relayed their suicidal intent to health care providers (Mays 2004). A review of 468 suicides over four years in a US metropolitan area found that 38% had either written a suicide note or had informed others of their intent (Shen et al 2006).

Importantly, most people who end their life have had contact with a health care provider within days or weeks of their suicide. Around half of people who have died by suicide speak to a GP in the previous month, though not necessarily disclosing their suicidal thoughts (Harwitz 8c Ravizza 2000; Luoma et al 2002; Stene-Larsen 8c Reneflot 2019). Of those appointments, where the cause of the appointment was known, 50% were for psychological or psychosocial reasons (Isometsa et al 1995). On average, 45% of suicide victims have had contact with primary care providers within one month of suicide. Older adults had higher rates of contact with primary care providers within one month of suicide than younger adults. A systematic review of 44 studies from 2000 to 2017 (Stene-Larsen 8c Reneflot 2019) found less than one in three people who end their life by suicide had contact with a mental health service in the previous month. So the majority of people who die by suicide do not approach mental health services for support. However, many do visit their GP in the preceding months before their death, although they may present with physical, rather than mental health, problems.

Goodpractice point

Primary care has a crucial role to play in identifying people at risk of suicide and ensuring they receive appropriate treatment and care (Centre for Mental Health 2019; Stene-Larsen 8c Reneflot 2019). Ideally GPs should be alert to the possibility of depression and suicide risk in high-risk groups, even if the patient does not present with this as their main problem (Booth et al 2000).

See for suicide awareness training for GPs.

Not all patients at risk communicate suicidal ideation to clinicians (Hall et al 1999). Of those people who are referred to mental health services and assessed, there is a small but important minority of patients who do not inform their providers of their plans or intent. A prospective study of patients who killed themselves within six months of a thorough mental health assessment found that more than half denied any suicidal ideation or reported, at most, vague suicidal ideation (Fawcett et al 1993). For those individuals who do have contact with health care services, only 3-22% had reported suicidal intent at their final appointment with a health care professional before ending their life (Matthews et al 1994; Isometsa et al 1995; Pearson et al 2009).

There are a number of barriers people may have to approaching mental health services or even their GP, including the stigma of having a mental health problem and using mental health services.

Czyz et al (2013) found the most commonly reported barriers to helpseeking included perception that treatment is not needed (66%), lack of time (26.8%) and preference for self-management (18%). Stigma was mentioned by only 12% of students. There were notable differences based on gender, race and severity of depression and alcohol abuse. Online surveys indicate that men in particular are less likely to seek professional help for suicidal thoughts and urges. A Samaritans survey published in March 2019 found two in five (41%) men in England, Scotland and Wales aged 20-59 do not seek support when they need to, because they prefer to solve their own problems. The survey also showed that men often do not want to feel a burden and don’t feel their problems will be understood.

See encourage-men-seek-help/.

An online survey conducted by Atomik Research among 501 adult men aged 18 and over in the Republic of Ireland found one in four men (25%) who had suicidal thoughts in the previous 12 months did not reach out for help due to feeling they had no one to trust, with 37% feeling like a burden. The survey also found that some of the main reasons why these men find life so challenging include job loss or employment issues (38%), relationship or family problems (38%) and debt or financial worries (37%).

See to-seek-help-talk-to-us/.

Patients who are intent on attempting suicide may not reveal their plans. Those who truly want to die and see no hope of relief have little reason to disclose their risk and may even actively deny it. Even if their ambivalence about attempting suicide leads them to voluntarily call a crisis line or go to an Emergency Department (ED), they may be quite cautious about revealing the full truth. They may share only some of their suicidal ideation, plan or actions taken toward that plan, whilst hiding their real intent. The more intensely someone wants to proceed with suicide, the more likely they are to withhold their true intent. Shea (2016) gives a number of reasons why people may be hesitant to openly share. They may:

  • • lack extensive suicidal ideation before attempting suicide but act with impulsivity;
  • • have had marked suicidal ideation and be serious about dying by suicide but purposely not relaying suicidal ideation or withholding the method of choice because they do not want the attempt to be thwarted;
  • • feel that suicide is a sign of weakness, immoral or a sin and be ashamed to acknowledge it;
  • • fear the consequences - they may be detained or hospitalised; others will find out or be at risk of losing their children;
  • • not believe that anyone can help;
  • • have alexithymia or difficulty describing emotional pain or material.

They may also have had negative previous experiences of health care when they have previously disclosed suicidal thoughts or urges. For all these reasons, Shea argues that determining the credibility of the person’s self-report is vital. Other sources of information such as family members, therapists and police can also have an important role in a comprehensive risk assessment.

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