A range of care should be available for any individual according to their risk level and need. Any level of suicidality warrants the person receiving an initial assessment, safety plan and treatment plan. This is based on the fact that suicide is highly unpredictable and many who die by suicide have been deemed low risk. Delivering an SFI requires that the person is able and willing to engage with the process. This means being able to sit and have a conversation. If a person cannot do this, for example if she or he is manic or psychotic or if a person, despite repeated efforts by clinicians, refuses to engage, then alternative interventions should be considered depending on their level and immediacy of risk.

Jobes (2016) proposed a stepped care model with a range of interventions. Jobes and Chalker (2019) argue that suicidal patients are by definition seen as mentally ill and out of control, which demands hospitalisation and the treatment of the mental disorder (often using a medication-only approach). However, the evidence for inpatient care and a medication-only approach for suicidal risk is either limited or totally lacking. Thus, the “one-size-fits- all” approach to treating suicidal risk needs to be re-considered in lieu of the evolving evidence base. The authors highlight a series of evidence-based considerations for suicide-focused clinical care, culminating in a stepped care public health model for optimal clinical management of suicidal risk that is cost-effective, least-restrictive and evidence-based.

If the risk of suicide is considered to be high or uncertain, the person should be referred immediately to mental health services (Fazel & Runeson 2020). People at high risk and unable to keep themselves safe maybe offered admission to a psychiatric unit and if this is refused detained involuntarily under the Mental Health Act. The Mental Health Act in England and Wales recommends that patients should generally be admitted under Section 2 (for assessment lasting 28 days) or Section 3 (for treatment lasting six months) of the Act, which requires two doctors and an approved mental health professional (e.g. a social worker) to complete. Section 4 can only be justified in emergencies when only one doctor is available, it lasts for only 72 hours, and either a Section 2 or Section 3 must be completed during this 72-hour period. Part III of the Mental Health Act applies to patients who have been alleged to have committed a crime and their detention in hospital is through the criminal justice system. Essentially detention in hospital under the Mental Health Act is considered if the patient’s health or safety is at risk or the safety of others is at risk. In this context, individuals at potential risk of suicide may be involuntarily admitted. However, there is increased risk of suicide within the first seven days of involuntary hospital admission (Meehan et al 2006) (Figure 2.1).

See services/mental-health-act/.

Levels of care

Figure 2.1 Levels of care.

Least restrictive/lowest cost adapted from Jobes (2006).

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