Suicide safety plan: risk detection and management in primary care

EACH day, nine Australians die by suicide, and close to 200 will attempt to take their lives. Over two million Australians have seriously considered suicide at some point in their lives.

With numbers like these, it’s inevitable that front line health workers will come into contact with people at risk of suicide during the course of their daily work. In fact, over 40% of people who die by suicide have been in contact with a primary health care provider in the month before their death.

Suicide still carries a great deal of stigma, and those experiencing thoughts of wanting to die may be reluctant to disclose to a health worker.

Our new research with visitors to the Beyond Blue website has found there may be a way to open up these crucial conversations through the use of a simple screening tool.

The K10 test is a commonly used screener for warning signs of anxiety and depression. While it doesn’t directly ask questions about suicide, in our follow-up survey on the Beyond Blue website, visitors who scored in the very high range on this test had also often experienced thoughts of suicide during the past 4 weeks.

An important linking factor in this relationship was the sense of burden that a person felt: higher levels of psychological distress were associated with beliefs that loved ones would be better off if they were gone, which in turn led to thoughts of suicide.

Visitors with higher levels of psychological distress also reported lower help-seeking intentions, financial wellbeing, and social disconnectedness that appeared to additionally fuel this sense of being a burden on others, illustrating how pervasive and complex these beliefs can be.

Screening for psychological distress and asking questions about thoughts of being a burden may serve as a softer entry point for prompting a discussion around suicide during routine health check-ups.

If suicidality is indicated, the door is now open for more detailed assessment and referrals.

The concern remains about how a person at risk of suicide will stay safe once they leave their appointment. As most suicide crises will occur when a person at risk is on their own, this requires a self-guided intervention that the person can use when suicidal distress is at its highest, and their ability to problem-solve is compromised.

Making a suicide safety plan

This is where a suicide safety plan can be of immense value. It’s a brief, evidence-based intervention that has been shown to reduce the likelihood of future suicide attempts and strengthen a person’s ability to cope during a suicide crisis.

Made collaboratively with a person at risk, suicide safety plans draw together a person’s coping strategies and supports in a series of prioritised steps that can be worked through. These personalised steps include:

• warning signs: such as increased drinking or thoughts of being a burden on others;
• make my environment safe: for when a specific suicide plan has been disclosed, limiting access to ways of hurting themselves;
• reasons for living: reminders of positive life experiences and connections;
• things I can do by myself: distraction techniques and coping strategies;
• people and places to connect with: an extension of distraction techniques, but involving the presence of other people;
• people I can talk to: if the first five steps have not resolved the crisis, this step lists trusted others that the person can disclose their suicidal thoughts to; and
• professional supports: emergency contacts if the person is at immediate risk of harming themselves.

Safety plans can be made on paper or digitally in mobile applications (apps) such as Beyond Blue’s Beyond Now. App-based safety plans carry the advantage of being more easily accessible. When Beyond Blue developed the Beyond Now app alongside clinicians and people with lived experience of suicide, a number of additional features were added to enhance the utility of the safety plan. These included the ability to share the plan with a trusted other, adding photos or videos into the “reasons for living” section, and one-touch calling of support and emergency numbers from within the app.

Over 50 000 people have used the Beyond Now app in the past 12 months (unpublished internal data). Our evaluations show that most use the app when experiencing a suicidal crisis, but many also report using it when noticing their warning signs or when seeking reassurance. This suggests safety plans can act as protective tools in addition to mitigating a crisis.

Not all safety plans are created equal. Generic plans are not as helpful as quality plans that contain highly specific and personalised detail that a person can easily follow when highly distressed. This requires collaboration between practitioner and client when making a safety plan to not only build on a person’s strengths but also overcome any barriers to using the plan during a crisis.

Research with military veterans has found that an individual’s likelihood of attempting suicide in the future decreases by more than 10% for each high quality item in a safety plan. Safety planning is perceived as most meaningful and helpful when clients feel a practitioner is partnering with them to work through concerns, highlighting again the importance of a person-centred, collaborative relationship when managing suicide risk.

If you’re interested in learning more about suicide safety planning and how to develop quality plans with clients, a free, accredited training webinar for health professionals in digital safety planning is being held on 22 February through the Black Dog Institute’s eMHPrac program — the recording can still be accessed after 22 February.

Conclusion

Suicide remains a leading preventable cause of death in Australia. Thoughts of suicide can be driven by beliefs of being a burden on others that arise from heightened levels of psychological distress. These beliefs may be hidden, and identifying them early through simple screening tools can help with more accurate triage. For people identified as at-risk, a well-crafted, collaborative safety plan can enhance the therapeutic relationship, a client’s self-efficacy, and their ability to successfully cope with a suicide crisis in the future. It’s a simple, brief intervention that substantially reduces the risk of future suicidal behaviour.

Christopher Rainbow is a suicide prevention researcher at Beyond Blue, who manages the ongoing improvement and evaluation of digital, self-guided suicide prevention interventions; including psychological distress screening for website visitors and the Beyond Now suicide safety planning app.

Dr Grant Blashki is a practicing GP, lead clinical advisor for Beyond Blue, and Associate Professor at the Nossal Institute for Global Health, University of Melbourne.

If this article has raised issues for you please reach out to any of the following resources:

DRS4DRS: 1300 374 377

• NSW and ACT … 02 9437 6552
• Victoria … 03 9280 8712
• Tasmania … 1800 991 997
• Queensland … 07 3833 4352
• WA … 08 9321 3098
• SA and NT … 08 8366 0250

If you or someone you know is having suicidal thoughts, there are people here to help. Please seek out help from one of the below contacts:

• Lifeline| 13 11 14: 24-hour Australian crisis counselling service
• Suicide Call Back Service| 1300 659 467: 24-hour Australian counselling service
• beyondblue| 1300 22 4636: 24-hour phone support and online chat service and links to resources and apps

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.