Staying safe from suicide- beyond risk prediction

NHS England have produced new best practice guidance called ‘Staying safe from suicide’.

Central to the guidance is the concept that suicide prediction tools and static risk stratification (e.g. low, medium or high risk) is inherently unreliable due the highly fluctuant nature of suicidal impulses.  They point to evidence that people may have no planned intent just minutes prior to acting on a thought of suicide. Additionally, they highlight the ‘low-risk paradox’: the majority of people in contact with mental health services who die by suicide have been assessed as low risk at their last encounter, with 80% judged at low risk. In stark language, they advise that the use of static stratification is ‘unacceptable’.

This aligns with current NICE guidance NG225 ‘Self-harm: assessment, management and preventing recurrence’ which states: ‘Do not use risk assessment tools to predict future suicide of repetition of self-harm’, and goes on to clarify that treatment decisions should not be based on the outcome of these tools, nor global risk stratification (e.g. low, medium, high risk).

So what should we be doing?

NHSE advocate moving away from risk prediction to a ‘holistic, person-centred approach’. A recent BMJ editorial describes this as a ‘safety first approach’. Use a biopsychosocial approach to explore the presenting problem/ current safety concerns, identify modifiable and dynamic risk factors, and then formulate individualised safety and treatment plans to address safety concerns. Regular reassessment and patient collaboration is key.

NHSE breaks it down into three core components:

1. Safety assessment: ‘explore’ information about past present and future risks. Engage, listen and display compassion
2. Safety formulation: ‘map’ a shared understanding of any current safety concerns and highlight factors that may change the risk. Use the ‘three Ps’ as a framework:
   • Presenting problem: what are the current difficulties with staying safe?
   • Protective factors (e.g. support network, future plans, exercise)
   • Precipitating factors (e.g. financial stress, alcohol use, relationship breakdown)
   • Also consider predisposing factors (chronic conditions/ previous trauma), and perpetuating factors (e.g. addiction)
3. Safety management and planning: 
   • Immediate safety actions: Do you need to refer to the crisis team? What actions can be taken to mitigate risk? Involve trusted others (e.g. friends and family)?
   • Longer term safety planning: collaborate with the patient to create a safety plan to manage future changes in safety and review regularly. Discuss next steps and actionable treatment/ support options. (For an example safety plan see the NHSE guidance, or for patient accessible resources see the RCPsych and Samaritans templates). Note evidence from a metanalysis demonstrating the effectiveness of safety plans, with a NNT of 16!

As a recent BMJ editorial points out, the NHSE guidance was developed from the consensus of 120 research, clinical and lived experience experts rather than systematic review. As such it should be regularly re-evaluated in light of NHS outcomes. Advances in research methods, modelling and AI may lead to more nuanced risk prediction models.  One day we may be embracing new risk models to support clinical decision making again!

For now, the take home message is to adopt a person-centred holistic approach, understand their unique situation and build safety measures into the treatment plan. Many of the principles of good care detailed in the guidance describe areas in which primary care is ideally placed to excel. NHSE highlight the importance of ‘relational safety’ (i.e. building and maintaining a collaborative therapeutic relationship) as a strong predictor of good clinical outcome. Other principles include clear communication, inclusivity, and involvement of the patients’ wider support network (where appropriate). Overall, this feels like good sensible general practice!