Maria Michail is a Senior Research Fellow at the Institute for Mental Health, University of Birmingham. She has expertise in suicide prevention research and has in the past worked with the RCGP to develop an educational resource to support GPs in the assessment and management of suicide risk
People with self-harm and suicidal behaviour often present to primary care to seek help. In fact, 80% of those who die by suicide contact primary care in the year (even months) prior to the suicide.1 We know from our work2 and that of others3 that GPs are a trusted and valued source for help-seeking among those who are at-risk of suicide.
Suicide prevention remains, however, a challenge for primary care with many GPs citing constraints including time pressures, lack of training and resources, and lack of clear and effective care pathways.4 Managing risk in primary care, with little input from other professionals or agencies, is an ongoing concern for many GPs. As one GP, I recently spoke to, said: “There’s nothing worse than losing a patient to suicide. What it comes down to is this: How can I keep this patient safe?”
“There’s nothing worse than losing a patient to suicide…. How can I keep this patient safe?”
This is where safety planning comes in. Safety planning is a simple and brief intervention5 whereby a clinician and a patient work collaboratively to identify:
i) Signs (e.g. behaviours, feelings or situations) in the patient’s life that can trigger a suicidal crisis.
ii) Protective factors such as coping strategies or resources the patient can use before or during a suicidal crisis to help them cope.
Why is safety planning important?
Because during an acute suicidal crisis, what people often experience is hopelessness along with a claustrophobic sense of being trapped. Feeling like there is no hope that things will ever get better; and no way of escaping from the pain. During a suicidal crisis, what can make a difference is having a list of tools, coping strategies and resources patients can use to help them break the cycle of suicidal thinking.
Safety planning is recommended as best practice for the management of suicide risk by NICE. New evidence published in the British Journal of Psychiatry shows that safety planning can reduce the risk of suicidal behaviour by 43% among patients who have received such an intervention. For GPs, safety planning can be a practical way of identifying risks and needs in primary care but also key for building a trusting relationship with a patient.
Five key questions can be used by GPs5 to co-create a safety plan with a patient:
1. What are those signs (e.g. stressful situations, distressing thoughts and feelings) that might trigger your suicidal thoughts?
2. What are some of the things you can do to distract yourself when having suicidal thoughts?
3. Whom would you turn to (e.g. friend, family member) or where would you go for help when feeling suicidal?
4. Which professionals or agencies can you contact when feeling suicidal (e.g. helplines, emergency services)?
5. What things (e.g. sharp objects, medication) can we remove or limit access to in order to keep you safe?
Some practical tips about co-creating a safety plan:
• Write down the safety plan using the patient’s own words- if the plan is personalised it would be easier for the patient to engage with it.
• Keep it brief and simple.
• Work with the patient to identify reasons to live; for example, what keeps them going; what do they look forward to in the future.
• Give the patient a copy of the safety plan to take with them so they can use it whenever they feel suicidal.
Safety planning is a quick, practical and effective intervention, grounded in the realities of general practice, that can save lives.
- Stene-Larsen K, Reneflot A. Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scandinavian Journal of Public Health. 2019;47(1):9-17. doi:1177/1403494817746274
- Farr J, Surtees ADR, Richardson H, et al. Exploring the processes involved in seeking help from a general practitioner for young people who have been at risk of suicide. Int J Environ Res Public Health. 2021;18(4):2120
- Bellairs-Walsh I, Perry Y, et al. Best practice when working with suicidal behaviour and self-harm in primary care: a qualitative exploration of young people’s perspectives. BMJ Open. 2020;10(10):e038855
- Michail M, Tait LExploring general practitioners’ views and experiences on suicide risk assessment and management of young people in primary care: a qualitative study in the UKBMJ Open 2016;6:e009654. doi: 10.1136/bmjopen-2015-009654
- Stanley, B, Brown, GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract 2012; 19(2): 256–64
- Strengthening the frontline. Investing in primary care for effective suicide prevention. Centre for Mental Health & Samaritans, London 2019.