Mental health is challenging and emotional; as allied health professionals (AHCPs), most of us received zero mental health education during our long training. However, every osteopath (and other AHCPs) should have the basic knowledge to help confidently with a mental health crisis.
While suicidal emergencies are not everyday occurrences in our clinics, reducing suffering is fundamental to our work. Research tells us that people with persistent pain are at higher risk of death by suicide. Understanding the potential risk factors and support options available to us and those who need help with a mental health crisis is as important as knowing what action to take when presented with the signs and symptoms of a heart attack or stroke.
The impact of suicide is enormous; evidence from The World Health Organization (WHO) shows that it’s a global issue that affects all countries, cultures, and ages. For each adult who died by suicide, over 20 others may have been attempting it, and the consequences on their friends, family, and community are monumental.
Identifying if someone is suicidal is always a concern raised during my mental health awareness courses and has been the subject of many DMs in my inbox over the last few years. Suicide is complex and multifactorial; many aspects remain poorly understood. In the UK, 1 in 5 people thinks about suicide in their lifetime. It is worth saying that experiencing suicidal thoughts doesn’t mean someone will take action, but it is essential to take anyone who feels or talks about being suicidal seriously; it’s never just attention-seeking behaviour.
Every suicide is preventable and avoidable; all HCP, including osteopaths, have a role in identifying and supporting someone at risk of suicide to stay safe. WHO estimates that 700,000 people die by suicide yearly; 5,000 – 6,000 deaths occur in the UK.
Risk factors include:
- Previous suicide attempts.
- Mental health problems.
- History of self-harm/deliberate self-injury
- Being bullied or facing harassment or discrimination.
- Experiencing physical, sexual or emotional abuse.
- Recent trauma or life shock, such as the death of a loved one.
- Losing a loved one to suicide.
- Relationship breakdown/divorce
- Drug and alcohol misuse or addiction.
- History of adverse childhood events (ACEs) – neglect or trauma.
- Financial problems or homelessness (and the risk of these).
- Being imprisoned or the risk of being jailed
- Academic or work pressures
- Long-term physical ill health
- Social isolation
Suicide occurs more frequently with the coexistence of psychiatric and physical illness. Approximately 90% of those who attempt or die by suicide have one or more mental health conditions. However, reports suggest that many were not formally diagnosed before their suicidal crisis, and two-thirds were not in contact with any services around the time of their attempt, which meant warning signs were missed.
According to the Office for National Statistics (ONS), the rate of suicide in women in their early 20s has been at its highest for two decades, but middle-aged men are at the greatest risk; the most significant threat is after a relationship breakdown and among divorced men.
Did you know that more men die by suicide in the UK than in road traffic accidents?
Other risk factors
There is an acknowledged link between eating disorders, self‐harm and subsequent death by suicide, not just in adults, about 7% of children have attempted suicide by age 17, and 25% say they have self-harmed in the past year. According to a British Journal of Psychiatry, these figures could rise because of the Covid pandemic.
Three critical predictors of suicide attempts?
- History of suicidal behaviours or ideation
- Functional impairment from mental health disorders
- Socioeconomic disadvantage
Let’s break a myth
Asking about self-harm and suicide does not make it more likely to happen or put thoughts in someone’s mind, but it might save someone’s suffering. Here are the words of a suicide survivor –
“I still find it hard when I’m suicidal to say those words, but it’s such a relief when people are direct with me. If they’re calm about asking and don’t make it a big deal, it makes such a difference. By having someone ask – are you feeling suicidal/thinking about taking your own life? While it doesn’t get rid of the thoughts and feelings, it stops the overwhelming intensity, which is pretty scary because you don’t have to hold on to it all. Have that conversation; you don’t realise the difference that can make for the person feeling that way.”
Did you know that suicide was illegal in the UK until 1961, hence the term “committed”? So, if the situation was not bad enough, an individual could be sent to jail if they failed to take their own life. As suicide is no longer a criminal offence, other terms, such as ‘completedsuicide ‘and ‘died by suicide, are more compassionate and less stigmatising. Likewise, ‘attempted suicide’ or ‘suicide attempt’ are better terms than ‘unsuccessful ‘, which is a poor choice of words because it suggests an achievement or positive action.
You might also see other terminology, ‘suicidal behaviour disorder’, which encompasses a spectrum from preparation attempts to complete suicide. Or ‘suicidal ideation’ – used to describe thinking about, considering, or planning suicide. Either could be momentary or fleeting thoughts through to a detailed plan for how and when they may take their life. Research has shown that the language used to report suicide can make all the difference, so consciously choosing safe messaging reduces ‘suicide contagion.’
Exposure to behaviours within a family, peer group, or media can increase suicidal behaviour in vulnerable individuals, especially adolescents. Reports of suicide should not divulge detailed descriptions of the method used to avoid possible copycat incidents.
Photo credit: Monkey Business via Canva
It’s good to talk
Starting a compassionate, non-judgemental conversation can help tackle the stigma surrounding mental health and help the individual aware that they are not alone, but before beginning this dialogue:
- Be prepared; think ahead if someone needs help urgently. What should you do? For example, do you record the ICE contacts for all your patients? Could you leave your practice and take them to the nearest Emergency Department (ED)?
- Have a plan before you start the conversation; do you have the details of organisations that can help?
- Think carefully about what you want to say and ensure you are in the right environment without interruptions. Remember, you don’t need to have the perfect words, be yourself and show the person you care.
- Keep calm; I know this can be very distressing.
- Avoid closed questions that only require a “yes” or “no” answer.
What to do in a mental health crisis or emergency
In the same way, we screen for red flags; the first step in helping someone experiencing a mental health problem is to look for signs of a significant risk of suicide or self-harm. If someone is actively suicidal or in immediate danger; to themselves or others, dial 999 and ask for the ambulance service, or if it is safe to do so, take them to ED and ask for the duty psychiatrist.
How to start a non-judgemental conversation about mental health
A non-judgemental conversation is not just about listening; it includes verbal and non-verbal communication skills. It’s essential to listen carefully without personal judgement. Asking open questions like “How long have you been feeling like this?” usually provides a basis for a more detailed response. Long silences are also okay; allowing time to process information and gather thoughts is helpful.
Listening to a person in a mental health crisis, including suicidal distress, can be extremely difficult. It is natural to judge what the person is telling you; allow time to reflect. Nevertheless, you must keep your opinions to yourself and communicate with the person empathetically, displaying no personal judgment.
There are several options for non-life-threatening emergencies, including contacting their ICE (in case of emergency) contact. Or their GP; you can expedite an emergency appointment by asking to speak to the duty doctor at the patient’s surgery. Note some will tell you to refer to ED or call 999.
Please understand that unless someone is in immediate danger, they have the right to refuse your help.
Trust and the patient-practitioner relationship
The foundation of the patient-practitioner relationship is trust and confidentiality. However, breaching is permitted and sometimes necessary to keep someone alive, or if there’s a significant risk of deliberate self-harm, that’s what suicide attempts may be recorded as on someone’s medical file.
Clarifying what you can and cannot keep confidential and the circumstances when information needs to be shared is helpful to explain at the first appointment; make it a routine part of your case history taking.
Photo credit; Canva
Look after yourself
Having the knowledge and confidence to discuss suicide and knowing what to do can save a life is a skill, but understanding your limitations and boundaries is essential in your role as a healthcare professional and crucial for your wellbeing and that of all your patients. Be honest; if this subject is too triggering, that’s okay; we are people first. However, have a plan and resources so people, including yourself, can manage if this situation arises.
Mental Health Crisis Resources
Being heard and talking can make sense of folks’ feelings. Familiarise yourself with the procedures and offerings local to you; keeping the contact details of your local crisis team and the Samaritan’s free helpline number to hand is helpful: Below is a list of help staffed by trained individuals ready to listen without judging.
Confidential support for people experiencing feelings of distress or despair. Phone: 116 123 (free 24-hour helpline) https://www.samaritans.org.uk
SANEline. For those experiencing a mental health problem or supporting someone else, 0300 304 7000 (4.30 pm–10.30 pm every day).
National Suicide Prevention Helpline UK. 0800 689 5652 (6.00 pm–3:30 am every day).
Campaign Against Living Miserably (CALM). 0800 58 58 58 (5.00 pm-midnight every day)
Shout. Confidential 24/7 text-based mental health support—text SHOUT to 85258.
PAPYRUS Young suicide prevention society. Phone: HOPElineUK 0800 068 4141 (Mon to Fri, 10 am to 5 pm & 7 to 10 pm. Weekends 2 to 5 pm) https://www.papyrus-uk.org
SOBS – Survivors of bereavement by suicide https://uksobs.org
Calati, R., Bakhiyi, C. L., Artero, S., Ilgen, M., & Courtet, P. (2015). The impact of physical pain on suicidal thoughts and behaviours: meta-analyses. Journal of psychiatric research, 71, 16-32.
Elzinga E, de Kruif AJTCM, de Beurs DP, Beekman ATF, Franx G, Gilissen R (2020) Engaging primary care professionals in suicide prevention: A qualitative study. PLoS ONE 15(11): e0242540. https://doi.org/10.1371/journal.pone.0242540
Khazem, L. R. (2018). Physical disability and suicide: recent advancements in understanding and future directions for consideration. Current opinion in psychology, 22, 18-22.
Lundin, Å., Bergenheim, A. Encountering suicide in primary healthcare rehabilitation: the experiences of physiotherapists. BMC Psychiatry 20, 597 (2020). https://di.org/10.1186/s12888-020-03004-1
Office of National Statistics (2019). Suicides in the UK.