Suicide prevention as a prerequisite for recovery from severe mental illness

For a significant number of people suffering from severe mental illness (SMI) prevention of suicide is a prerequisite for their recovery. This review summarises and interprets risk/protective factors for suicide in the context of schizophrenia and bipolar disorder, thereby enabling evidence-based suicide risk assessment and management. A history of self-harm greatly increases suicide risk among people with schizophrenia or bipolar disorder. Suicide prevention for patients with SMI necessitates constant vigilance by (mental) health and social care professionals in contact with them, particularly those with a history of self-harm, males, young people, those near illness onset, people with a family history of suicidal behaviour (especially suicide), victims of childhood abuse, those challenged by recent adverse life events (notably interpersonal conflict), people with aggressive/impulsive personality features, and those who have expressed hopelessness. Research suggests that suicide risk associated with SMI should be reduced by early intervention, restricting access to lethal means, improvement of treatment adherence, treating more patients with clozapine and lithium, assertive outreach, treating psychiatric comorbidity (depression, alcohol/drug misuse, etc.), 24-hour crisis care, timely (compulsory) hospitalization (sufficient bed provision imperative), improving psychiatric inpatient ward safety, lowering the risk of absconding from wards, appropriate use of electroconvulsive therapy, intensive follow-up postdischarge, and improving access to psychological/psychosocial interventions, notably cognitive behavioural therapy. The clinical interview is the optimum method of suicide risk assessment and locally developed risk assessment tools should not be used. Evidence-based suicide risk assessment/management within primary care and secondary mental health services warrants recurrent, mandatory training.