Who / when
- Anyone with extreme hopelessness or despair, current or past thoughts, plans or acts of self-harm.
- Anyone with signs of poisoning, a self-inflicted wound, unexplained drowsiness or loss of consciousness.
- Also ask everyone with depression, psychosis, epilepsy, alcohol or drug problems, chronic pain or severe emotional distress.
Red flags: refer now
- Medically serious self-harm: signs of poisoning or intoxication, bleeding from a self-inflicted wound, loss of consciousness, extreme lethargy.
- Imminent risk: current thoughts or plan of suicide; or thoughts or plan in the past month, or an act in the past year, in someone now extremely agitated, violent, distressed or not communicating.
Medical safety firstTreat the injury or poisoning first. Stay with the person. Remove anything they could use to harm themselves.
Assess
- Ask directly and calmly, in private: "Have you had thoughts of ending your life? Have you made a plan? Have you done anything to harm yourself?"
- Ask about the past month (thoughts or plans) and the past year (acts).
- Look for concurrent conditions: depression, alcohol or drug use, psychosis, epilepsy, and chronic pain.
- Ask about severe emotional distress, difficulty with daily life, and repeated self-medication.
- Ask who can support the person, and what means are at home (pesticides, medicines, firearms).
Classify
| Picture | Classify as | Action |
|---|
| Poisoning, bleeding, unconscious or very lethargic after self-harm | Medically serious self-harm | Treat now (Protocol 1); then reassess risk |
| Current thoughts or plan; or recent thoughts or act with extreme agitation or distress | Imminent risk of suicide | Protocol 2: constant supervision |
| Thoughts or plan in past month, or act in past year, not imminent | Risk of self-harm or suicide | Protocol 3: support and close follow-up |
| None of the above | Risk unlikely | Manage other conditions; ask again at future visits |
Treat
Protocol 1: medically serious act
- Secure, supportive place in the facility; never leave the person alone.
- Treat the injury or poisoning. Pesticide poisoning: treat only where staff can resuscitate and manage the airway and have IV atropine and diazepam; otherwise transfer immediately. Activated charcoal only if conscious, consenting and within 1 hour. Do not force vomiting; no oral fluids.
- If admitted to a general ward, monitor closely to prevent further self-harm.
Protocol 2: imminent risk
- Remove means of self-harm. Offer a quiet, separate room if possible.
- Never leave the person alone: name a staff member or relative to stay with them at all times.
- Attend to the mental state and distress; give psychoeducation; activate support; consult a specialist if available.
Protocol 3 and everyone at risk
- Explore reasons and ways to stay alive; build on how past problems were solved.
- Make a safety plan together (warning signs, coping steps, people to contact, removing means), with follow-up support.
- Problem-solving therapy for people who self-harmed in the past year, if trained staff are available.
- Mobilise family, friends and community supports to watch over the person while risk persists.
- Treat depression, alcohol use or other conditions (see those protocols).
If you prescribeChoose the least dangerous medicines (avoid amitriptyline), give short supplies (for example one week at a time), and ask a carer to keep and give the tablets.
Follow-up
- Frequent contact at first (for example daily or weekly) for 2 months, by visit, phone, home visit or message.
- Then every 2 to 4 weeks, reducing as the person improves; continue for 2 years (for example twice in the second year).
- At every contact, ask again about suicidal thoughts and plans. Increase contact if risk rises.
Counsel
- It is all right to talk about suicide; talking does not cause it. Suicide can be prevented.
- If thoughts of self-harm come back, tell a trusted person or come to the clinic straight away.
- Self-harm is a sign of severe distress; help is available for the problems behind it.
- Carers: remove pesticides, stored medicines and weapons from the home; avoid hostility and criticism; look after yourselves too.
Thank you for telling me. Many people feel this way when things are very hard, and it can get better. Let us work out together how to keep you safe today.
When to refer
- Immediately: medically serious self-harm or pesticide poisoning beyond your facility's resources.
- Imminent risk when the person cannot be kept safe with supervision.
- Consult a mental health specialist, if available, for everyone with imminent risk, and when prescribing.
- Concurrent psychosis or severe depression.
Sources
World Health Organization. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0. 2016. World Health Organization. Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. 2023. World Health Organization. Clinical management of acute pesticide intoxication: prevention of suicidal behaviours. 2008.