Early detection of suicide risk

Table of contents

Early detection of suicide risk

Early detection and response to suicide risk are central to effective, person‑centred care in general practice⁷. As GPs have ongoing, trusted relationships with a large proportion of the population, they are uniquely positioned to notice changes in a patient’s mental health, functioning and circumstances.

Many people who experience suicidal distress present first – and sometimes only – to primary care⁸, often for reasons that are not explicitly related to their mental health (eg somatic symptoms, sleep disturbance, substance use, frequent attendance or changes in engagement or affect). GPs therefore have a critical role in recognising distress and gently exploring suicidal thoughts, including when presentations are indirect. A ‘tough love’ approach is not recommended, as this opposes the person-centred and trauma informed approach encouraged by suicide prevention guidelines.

Unfortunately, suicide risk is dynamic and cannot be predicted, so early identification relies on awareness of risk and protective factors, combined with compassionate enquiry and a willingness to revisit conversations when a patient’s circumstances change, especially during periods of stress, illness, loss or transition.

Ongoing training and education is essential

Maintaining your skills and confidence in suicide prevention is essential, as ongoing education supports effective, responses that are free of stigma and evidence-informed, and the use of local pathways, specialist advice and community resources.

Risk factors, protective factors and social determinants of suicide

The following sections outline key risk factors and warning signs to remain alert for, so that you can exercise clinical judgement, guide conversations and initiate timely follow-up. Please note that they are not to be used as predictive tools.

By focusing on risk factors, responding early to warning signs, and supporting connection, GPs can contribute to reducing suicidal distress and improving safety over time.

Population as a factor

Suicide does not discriminate, which means that what matters more than population or demographics is risk factors that contribute to suicidal distress. While it’s important to be aware that some populations are more at risk than others, labelling or ranking populations only serves to incorrectly minimise the risk of others who do not fall into those categories.

Preventing suicide therefore requires GPs to be aware of risk factors, and to treat each person individually and without judgement.

Warning signs of suicidal distress

Suicidal distress often arises when a person comes to believe there is no other way to relieve overwhelming pain or to resolve an intolerable sense of distress⁹.

People considering suicide may communicate their distress in various ways, including:

changes in behaviour
expressions of hopelessness
withdrawal
indirect references to death.

These warning signs often occur together, though it is important to recognise that some people may show few or no outward signs.

Personal risk factors

Personal risk factors can increase a person’s vulnerability, particularly when interacting over time. These include:

cumulative stress
types of loss, including death, employment, relationship etc
isolation
shame
self-doubt
lack of support
barriers to accessing care¹⁰.

Protective factors

Preventing suicide is therefore not solely about averting an individual attempt, but about addressing the conditions that allow distress to escalate. This includes:

reducing emotional pain and shame
strengthening connection and belonging
creating environments where people feel safe to seek help.

The following tables outline the risk factors that can contribute to suicide, and the protective factors that can contribute to prevention, as well as the clinical relevance and considerations of each one.

Table 1: Common suicide risk factors
Risk factor	Clinical relevance and considerations
Previous suicide attempt(s)	One of the strongest predictors of future suicide risk. Warrants careful exploration, particularly during periods of transition, stress, or reduced support.
Substance abuse	Alcohol and other drugs can worsen mood, increase impulsivity, and lower inhibition, particularly during intoxication, withdrawal, or escalation of use.
Low/limited social support	Fewer protective connections can reduce buffering against stress and decrease opportunities for help-seeking or early intervention.
Feelings of hopelessness or despair	This is a strong indicator of suicide risk, reflecting a perceived lack of future options or relief from distress.
Having lost a family member to suicide	This increases risk through grief, trauma, identification, and social transmission, particularly in the absence of culturally or socially appropriate postvention support.
Feelings of shame and self-doubt	These undermine self-worth and belonging, increase self-criticism and perceived burdensomeness, and can inhibit help-seeking, leaving people feeling trapped and isolated during periods of distress.
Mental disorders	Depression, anxiety, trauma-related distress, psychosis, and neurodevelopmental conditions can increase risk, especially when symptoms are acute or co-occurring.
Cultural shame and stigma	Fear of judgement, exclusion, or community consequences can delay disclosure and reduce engagement with care.
Isolation and loneliness	Social disconnection can intensify distress and amplify feelings of burdensomeness or invisibility.
Financial instability	Debt, financial stress, or sudden loss of income can contribute to feelings of entrapment, shame, or loss of control.
Family instability	Ongoing conflict, relationship breakdown, or unsafe home environments can increase distress and the patient’s perception that they have little or no support.
Unemployment and cost-of-living pressures	Loss of work or financial pressure can affect identity, purpose, and self-worth, particularly when compounded by other stressors.
Housing instability or homelessness	This can lead to chronic stress, marginalisation, reduced access to care, and increased exposure to trauma.
Illness and disability	Chronic illness, pain, or disability can increase vulnerability through distress, functional loss, or perceived burden on others.
Impulsivity	Higher impulsivity can increase the likelihood of acting on suicidal thoughts, particularly in acute crises or when substances are involved.

Table 2: Effective suicide protective factors
Protective factor	Clinical relevance and considerations
Adaptive coping skills	Skills such as emotional regulation, distress tolerance, and help-seeking can reduce the likelihood of suicidal thoughts escalating during periods of stress.
Effective problem-solving skills	The ability to identify options and take manageable steps can reduce feelings of entrapment and increase perceived control.
Self-understanding	Insight into personal triggers, warning signs, and needs can lead to earlier intervention and self-advocacy.
Sense of competence or self-efficacy	Feeling capable or useful, through work, caregiving, creativity, or daily tasks, can strengthen hope and purpose.
Spirituality or personal belief systems	Spiritual, cultural, or philosophical beliefs can provide meaning, connection, and comfort during distress (where relevant to the individual).
Connection to family	Supportive family relationships can provide emotional safety, practical assistance, and a sense of belonging.
Sense of responsibility to others	Caring roles or commitments (e.g. to children, parents, pets, community) can strengthen reasons for living.
Involvement in social or community activities	Participation in groups, clubs, or cultural activities can foster connection and reduce loneliness.
Access to supports within financial means	Affordable, accessible services can increase the likelihood of ongoing engagement with care.
Cultural identity and connection	A strong sense of identity, culture, language, belonging, kinship, Elders, ceremony and community governance can be deeply protective, particularly for marginalised groups.
Affirming relationships and environments	Acceptance, affirmation, and access to inclusive healthcare and community spaces are strongly protective, particularly for those in marginalised communities.
Supportive work environment	Workplaces that are flexible, respectful, and responsive to wellbeing needs can be important protective settings.
Positive relationships with colleagues	Feeling valued and connected at work can reduce isolation and provide informal support.
Access to professional development	Opportunities for learning and growth can support identity, purpose, and future employment possiblities.
Access to employee assistance or wellbeing programs	Timely, confidential support can lower barriers to care during periods of increased stress.

Mental disorders associated with suicide risk in primary care

Many people with mental disorders may experience periods of elevated risk at specific times, but there are also many who will never experience suicidal thoughts.

In general practice, early recognition, compassionate enquiry and ongoing follow-up are key protective factors.

Suicidal ideation

Suicidal ideation may fluctuate and might not be volunteered unless the patient is asked about it directly in a supportive manner.

Below are some some of the mental disorders you will commonly come across that may lead to suicidal ideation. This is not a conclusive list.

Depression

Depression is one of the mental disorders most strongly associated with suicide, particularly when symptoms are severe, persistent, accompanied by hopelessness, or complicated by substance use, chronic pain, social isolation or major life stressors¹¹.

In primary care, depression frequently presents indirectly¹². Many patients do not initially describe low mood, but instead mention their somatic, sleep or energy-related complaints. This is especially common in older adults, people from culturally and linguistically diverse backgrounds, and those with co-existing physical illness.

When physical symptoms persist without a clear explanation, or when functional decline is evident, you need to be alert for depression and suicide risk.

Common presentations and warning signs

Patients experiencing depression may describe¹³:

withdrawal from usual activities, work or relationships
changes in sleep (insomnia, early waking, or hypersomnia)
persistent fatigue, low energy or feeling “run down”
somatic symptoms such as headache, gastrointestinal upset, or musculoskeletal pain
reduced appetite or increased appetite with weight change
difficulty concentrating, slowed thinking or indecisiveness
increased reliance on alcohol or other substances
feelings of guilt, worthlessness, shame or of being a burden
irritability, agitation or emotional numbness
thoughts of failure, hopelessness or feeling “stuck”.

Anxiety disorders

Anxiety disorders are the most prevalent mental health conditions in Australia¹⁴ and are an independent risk factor for suicidal ideation and behaviour, particularly when symptoms are severe, chronic, or co-occur with depression, substance use or trauma exposure¹⁵. Suicide risk may also increase during periods of panic, perceived loss of control, or prolonged distress accompanied by exhaustion and hopelessness.

In general practice, anxiety frequently presents as physical symptoms, repeated reassurance-seeking, or difficulty managing chronic illness.

Common presentations and warning signs

Patients experiencing anxiety might describe¹⁶:

persistent or escalating worry that feels difficult to control
racing heart, palpitations or chest tightness
shortness of breath or feeling unable to get enough air
dizziness, light-headedness or nausea
hot or cold flushes, sweating or trembling
muscle tension or headaches
sleep disturbance due to rumination or fear
difficulty concentrating or feeling “on edge”
irritability or heightened sensitivity to stress.

GPs should be alert to suicide risk when anxiety is associated with entrapment, avoidance, functional impairment, or comorbid depression.

Bipolar disorder

Bipolar disorder carries a substantially elevated lifetime risk of suicide, particularly during depressive episodes, mixed states, and periods of rapid mood change¹⁷. Suicide risk is highest when individuals experience depression combined with agitation, impulsivity or hopelessness.

In primary care, bipolar disorder is commonly misdiagnosed as unipolar depression¹⁸, as many people seek help during depressive phases and may not recognise or report hypomanic or manic symptoms unless specifically asked.

Careful longitudinal history-taking is essential, particularly before initiating antidepressant treatment.

Common presentations and warning signs

People with bipolar disorder might experience¹⁹:

recurrent depressive episodes with poor response to antidepressants
periods of elevated or irritable mood
increased energy, reduced need for sleep
racing thoughts or pressured speech
increased goal-directed activity or risk-taking behaviour
impulsivity, agitation or emotional reactivity
changes in judgement or insight.

Antidepressant treatment without appropriate mood stabilisation can worsen their agitation, mixed symptoms or mood instability, potentially increasing the suicide risk. Any history that suggests bipolar disorder warrants specialist input and careful medication planning.

Use of alcohol and other drugs

Alcohol and other substance use disorders are strongly associated with suicide risk, particularly where use is heavy, chronic, or occurs alongside mental illness, social adversity, or trauma. Substance use can increase impulsivity, worsen mood symptoms, and reduce inhibition, making suicidal thoughts more likely to be acted upon.

In primary care, alcohol and other drug use is often under-reported or minimised. Patients may present with physical symptoms, mental health concerns, or social difficulties rather than directly identifying substance use as a problem. This may be particularly evident in older adults, individuals experiencing stigma, and those with co-existing psychiatric or medical conditions.

Common presentations and warning signs

increased frequency or quantity of alcohol or drug use
difficulty controlling use or unsuccessful attempts to cut down
withdrawal symptoms (e.g. tremor, sweating, anxiety, irritability)
neglect of responsibilities at work, school, or home
relationship conflict or social withdrawal related to substance use
risk-taking behaviours or impaired judgement when intoxicated
sleep disturbance, fatigue or ongoing low mood
physical health problems (e.g. liver disease, injuries, infections)
use of substances to cope with distress, trauma or insomnia
feelings of guilt, shame or loss of control related to use

Chronic Pain

Chronic pain is a significant and often under-recognised contributor to suicide risk, particularly when pain is persistent, poorly controlled, or associated with functional impairment, disability, or loss of role. The interaction between chronic pain, depression, sleep disturbance and social isolation can further increase vulnerability.

In primary care, chronic pain commonly presents as a complex and multifactorial condition. Patients may focus on physical symptoms, while associated psychological distress or hopelessness may not be immediately disclosed. This is particularly common in patients with longstanding conditions, injury-related pain, or multiple comorbidities.

Common presentations and warning signs

Patients experiencing chronic pain may describe:

persistent or recurrent pain lasting longer than expected healing time
reduced ability to perform usual activities or maintain employment
sleep disturbance due to pain or discomfort
fatigue, low energy or reduced physical functioning
reliance on medications, including opioids or sedatives
frustration with limited treatment response or diagnostic uncertainty
withdrawal from social, recreational or meaningful activities
low mood, irritability or emotional distress related to pain
feelings of hopelessness, helplessness or loss of purpose
passive thoughts that life is not worth living due to ongoing suffering

Sleep Disorders (e.g. Insomnia)

Sleep disorders, particularly insomnia, are independently associated with increased suicide risk. Persistent sleep disturbance can impair emotional regulation, worsen mood disorders, and contribute to cognitive difficulties, fatigue and reduced coping capacity. The risk is heightened when insomnia co-exists with depression, anxiety, substance use or chronic health conditions.

In primary care, sleep problems are very common and frequently present as standalone complaints. Patients may prioritise sleep difficulties over underlying psychological distress, and clinicians may focus initially on behavioural or pharmacological management without recognising broader risk factors.

Common presentations and warning signs

Patients experiencing sleep disorders may describe:

difficulty falling asleep, staying asleep, or early morning waking
non-restorative or poor-quality sleep despite adequate opportunity
daytime fatigue, low energy or reduced concentration
irritability, mood changes or increased emotional reactivity
reliance on alcohol, sedatives or other substances to initiate sleep
worry or rumination at night, including racing thoughts
disrupted daily routines or irregular sleep–wake cycles
reduced productivity, motivation or engagement in daily activities
exacerbation of anxiety, depression or pain symptoms
increased feelings of distress, overwhelm or difficulty coping

References

Screening and Assessing Suicide Risk in Medical Settings: Feasible Strategies for Early Detection. [Accessed February 2026]
Suicidal ideation and risk factors in primary care patients with anxiety disorders. [Accessed February 2026]
Understanding the psychodynamics of the pathway to suicide. [Accessed February 2026]
Mok K, Riley J, Rosebrock H, Gale N, Nicolopoulos A, Larsen M, Armstrong S, Heffernan C, Laggis G, Torok M, Shand F. (2020) The lived experience of suicide: A rapid review. Black Dog Institute, Sydney. [Accessed February 2026]
Understanding the Complex of Suicide in Depression: from Research to Clinics. [Accessed February 2026]
The Many Faces of Depression in Primary Care. [Accessed February 2026]
Biological, Psychological, and Social Determinants of Depression: A Review of Recent Literature. [Accessed February 2026]
Anxiety management in Australian general practice: an analysis of encounters from 2006 – 2016. [Accessed February 2026]
Anxiety and its disorders as risk factors for suicidal thoughts and behaviors: A meta-analytic review. [Accessed February 2026]
Generalized Anxiety Disorder. [Accessed February 2026]
Suicide Risk in Bipolar Disorder: A Brief Review. [Accessed February 2026]
Misdiagnosis of Bipolar Disorder. [Accessed February 2026]
Bipolar Disorder. [Accessed February 2026]

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Suicide prevention and first aid a resource for GPs