01Purpose and principlesWhat the treatment does and how it fits into care.
Start from a formulation, not a template. Define the feared outcome, likely trigger, method, timeframe and sequence from first warning sign to action. Ask what the person notices in thoughts, body, behaviour, sleep, internet use, substance use and social contact. Choose internal coping that has previously created distance from action, such as moving rooms, grounding, music, delaying access or a short task. These steps support time but do not replace treatment or professional help when danger is high.
Build outward in layers. Identify safe places or activities, then specific people for distraction and people who can hear suicidal thoughts. Confirm who is awake, reachable and willing at the relevant time. Add GP, crisis team, local urgent line, emergency department and 999 in escalating order, with exact contact details and transport. A supporter should know warning signs and when to seek emergency help but should not become the sole untrained observer or medicine custodian without agreement.
Means safety is practical and collaborative. Review the method in the risk scenario, current prescriptions, duplicate supplies and household access. Options include smaller quantities, pharmacy instalments, locked storage controlled by a willing adult, removal of firearms or toxic substances and avoiding high-risk locations. Preserve access to essential medicine and dignity. Explain any necessary information sharing and record who is responsible, duration and contingency if the arrangement fails.
Follow-up is part of protection. NICE recommends initial aftercare within 48 hours when ongoing safety concerns remain after self-harm. Depression treatment reviews may need one-week timing after antidepressant initiation for younger adults or particular suicide concern. Contact should assess intent, means, activation, akathisia, sleep, adherence, psychosis, function, support and use of the plan. Missed contact is clinical information: check safety and barriers rather than closing the referral automatically.
Escalate when the plan is unusable. Intoxication, psychosis, severe agitation, intent with means or unsafe accommodation may require emergency or inpatient care. Assess decision-specific capacity and voluntary options, then use jurisdiction-correct law only if criteria are met. At transfer, confirm acceptance, transport and observation and communicate physical findings, medicines, dependants, legal status and warning signs. Review the plan after each crisis and remove steps that proved inaccessible or shaming.
Key points
- Build the plan with the person in their language and preferred format, involving a chosen supporter with consent when that is safe and helpful.
- List personal warning signs such as withdrawal, searching methods, drinking, stopping sleep, medicine stockpiling or psychotic guilt.
- Agree internal actions that create time, then safe distraction, specific supporters, professional contacts and emergency services in a graded sequence.
- Verify phone numbers, opening hours, transport, language, digital access and alternatives when a service or supporter cannot respond.
- Reduce access to the actual method through limited dispensing, safe storage, temporary removal, supervised access or environmental change.
- Treat depression, insomnia, pain, substance use, psychosis, abuse and practical crisis as drivers within the safety plan rather than separate later problems.
- For ongoing safety concerns after self-harm, arrange initial aftercare within 48 hours in line with NICE, and use earlier emergency response when needed.
- Increase contact after discharge, antidepressant initiation or dose change, major loss and other transitions identified in the formulation.
- Share the formulation and plan directly with the responsible clinician and define what happens after missed contact or deterioration.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
A personal change in sleep, isolation, agitation, searching, substance use or medicine handling reliably precedes stronger intent and enables earlier action.
The person can perform a specific brief action independently that reduces intensity or creates time before contacting another person.
The method in the formulation remains immediately available despite verbal willingness, requiring concrete storage, supply or environmental change.
Discharge, rejection, bereavement, court event, antidepressant change or loss of support creates a foreseeable period needing increased contact.
Intent, impairment or environment prevents use of coping and contact steps, making urgent supervised assessment the safer route.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Scenario and warning-sign mapFirst step - Why
- Connect foreseeable suicide behaviour to triggers, means, timeframe and personally observable escalation.
- Interpretation and limitations
- Use specific sequences rather than global categories. Add alternative scenarios when accidental self-harm lethality or violence is also plausible.
- 02
Coping and contact rehearsal - Why
- Test whether each step can be remembered, accessed and used during depressive cognitive narrowing.
- Interpretation and limitations
- Replace vague or inaccessible actions, verify contact details and allow a concise portable format that does not expose the person to an abuser.
- 03
Means and prescribing review - Why
- Identify actual access to medicines, firearms, ligatures, heights, vehicles and toxic substances.
- Interpretation and limitations
- Choose proportionate reduction with a responsible person and timeframe; means restriction reduces opportunity but does not resolve depressive drivers.
- 04
Supporter feasibility assessment - Why
- Confirm willingness, safety, availability, understanding and limits of each informal support role.
- Interpretation and limitations
- Do not count an absent or coercive relationship as protection and do not assign continuous observation to an unsupported family member.
- 05
Follow-up and missed-contact plan - Why
- Define timing, named clinician, active outreach, access barriers and emergency escalation.
- Interpretation and limitations
- Referral sent is not care transferred. Ongoing concerns after self-harm warrant prompt aftercare, with more urgent response when danger intensifies.
04Treatment approachPreparation, options, escalation and aftercare.
01Build safety planMove from early signs to emergency helpFirst stepThe person can collaborate and immediate danger is contained enough for planning.+
- 1Define personal warning signs and internal coping actions that create time, then add safe distraction and specific supportive people.
- 2EscalationList professional and emergency contacts in escalating order and verify availability, communication and transport.
- 3Address means, medicines, accommodation and dependants and provide an accessible copy with agreed supporter roles.
02Active follow-upReview during high-change periodsSelf-harm, discharge, antidepressant change or another formulation-linked transition raises near-term vulnerability.+
- 1Arrange initial timing from need, including within 48 hours after self-harm when ongoing safety concerns are identified.
- 2Assess intent, means, activation, akathisia, psychosis, sleep, substances, function and whether each plan step worked.
- 3Respond to missed contact through active safety and access review and increase or reduce intensity according to the updated formulation.
03Escalate careUse supervised safety when the plan failsEscalationCurrent intent, means, severe impairment or environment makes community steps unreliable.+
- 1Remove immediate hazards, treat physical illness and arrange proportionate observation and urgent specialist assessment.
- 2Protect dependants or potential victims and share necessary information, using voluntary care or lawful restriction according to criteria.
- 3Confirm receiving responsibility, transport and observation and communicate the full formulation and plan rather than a risk label alone.
05Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Review warning signs, current intent and means after every use of the plan and after changes in home, relationships, work or medicine supply.
- Ask specifically about activation, akathisia, reduced sleep need and suicidal change during early antidepressant review.
- Confirm that follow-up occurred at the intended interval and escalate when the person is unreachable or services reject the referral.
- Review supporter burden and safety and replace unsustainable observation, transport or medicine-control arrangements.
- Track depressive symptoms and concrete function while maintaining crisis access after apparent symptom improvement.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Plan reduces decisions
A rehearsed sequence allows action during cognitive narrowing without requiring the person to generate options at peak hopelessness.
Means change is time
Creating delay between impulse and method can allow distress to fall or another person to intervene even before mood improves.
Missed contact communicates
Non-attendance may reflect deterioration, shame, executive impairment, transport or unsafe monitoring and requires curiosity rather than punitive closure.
Support has a ceiling
Relatives can contribute but need permission, training, rest and professional backup and should not carry sole responsibility for survival.
Transition plans expire
A plan built for discharge may become obsolete after a move, relationship change or prescription refill and needs rapid revision.
07Common pitfallsFrequent interpretation and management errors.
- 01
Using a promise not to self-harm as evidence that discharge is safe.
- 02
Writing call for help without named contacts, hours, transport and alternatives.
- 03
Leaving the anticipated method accessible while discussing only coping strategies.
- 04
Treating family as unlimited observation without checking willingness and safety.
- 05
Scheduling routine distant follow-up despite ongoing concerns after self-harm.
- 06
Closing care automatically after missed contact during a high-risk transition.
- 07
Transferring a low-risk label instead of scenarios, actions and responsibility.