"I'm fine, honestly" — assessing suicide risk

PLAB 2 & PRES 3 · mental health / risk assessment · hard · 10 minutes

Candidate brief

You are an FY2 doctor in a GP surgery. Daniel Mercer, 24, has booked this appointment at his sister's insistence. She rang the practice yesterday, worried: Daniel has been low for months, has stopped seeing friends, and last week she saw searches about suicide methods on his phone. Daniel sits down and says: "I'm fine, honestly. She's just worrying over nothing. I don't even know why I'm here." His records show no mental health history. Please assess him.

What examiners look for

Ask the question. Asking about suicide does not increase risk — the evidence is consistent on this — and in this station, as in the room, the direct question is the whole consultation: Daniel's plan, stockpile and note exist only on the far side of "have you thought about how you would do it?" Euphemisms ("you're not thinking of doing anything silly?") are collusion wearing a caring face; they invite the "no" they pretend to fear. Assess in layers: thoughts → plan → intent → means → preparations. Each layer changes management. Passive ideation alone might mean support and review; ideation with a plan, a stockpile and a written note means same-day escalation and means removal. And explore ambivalence properly — "I keep not doing it, by less" is the most important sentence in the station: risk lives in the direction of travel, not in a score. NICE NG225 is explicit: do not use risk tools or stratification to predict suicide or decide disposal. A SAD PERSONS-style score would call Daniel whatever it called him and change nothing; a formulation — a young man, isolated, drinking, sleepless, with nightly ideation, a bag of tablets and a shrinking margin — produces a plan. Formulate; don't tally. Means restriction is treatment. The unglamorous act of that bag of paracetamol leaving his wardrobe today — agreed with him, done by his sister — is one of the few interventions with hard evidence behind it. Stockpiled medication, like the note and the chosen timing, is preparatory behaviour: treat its discovery as the clinical finding it is. And build the safety plan WITH him, in writing, for tonight — not a contract extracted from him ("promise me you won't") but a sequence he helped design: what the peak looks like, what he does first, who he calls, the numbers in his phone (Samaritans 116 123; text SHOUT to 85258; NHS 111 option 2). Then same-day specialist assessment, follow-up in days, and documentation that quotes him. The next clinician should inherit his words, not your adjectives.

Guideline references

Practise this station

Role-play it with an AI patient and get feedback against the full marking scheme. Create a free account — 3 stations per month free.