Self-harm or attempted suicide? Do suicide notes help us decide the level of intent in those who survive?

A suicide note can be a very powerful communication to the family and friends of the deceased. However, in a number of cases a note is written by an individual who survives an apparent act of attempted suicide. These cases will frequently present at a hospital accident and emergency department (A&E) and will be classified as incidents of self-harm. Despite the importance of suicide notes in determining the motivation of people who die by their own hand, research findings have been patchy and ambiguous. This is also true when someone writes a suicide note but survives an act of apparent attempted suicide. In such cases the question is raised whether the person truly intended to complete suicide or whether their actions had some other motivation. This paper seeks to throw some light on this matter by examining the meaning that should be attributed to a suicide note when it has been written by someone who presents at a hospital accident and emergency department after intentionally harming or injuring themselves. More specifically, the study addresses the question whether the presence of a suicide note in such cases is more likely to reflect a serious act of attempted suicide than it is to reflect an act of self-harm with low suicidal intent. Using a large dataset collected over a 5-year period the authors compare note-leavers with self-harm patients who have not written a suicide note, focussing on the presence or absence of other known risk indicators for completed suicide in each of the two patient groups. The aim is to test the hypothesis that patients presenting at A&E with self-harm who have left a suicide note, are at higher risk of future completed suicide than are self-harm presenters who have not left a note. The conclusion reached is that clinical staff in the emergency department should err on the side of caution and regard the presence of a suicide note as an indication of a failed but serious attempt at suicide.