Risk Assessment in Mental Health

Risk Assessment and Mental Health

• The presentation covers risk assessment in clinical settings, including suicide and harm to others.
• Aims to highlight various risk presentations, introduce risk assessment/management approaches in psychiatry, and empower professionals regarding risk discussions.
• Objectives include defining risk types, listing risk factors (static vs. dynamic), applying a standard NHS risk assessment tool, and discussing risk assessment limitations.
• The session's outline includes a lecture on risk, group discussions on cases, and a summary/Q&A.
• Risk is defined as the possibility of loss (immediate, delayed, long-term, chronic), and introduces the dynamic vs actuarial approaches.

General Principles

• Risk assessment affects all aspects of psychiatric practice.
• A holistic, individual, and responsive approach is crucial.
• Multidisciplinary collaboration is essential.
• Risk versus protective factors are considered.

Actuarial Approaches

• Actuarial approaches utilize records and statistics to calculate risk.
• This approach is structured, empirically-based, and objective.
• Questions of rigidity and reliability are raised.

Clinical Assessment

• Clinical assessment is conducted by clinicians and is historically informed.
• The aim is to be responsive and dynamic.
• Potential biases and blind spots in clinical assessments are recognised.

Risk Assessment

• Risk assessment considers the size and acceptability of risk, along with dangerousness and likelihood.
• Risk assessment is a dynamic process.
• A comparison between clinical and actuarial assessments (with their respective advantages and disadvantages) is presented.
• It is impossible to eliminate risk at an individual level.

Why Formulate Risk

• A working model for risk assessment is presented, including patient liaison and bringing information together.
• Intervention and communication are crucial aspects of risk assessment.
• A reference is included connecting risk formulation with the HCR-20 version 3.

Assessment Linked with Action

• The process of risk assessment involves establishing context, identifying, analyzing, evaluating, treating, and monitoring risks.
• This approach of risk assessment has an emphasis on ongoing communication and consultations.

Risks in Mental Health

• Issues are discussed using examples from the news and case studies, including the violence by individuals with mental illness.

Risk Domains in the Mental Health Act

• The domains of risk to self, risk to others, and risk to health are outlined.

Self Harm I

• The Royal College of Psychiatrists indicate that 10% of the UK population experiences self-harm.
• Common contributing circumstances include difficult personal circumstances, past trauma, social/economic deprivation, and substance misuse.

Self Harm II

• Self-harm is positioned as a risk in itself, a communication of distress, and representing ambivalence towards life.
• People who self-harm have a significantly increased risk of suicide.

Suicide I

• England and Wales suicide rates are increasing (11.4 deaths/100,000 in 2023, which is a 7.6% increase from 2022).
• Males account for around 75% of recorded suicide deaths.
• Suicide rates showed a downward trend since 1981, but recent years have shown an upward trend, with 2023 producing the most deaths since 1990.

Suicide II

• Highest age-specific suicide rates in 2023 for men aged 45-49 (25.5/100,000) and women aged 50-54 (9.2/100,000).
• Hanging and poisoning are the most common methods of suicide.

Suicide III

• Most suicides are linked to mental disorders, with an estimated 21% population attributable fraction.
• Mental disorders significantly increase the risk of suicide (e.g., 8 times higher for people with mental disorders compared to the general population).
• Specific mental disorders associated with higher suicide risk include psychosis, mood disorders, substance misuse, and personality disorders.

Suicide IV

• A pie chart illustrated the primary diagnoses for UK suicide cases in 2023.
• Affective disorders (depression or bipolar disorder) are the most frequent primary diagnoses, followed by schizophrenia.

Defining Risk Factors

• Static risk factors are unchanging aspects that increase risk, such as childhood experiences, age at first diagnosis, and demographic characteristics.
• Dynamic risk factors are aspects that change over time, including mental state, support systems, and the wider environment.

Risk Factors for Suicide

• Previous suicide attempts or self-harm increase suicide risk.
• Male gender is a significant risk factor (3x higher likelihood).
• Concurrent mental disorders and previous psychiatric treatment increase risk.
• Unemployment, homelessness, social isolation, loneliness, alcohol/drug abuse, and physical illness are additional suicide risk factors.

Protective Factors

• Social support (not living alone), having children at home, a sense of responsibility, strong religious faith, problem-solving skills, and strong connections/identity are protective factors against suicide.

Asking about Self-Harm: Examples

• Question prompts for exploring self-harm are provided.

Serious Untoward Incident

• Incidents impacting patients, families, or staff are addressed with a focus on learning and preventing future harm, instead of blaming.

Case Scenario 1

• A 49-year-old male presenting with suicidal ideation, recent intensification of thoughts, history of previous attempts, and a protective factor of children abroad is used as a case study.
• The case also considers how the risk might be rated.

Case Scenario 2

• A 29-year-old man with schizophrenia, multiple risk events, weapons history, violence to strangers, and multiple residences is presented as another clinical case.

The Christopher Clunis Inquiry

• Information about an inquiry into the treatment of Christopher Clunis is furnished.

Continuity of Care

• The Ritchie enquiry's findings highlight issues of inconsistent and inadequate care continuity with patients moving between multiple care providers.

CQC Findings

• The Care Quality Commission highlighted issues with inconsistent risk assessments, inadequate care planning and engagement, and poor risk mitigation associated with the discharge of one patient.

Violence and Mental Illness

• The presentation highlights an overemphasis on homicides by people with mental illness, which deviates from actual risk.
• Sociodemographic and economic factors and substance misuse can be major contributors to violent acts, apart from mental illness.
• People with mental illness are more often victims than perpetrators of crime

Violence and Mental Illness (page 37)

• A modest link between violence and mental illness remains a focus in recent studies, but methodological issues and possible biases in studies lead to limited conclusions.
• Studies have shown little conclusive results on the link between schizophrenia and violent acts.

Rates of Violence Compared

• Studies compare violence rates in people with schizophrenia, with and without concurrent substance abuse, against matched control groups.
• Data shows significant increase of violence rate in individuals with both schizophrenia and concurrent substance abuse disorders.

General Principles (page 39)

• Factors in history (past violence, engagement, substance misuse, domestic violence) are presented as risk indicators.
• Environmental indicators (access to victims and weapons) are discussed as risk factors.
• Mental state factors (symptoms of threat/control, violence-related thoughts, suicide, psychopathy, or restricted insight) are discussed.

Types of risk

• The presentation lists the types of risk as: risk to self, risk to others and risk to health.

Risk to Health: Some Examples

• The presentation contains examples of risk to health, such as severe psychotic symptoms, squalid/uninhabitable homes, and symptoms of depression that accompany these conditions.
• Risk to health, including severe conditions or lack of adherence to medication, also occurs.

Risk From Others

• The likelihood of harm from others, including physical harm, sexual violence, emotional abuse, unlawful restrictions, or financial abuse, is addressed.
• This presentation explores the importance of safeguarding considerations for individuals vulnerable to violence from others.

Risk from Others (page 44)

• Individuals with mental illnesses are frequently victims of violence more than they commit acts against others.
• The presentation explores diverse forms of violence such as institutionalisation, ostracisation, verbal, physical, and sexual abuse, exploitation, and retraumatisation.

Other Risk Considerations

• A list of additional risk factors considered important to identify and discuss.

Clinical Tools (NHS - Psychiatric Risk Assessment)

• A list of particular features pertaining to identifying risk to self, presented as a tool for psychiatric assessment.

Evidence of harm TO OTHERS

• A list of harm indicators towards other individuals or groups.

Evidence of risk of ACCIDENTS

• The presentation provides various cases of risk to self due to accidents.

Evidence of risk to CHILDREN or VULNERABLE ADULTS

• Discussions of factors of risk towards children or vulnerable adults, including Multi-agency Public Protection Arrangements (MAPPA), Multi-agency Risk Assessment Conference (MARAC), disclosure of abuse, non-compliance with treatment plans, and circumstances of substance misuse.

Physical Health risks

• Factors are identified that pertain to physical health concerns, such as access to general practitioners (GPs), necessary investigations, and recommended treatments.

Substance Misuse Risks

• The presentation lists the indications and risks of substance misuse, such as IV use, needles, overdose, and sex work.
• The presentation includes considerations for child safeguarding if the patient has children or if there are children in the household.

Clinical Tools, HCR-20

• The Historical/Clinical/Risk Management-20 Scale is introduced and details some of the pertinent features in clinical tools, such as past and present features, and categories of risk.

...AND IT'S NOT ALL ABOUT RISK ASSESSMENT

• The presentation highlights the findings of a survey regarding risk assessments' practice in the field.
• It explores potential over-reliance on risk assessment tools, the importance of interaction with patients, and the limited predictive value of such tools.

Vignettes

• A few brief case examples (vignettes) are included.

Considerations

• Various questions are raised about risk management practices' potential shortcomings, including over-risk-aversion, duty of care, and the role of technology in the future.

Summary and Questions

• An understanding of risk and its clinical significance is highlighted.
• Crucial characteristics of effective risk assessments (being current, precise, individualized, and responsive) for successful risk identification are stated.
• Risk assessment does not prevent but rather informs and assists in mitigating risks.

Other Resources

• A list of available resources for further support and information on mental health, including suicide prevention and child safeguarding, are provided.

References

• A list of references supporting the material presented in the presentation is detailed.