UCL MSc Risk Assessment Nov2024 PDF

Risk Assessment and Mental Health November 2024 Dr Farhana Mann Consultant Psychiatrist  SESSION AIMS To highlight the variety of different ways risk can present in clinical settings. We will be discussing topics including suicide and harm to...

Risk Assessment and Mental Health November 2024 Dr Farhana Mann Consultant Psychiatrist  SESSION AIMS To highlight the variety of different ways risk can present in clinical settings. We will be discussing topics including suicide and harm to others. To introduce approaches to risk assessment and management in psychiatry To empower professionals when asking about and discussing risks  OBJECTIVES Define different types of risks in mental health settings List risk factors for certain types of risk, especially suicide and harm to others (static vs. dynamic) Apply a ‘standard’ NHS risk assessment tool Discuss the limitations of ‘risk assessments’  OUTLINE OF SESSION Lecture on risk Some cases to discuss in groups Summary and Questions  DEFINE RISK The possibility of loss Immediate, delayed, long term, chronic Dynamic vs Actuarial Risk and responsibility  GENERAL PRINCIPLES Affects all aspects of psychiatric practice Holistic, individual, and responsive Multidisciplinary Risk vs protective factors  ACTUARIAL APPROACHES Translation of records and statistics to calculate risk Structured, empirically-based and objective Rigid? Reliable? ‘Risk assessment should be characterized as an informed process to reduce uncertainty within a complex system of unknowable future states…’ Nathan & Bhandari, BJPsych Advances 2024  CLINICAL ASSESSMENT Clinician led Historically informed Aim to be responsive and dynamic Biased? Blind spots?  RISK ASSESSMENT Size and acceptability Dangerousness and likelihood It is dynamic Clinical versus actuarial (advantages + disadvantages) Impossible to eliminate at individual level  WHY FORMULATE RISK Working model Patient liaison Bringing together information Intervention Communication Caroline Logan (2014) The HCR-20 Version 3: A Case Study in Risk Formulation, International Journal of Forensic Mental Health, 13:2, 172-180, DOI: 10.1080/14999013.2014.906516 ASSESSMENT LINKED WITH ACTION  RISKS IN MENTAL HEALTH Image result for child protection Image result for rubbish  RISK DOMAINS IN THE MENTAL HEALTH ACT Risk to self Risk to others Risk to health  SELF HARM I Royal College of Psychiatrists suggests 10% of UK population will self harm although incidence is difficult to describe Contributing circumstances are individual; commonly include: – difficult personal circumstances – past trauma (including abuse, neglect or loss) – social or economic deprivation (together with some level of mental disorder) – can be associated with the misuse of drugs or alcohol  SELF HARM II Risk in and of itself, a communication of distress Can represent an ambivalence towards life People who self harm are 50 times more likely to kill themselves  SUICIDE I England & Wales: 6069 deaths – 11.4 deaths/100 000 (2023 – up 7.6% from 2022) Males account for ~75% of suicide deaths registered 2023 (similar trend sine 1990s) Were coming down since 1981, but recent years have seen a climb. 2023 saw highest suicide rates in men and women since 1990s.  SUICIDE II Age-specific highest rates in men aged 45-49 (25.5/100 000) and women aged 50-54 (9.2/100 000) Most common method of suicide hanging (60% of men, 42% of women) and poisoning (18% of men, 38% of women)  SUICIDE III Majority of suicides are linked to mental disorder. Population attributable fraction 21%. Individuals with mental disorder have significantly higher risk of suicide than general population (one estimate is 8 times higher than general population) High risk with psychosis (RR 13.2), mood disorders (RR 12.3), substance misuse (RR 4.4), ‘personality disorder’ (8.1) and others Too et al (2019) Journal of Affective Disorders 259 SUICIDE IV  DEFINING RISK FACTORS Factors that increase the likelihood of an adverse event (vs protective factors) STATIC factors Childhood experiences Age at first diagnosis / Age of first offence Unchanging demographic characteristics DYNAMIC factors Mental state Support Environment/wider context  RISK FACTORS FOR SUICIDE Previous suicide attempt or previous self-harm Male gender (3x more likely than women) Age Concurrent mental disorders or previous psychiatric treatment Unemployment Homelessness Social isolation, loneliness Alcohol and drug abuse Physically disabling or painful illness, chronic pain Socio-economic deprivation, loss of a job  PROTECTIVE FACTORS Social support, not living alone Having children in the home Sense of responsibility Strong religious faith Problem solving skills Strong connections, sense of identity  …EVER HURT YOURSELF HAVE YOU EVER ON THOUGHT LIFE WAS NOT HOW DO YOU FEEL PURPOSE WORTH LIVING? ABOUT THE FUTURE? IN ANY WAY? Asking about self harm: examples …EVER WISHED YOU COULD GO TO WHAT STOPS YOU HAVE YOU EVER BED AND NOT ACTING ON THESE THOUGHT ABOUT WAKE UP IN THOUGHTS? ENDING YOUR THE LIFE? HOW MORNING? WOULD YOU DO THAT?  SERIOUS UNTOWARD INCIDENT Following an incident where the consequence to patients, families or staff or where the opportunity to learn is considered great Focus is on learning and preventing future harm rather than attributing blame  CASE SCENARIO 49 year old male, attended A&E self reporting suicidal ideation Thoughts of harming himself intensifying over preceding few weeks. Appears agitated and distressed. History of previous attempt, wants to seek help to prevent repeat Identifies children abroad as protective factor No plan  CASE SCENARIO What are the risks? How would you rate the risk? – High – Moderate – Low Types of risk Risk to self Risk to others Risk to health  CASE SCENARIO 29-year-old man with schizophrenia Multiple risk events History of using weapons History of violence to strangers Multiple residences and different catchment areas Image result for christopher clunis inquiry  CONTINUITY OF CARE Ritchie enquiry Over 5.5 years had been under at least 30 named psychiatrists 10 episodes of inpatient care Remanded into police custody on 3 occasions Lived in bail hostel, two rehab hostels, 2 hostels for homeless, 6 B&Bs Crossed the river Thames on 4 occasions and was under three of four London health authorities at the time Nottingham stabbings 2023 CQC Findings  VIOLENCE AND MENTAL ILLNESS Undue emphasis on homicides by those with mental illness skews debate – Violence attributed to people with mental disorders vastly exceeds the actual risk presented – however should not risk complacency “Mental disorders neither necessary nor sufficient causes of violence” Major determinants of violence socio-demographic and economic factors substance misuse (+/- mental illness) People with mental illness are more often victims than perpetrators of crime  VIOLENCE AND MENTAL ILLNESS May be a modest link in recent studies (methodological issues, possibly focusing on most ill – some studies suggest 10% vs 2% comparing people with schizophrenia with population) 6% of UK homicides by people with schizophrenia compared with a population rate of schizophrenia of 1% Research is not conclusive - MacArthur violence risk assessment study followed a cohort of over 1000 pts; the risk came from concurrent substance misuse Combination of substance misuse with illness, non- concordance with medications and lack of insight seems to increase the risk of violence Past history of violence remains best predictor  GENERAL PRINCIPLES History – Previous violence, engagement, substance misuse, history of domestic violence Environment – Access to victims, access to weapons Mental State – Symptoms related to threat or control, emotional arousal, thoughts linking violence and suicide, psychopathy, restricted insight Types of risk Risk to self Risk to others Risk to health  SEVERE PSYCHOTIC SQUALID HOME, SYMPTOMS, ALSO NOT UNINHABITABLE EATING DUE TO PARANOIA SEVERE DEPRESSION Risk to health : some examples FLORID COGNITIVE PSYCHOSIS – IMPAIRMENT – UNABLE TO FORGETTING TO TAKE ADHERE TO MEDICATION MEDICATION  Types of risk Risk from others  RISK FROM OTHERS “Are they frightened of anyone? Do they feel safe?” of physical harm of sexual violence or exploitation of emotional or psychological abuse e.g. bullying/comments of unlawful restrictions e.g. locks on doors/not allowed out/coercion/control of financial abuse of neglect caused by medication or services of female genital mutilation, forced marriage or honour-based violence Where any of the above risks are posed by a partner or family member, this is Domestic Violence. To consider Child Safeguarding and Adult Safeguarding from any disclosures – raise safeguarding alert, assess for high risk domestic or sexual abuse  RISK FROM OTHERS People with mental illness more likely to be victims than perpetrators [92% lifetime prevalence] Takes many forms, direct and indirect violence – Institutionalisation – Ostracisation – Verbal, physical and sexual abuse – Exploitation – Retraumatising  OTHER RISK CONSIDERATIONS Risk of repeated self harm Physical health risks in anorexia nervosa Risk assessment in intellectual difficulties Specialist risk assessment in elderly with dementia/depression Child protection Violent children  CLINICAL TOOLS NHS - Psychiatric Risk Assessment Risk to SELF: Tool Suicidal ideation Act with suicidal intent History of a family member or friend dying by suicide (which method was used) Self-injury or harm Self-neglect Access to methods of harm Harmful eating patterns Evidence of harm TO OTHERS: Arson Exploitation (e.g. financial, emotional) Hostage taking, MAPPA Probation service involvement Risk to children Risk to vulnerable adults Sexual Assault (including touching/exposure) Sex Offenders Act 2003 Stalking Violence/aggression/abuse to family Violence/aggression/abuse to general public Violence/aggression/abuse to other clients Violence/aggression/abuse to staff Weapons Risk of Radicalisation (Consider Adult Safeguarding - Chanel) Risk of harm from OTHERS: “Are they frightened of anyone? Do they feel safe?” of physical harm of sexual violence or exploitation of emotional or psychological abuse e.g. bullying/comments of unlawful restrictions e.g. locks on doors/not allowed out/coercion/control of financial abuse of neglect caused by medication or services of female genital mutilation, forced marriage or honour- based violence Evidence of risk of ACCIDENTS: Accidental harm outside the home (e.g. wandering) Driving/Road safety Evidence of other RISK BEHAVIOURS: Falls Absconding/Escape Fire Correspondence (Letters, Email etc.) Unsafe use of medication Damage to property Safety at home Incidents involving the police Phone Calls FTAC Restricted client Theft Visitors Poor adherence to medication Poor engagement with service Evidence of risk to CHILDREN or VULNERABLE ADULTS: MAPPA (Multi-agency Public Protection Arrangements) MARAC (Multi-agency Risk Assessment Conference) Any disclosure of domestic or sexual abuse FGM Relapsing mental state Non-compliance with treatment plan (to include non-engagement with services) Young carer Known to social services Under CPP (Child Protection Plan) or CIN (Child in Need) Substance misuse by adults with caring responsibility PHYSICAL HEALTH risks: Access to GP Poor physical health Recommended medical investigations up to date ? If not, reasons for this. Recommended medical treatments (including medications) being appropriately used ? If not, reasons for this. SUBSTANCE MISUSE risks: IV use Sharing needles Accidental overdose Safeguarding Children: Sex working If the patient has children (or there are children in the household) is there a need for safeguarding of children to be considered? Does the patient have children who are known to social services? Risk Formulation and Management Plan http://www.rcpsych.ac.uk/usefulresources/managingandassessingrisk/riskmanagement.aspx  CLINICAL TOOLS, HCR-20 “The Historical Clinical Risk Management- 20” Version 3 (2013) Structured 20 items Focus on violence risk assessment Good predictive validity and inter- rater reliability Others - HCR 20, PCL-R, VRAG, RSVP… Scenarios …AND IT’S NOT ALL ABOUT RISK ASSESSMENT  VIGNETTES 34-year-old woman; postpartum 6 weeks; referred by GP with low mood & anxiety 15-year-old boy; referred by school for counselling after they have noticed his grades dropping & becoming more withdrawn. He has been keeping a knife under his pillow. 76-year-old man; referred by district nurses after noticing increasing isolation & poor self-care. His family say he is forgetful, and his diabetes is getting worse.  VIGNETTES 48-year-old woman with social anxiety. She has been struggling at work and was in a recent car accident. She feels like a failure as she can’t manage big presentations at the office. 31-year-old married man referred after neighbours initially complained he is up all night making loud noise. He tells you he is very busy, ‘extremely ecstatic’ and has a lot of plans. He has not been sleeping and is keen to get going so he can drive down to ‘No. 10’ and hand over his ‘societal master plan’ to Dominic Cummings. 37-year-old woman with history of a single psychotic episode. Has not been turning up for follow-up appointments. Neighbour noticed she is leaving rubbish outside her house, and she has shouted abuse and told people to stop ‘interfering’ with her. Curtains drawn at home, and lights seem to be off all day. She was seen fitting extra locks. She has a 7-year-old son.  CONSIDERATIONS Are we too risk averse? Too paternalistic? What about duty of care? Safety? Poor predictive value of structured suicide risk assessment tools Role of tech in future risk assessment? Who ‘holds’ the risk? Lead clinician? Whoever completes form?  SUMMARY AND QUESTIONS An understanding of risk is clinically essential Each interaction can inform the risk assessment For risk assessments to be helpful they must be Up-to-date Accurate Individual Responsive & dynamic Risk assessments don’t prevent adverse events but can inform clinical care to mitigate for them Thank You  Other resources https://www.nhs.uk/conditions/suicide/ https://giveusashout.org/ https://www.ucl.ac.uk/students/support-and-wellbeing/student- psychological-and-counselling-services https://www.mind.org.uk/information-support/types-of-mental-health- problems/self-harm/about-self-harm/  REFERENCES Caroline Logan (2014) The HCR-20 Version 3: A Case Study in Risk Formulation, International Journal of Forensic Mental Health, 13:2, 172-180 Risk Management in Mental Health Services – Health Service Executive of Ireland 2015 Chesney, E, Goodwin GM, Fazel S, 2014. Risks of all cause and suicide mortality in mental disorders: a meta review World Psychiatry. 13(2), pp.153-60. http://www.bmj.com/content/bmj/suppl/2017/03/30/bmj.j1128.DC1/suicide_v23_web.full.pdf Office for national Statistics - https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bullet ins/suicidesintheunitedkingdom/2017registrations https://www.hse.ie/eng/services/publications/mentalhealth/riskmanagementinmentalhealth.pdf Stuart, H (2003) Violence and mental illness: an overview. World Psychiatry. 2003 Jun; 2(2): 121– 124. Elbogen EB, Johnson SC (2009) The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 66(2):152-161 Fazel S, Gulati G, Linsell L, et al. (2009) Schizophrenia and Violence: Systematic Review and Meta- Analysis. PLoS Med. Aug 6(8): e1000120 Assessment and Management of risk to Others. Royal College of Psychiatrists, UK https://www.rcpsych.ac.uk/pdf/CR201GPGx.pdf Latalova, K. Kamaradova, D. Prank on, J. Violent victimisation of adult patients with severe mental illness: a systematic review Neuropsychiatric disease and treatment 10, 1925,2014