Lecture 27: risk assessment in mood disorders Flashcards
Generally what is defined as risk in mental health?
The possibility of an adverse event, behaviour or outcome arising from the actions of the patient
Commonly risk of harm refers to self, others of both but risk is broad and encompasses a number of domains
Can be considered vulnerabilities that a person with a mental health condition may be exposed to
Outline the types of assessment of risk
Unstructured –> based on clinical judgement - no rules dictate the judgement and decision is derived from intuition
Structured
1) Actuarial or standardised risk assessment - checklist approach using algorithms to combine risk factors for decision making
2) Structured clinical assessment or professional judgement
- Assessment of risk is based on a rational selection of risk factors personalised for the individuals case
What is the “low risk paradox”
Describes the phenomenon that a significant proportion of individuals who commit suicide have been previously assessed as low risk soon before death - national confidential inquiry data
- Therefore we should avoid simple low/medium/high risk judgements given the reductive nature of these terms that may prevent consideration of other risk factors
Define self harm
“An intentional act of poisoning, self-injury, irrespective of the motivation or apparent purpose of the act, and is an expression of emotional distress”
- The terms deliberate self harm, attempted suicide, para-suicide avoided now
- Reasons for self-harm are complicated but many do not describe suicidal intent rather coping mechanisms, need to damage self/feel pain to feel better, need to make body less attractive, expression of internal distress, to feel more in control
Do people with mental health conditions pose more of a risk of violence to others or from others
From others - often those with a mental health condition have a significant risk of violence from others or from self harm rather than to others through aggression
Past history of aggression can be used to assess if a future risk to others may be present
Describe some factors which may increase a patients risk to children (either through neglect or abuse)
Substance abuse Domestic abuse Financial hardship Housing problems Relationship problems Social isolation
- These can influence whether a parent may pose a larger risk to their child
- Can be used to help inform the need to safeguard the child
- Many parents are able to minimise the impact mental health problems have upon children
Name some domains that a patient may have risk from others?
Financial - patient may lose money
Emotional abuse/bullying
Sexual abuse
Physical abuse inc. domestic violence
Name the 6 principles of safeguarding vulnerable adults first introduced by department of health in the 2014 care act?
- Empowerment - being supported and encourage to make their own decisions and informed consent
- Prevention
- Proportionality - less intrusive response appropriate for the risk presented
- Protection - support and representation for those in greatest need
- Partnership - local solutions through services working with their communities
- Accountability - accountability and transparency in safeguarding practice
State some risks associated with depression?
Self injury / suicide
- BD-II > BD-I
- BD > MDD
Self-neglect / poor self-care
- Includes diet and hydration as well as hygiene, adhering to medication
Disruption of employment and close relationships
Alcohol/drug misuse
Psychotic depression
- Often high post-partum
- Can increase risk of suicide
Name some risks that can present during mania?
Socially disruptive behaviour (grandiosity)
- Puts individuals at risk from others
- Comes from grandiosity
Individual engages in heightened risk activities (grandiosity)
- May believe they are invincible
- Could be driving a car, jumping from a high place
Increased spending / overly generous:
- May lose significant amounts of money impacting the individual and their family
Damage from excessive drug/alcohol use
Risk from irritability/oppositional mood/rudeness:
- In mixed state –> dysphoric mood and increased energy an individual may harm others
- Can damage interpersonal relationships
Disinhibited behaviour:
- Socially inappropriate - canbe sexual or exhibitionism
- May damage occupational relationships, reputation risk
What is a risk formulation?
Serious?
Now or later?
Global or specific?
Static or volatile?
Signs of increasing risk?
What treatment/management can reduce risk? (they may target mediating/moderating factors)
Describe some points from the NICE guidance on self harm?
- Be aware of the discrimination and stigma that individuals who self-harm are exposed to
- Undertake risk assessments but to not use tools to predict the risk of self-harm/suicide
- Make a care plan - target achievable and realistic short and long-term goals
- MDT manner
- Consider 3-12 sessions for a psychological intervention that is aimed at targeting self-harm (CBT, psychodynamic or problem solving therapy)
- Treat co-morbidity
Outline some stratergies that may be used to negate risk of self harm
Negating self harm:
- Hand-in blades, tablet or money
- Lock sharp objects in cupboards
- Hand in keys/shoes
- Sellotape blades in a box
- Lock bedroom
- Negotiate restricted area to damage
- Medication
Safer forms of self harm
- Rubber band on wrist
- Listening to loud music
- Hand in ince
- Stand under a cold shower
- Punch a cushion
Distraction techniques
- Playing a game
- Calling a friend
- Watching TV
- Exercise
Relaxation techniques
- Guided meditation
- Focus on breathing
- Relax each muscle individually
- Massage hands
Emotional techniques:
- Journal
- List emotional triggers
- Write a diary
- Talk
- Rainy letter
Name some types of bias that may be present during ris assessments
Availability bias
- Clinicians risk assessment is biased to the information they can recall
Anchoring and adjustment:
- Risk assessment is based upon previous assessment of risk (anchor) and biases current risk judgement on this
Representativeness:
- Clinicians risk assessment is biased towards what they feel is “representative” for that type of patient
Confirmation bias:
- The clinicians risk judgment is based upon finding factors which confirm their initial attitude of the patients risk rather than considering all of the available factors
Fundamental attribution error:
- Risk judgement strong depends (is attributed) to internal characteristics rather than relying upon external contextual factors
