Risk Assessment Flashcards
What domains to think about when assessing risk?
- Any thoughts of self harm?
- Any thoughts of suicide?
- Any thoughts about harming others?
- Any risk of being harmed by others? - risky situations, people
Ask about medications online when taking DH
Two types of risk to self
- Suicide - killing onself intentionally
- Deliberate self harm - action of self harm where action was not with intention of death but to cause harm
- Parasuicide - victim survives attempt
Male vs female suicide rates
Male:female 3:1
45-64 highest age specific rate in both genders
Most common mechanism is hanging
When is risk highest for suicide?
- In patient stay - risk increased with forensic history, previous suicidal behaviour, violence to property, recent bereavement and presence of delusions
- Within 3 months discharge - post discharge = unplanned, lack continuity, unemployment, suicidal behaviour prior to admission
Risk factors for suicide
- Male
- Living alone
- Unemployment
- Deprivation
- Drug and alcohol miuse
- MH illness
- Past self harm
RF for suicide and how they are prevented
Correlates of depression and bipolar disorder with risk of suicide
Mood disorders eg depression
Disorders occuring in people who commit suicide
- Mood disorders eg depression
- Schizophrenia
- Substance misuse
- Personality disorder
- Physical illness
Associations with schizophrenia and suicide attempts
Early onset schizophrenia eg adolescents
Depressive symptoms
Positive psychotic symptoms
Male
High premorbid IQ
Feeling guilt/anxiety
Substance abuse
Treatment delay
First decade of illness
Recent discharge from hospital
Previous attempts
Substance misuse correlates
Male
Older age
Alcohol use
Previous attempts
Longer duration of problem
Single, divorced or widowed
Multiple substances abused
Comorbid depression
Highest risk PD for suicide
- Borderline PD - chronic suicidality
- Narcissistic second hightest
PD is diagnosis of exclusion
Physical illnesses associated with suicide
- Chronic disorders - neurological, GI,m CVS
- HIV
- Cancer
- Physical disability
- Chronic pain
- –> loss of job, family, money
Influences that can result in suicide
Deliberate self harm - types
- Behaviour is self initiated, harm is intended and results in injury/harm
- Two types - self-poisoning, self-injury
Epidemiology of deliberate self harm
- Higher rates females
- Peak age 11-25
- Increased risk of suicide - 30-100x in the year following self harm episode
- More than 50% who die by suicide have self harmed
Associations of deliberate self harm
- Previous self harm
- Alcohol/drug misuse
- Unemployment
- History of trauma, sexual or physical abuse
- Criminal record/history of violence
- Single/divorced/seperated
- FH - 4x increased risk, twin and adopted studies
Why do people DSH?
Motives:
* Wish to die
* Cry for help
* Communication with others
* Unbearable symptoms
Psychological:
* Implusivity
* Cognitive rigidity
* Difficulties in problem-solving
* Hopelessless
Coping mechanism:
* Temporary relief of anxiety, stress, emotional numbness
* Sense of failure
Substance abuse and DSH relationship
- Increased use at the time of DSH or just before
- Use of alcohol and illicit substances can potentiate dangers of OD
- alcohol can increase toxicity of psychotropic drugs or lead to unconsciouness and delay treatment
Risk assessment for suicide
- Psychiatric exam
- Explore protective factors - is there anything that stops you from doing it?
- Risk factors - which ones are modifiable or static?
- Specific suicide inquiry - have you made any plans, what is your intent?
- Formulate risk
Taking history re overdose
- Determine triggers
- Planning - planned in advance? How long did they think about it? what did they do to prepare? Final acts?
- Circumstances - did they make sure they were along? precautions against discovery? did they take tablets with alcohol?
- What did they think would happen? What did they want to happen?
- After the act - did they seek help, regret? Intent on doing it again?
What to ask about re thoughts after suicide?
- Ideation
- Intent - do they intend to do it again
- Plans made?
Assessing needs when taking history of OD
- Social dependents
- Untreated disorders
- Physical health
- Current coping mechansism and strengths
- Levels of functioning
- Financial difficulty
Management options after risk assessment - what to consider
- Depends on level of risk
- Reduce access to means - lock away medications, sharps etc
- Are they safe to go home, do they need support?
- Are they willing to engage with management? - eg crisis team?
- Treat psychiatric disorder
Risk management as an inpatient - things to consider
- Level of observations (eyesight, width)
- Adherance to treatment - long acting depot injection?
- Staffing numbers - need safe staff:patient number
- Staff training
- Safe environment - remove ligature points etc
