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
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
Substance misuse correlates
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
Risk to others male vs female
- Females more commonly killed by partner or ex-partner or family member
- Male more commonly friend, aquantance, stranger or other
Highest age for rate of victims homicide UK
- Children under age of 1
- Then 16-24, then 35-44
- Ask how old children are at home
Association between psychaitric disorder and homicide
- DSPD, alcohol/drug misuse and Schizophrenia cause small increase in risk to others
- In psychotic disorders risk increased by specific persecutory delusions/hallucinations and command auditory hallucinations
Risk assessment for risk to others
- Psychiatric disorder and relationship to previous violence
- Risk been modified by treatment
- Relevance of pre-morbid personality, substance misuse and alcohol
- MDT views - check
- Previous violent behaviour
- Potential victims
- Aftercare
Child protection - what to be aware of
- Ask about ages of children at home
- Enquire nature of relationship and how often they see them - place of residence
What to do when patient discloses previous abuse?
- Pass information on
- Need to inform seniors and maybe patients GP
Personal factors increasing risk - CAMHS
Family factors increasing risk- CAMHS
Social factors increasing risk - CAMHS
Need to ask re driving
