Risk Assessment

Question 1

What are the 7 domains of risk?

Answer 1

Harm to self 
Harm to others 
Neglect (of self or other)
Exploitation/vulnerability 
Adherence 
Absconding 
Damage to property

Question 2

What comes under harm to self?

Answer 2

Deliberate self harm - thoughts of, plans to, how, when, how long for,

Suicidal ideation, planning - if a patient can visualise the acting out of a plan = good indicator of high risk

Suicide attempts - intentions, how, how many, how far have you got, precautions to not be discovered, letters/social media posts,

Question 3

What comes under harm to others?

Answer 3

Any trouble with the police? (gets insight into convictions/cautions as well as possible victims)

Do they drive and is their condition affecting their ability to do so? Have to inform them to tell the DVLA or tell them yourself if you suspect they havent

Occupation - is their condition likely to affect their work? ie HGV drivers

Command hallucinations - any that directly concern harming a specific individual, you have a duty of care to breach confidentiality inform relevant persons

Home life - do you feel safe at/going home? (further DA questions)

Question 4

What is important to consider in risk management with children?

Answer 4

Children are liable to get caught up in schizophrenic delusions etc - safeguarding early is key

Question 5

What is the consensus on using risk stratification to predict completed suicide?

Answer 5

The risk stratification of psychiatric patients into ‘high’, ‘medium’ or ‘low risk’ is common in clinical practice
- These labels however are very ambiguous

There is a paucity of evidence addressing the positive predictive value of individual risk factors

An interesting review in the BMJ (BMJ 2017;359:j4627) concluded that ‘there is no evidence that these assessments can usefully guide decision making’ and noted that 50% of suicides occur in patients deemed ‘low risk’.

Whilst the evidence base is relatively weak, there are a number of factors shown to be associated with an increased risk of suicide:

male sex (hazard ratio (HR) approximately 2.0)
history of deliberate self-harm (HR 1.7)
alcohol or drug misuse (HR 1.6)
history of mental illness
depression
schizophrenia: NICE estimates that 10% of people with schizophrenia will complete suicide
history of chronic disease
advancing age (esp men aged 49-55)
unemployment or social isolation/living alone
being unmarried, divorced or widowed

Protective factors:
Being married
Being employed in a skilled occupation, barring exceptions whereby occupation provides easy access to means, e.g. physicians
Family support
Having children at home
Religious belief

Question 6

What are some factors that might predict repeat or completed suicide attempts?

Answer 6

Planning
Final acts such as sorting out finances
Leaving a written note
Violent method
Efforts to avoid discovery

Question 7

What is another method for understanding suicide risk?

Answer 7

“Reformulating Suicide Risk Formulation: From Prediction to Prevention” https://link.springer.com/article/10.1007/s40596-015-0434-6
- includes a good graphic representation

Formulates risk based on 4 different categories of judgement which are then used to inform intervention plans:

• Risk status (patient risk relative to a specific subpopulation, more enduring)
• Risk state (patient risk compared to their baseline or other specified time points, more dynamic)
• Resources available (to draw upon in times of acute crisis)
• Foreseeable changes (that may lead to a increase in risk)

Question 8

Prevention-Oriented Risk Formulation definition?

Answer 8

A concise synthesis of empirically based suicide risk information regarding a patient’s immediate distress and resources at a specific time and place

The goal of this synthesis is not to predict behaviour but to promote communication and collaboration among professionals, patients, and families to reduce risk in the short and long term.

Question 9

What are the 4 domains that summate to inform perception of:

1) Risk status
2) Risk state

Answer 9

Risk status:

• Strengths and protective factors
• Long-term risk factors
• Impulsivity/self-control (including substance abuse)
• Past suicidal behaviour (though within the past year seems to be most predictive)

Risk state:

• Recent/present suicide ideation, behaviour (incl. increasing amounts of self harm)
• Stressors/precipitants
• Symptoms (including chronic physical), suffering and recent challenges
• Engagement and alliance

Question 10

How might you explore/express risk status?

Answer 10

‘Higher than/similar to/lower than [comparison group]’

e. g.
- Compare patient X to general population, to other depressed patients you have seen in your career (that you currently manage in outpatients) and to the last 10 patients you have admitted to the inpatient service

Using this kind of framework can help clarify the most appropriate form of intervention at the current point

Also better than trying to ascribe a risk level in the abstract i.e. compared to no-one

Question 11

How might you explore/express risk state?

Answer 11

Expressed relative to a strategically chosen point or points in the patients own history - focussing clinicians on temporal changes and how immediate distress fits within the events and patterns of the patient’s life

e.g. risk might be higher than pre-morbid baseline; higher than pre-[adverse event] but similar to what it has been for the past X months

Question 12

How do we understand available resources and foreseeable changes?

Answer 12

Available resources:

• Those immediately accessible to the patient and treatment team to support a crisis
• Different from ‘protective factors’ insofar as these are broad strengths or epidemiologically derived traits e.g. having children in the home, holding attitudes against suicide etc. - important but not always readily available in crisis
• Refers to the range of biopsychosocial and follow up/locations in which someone can be seen

Foreseeable changes:

• Events or stressors which, if they occurred, could reasonably be expected to increase or decrease risk
• This allows for specific contingency plans to be activated - either by the patient themselves or by treating team - under certain circumstances
• This serves to increase risk prevention (not prediction)

Try to identify at least two of each

• Ideally in consultation with the patient themselves, but can also be formulated based on the clinicians knowledge of the patient (esp. if patients mental state is impaired at the time)
• Being able to name resources and plan for challenges appropriately may be a vital step in discharge planning from services too