Assessment of risk

Assessment of risk


Assessment of patients with mental illness is not complete without an assessment of risk. The following risks should be considered in every case:


image suicide

image deliberate self harm

image aggressive behaviour

image neglect or exploitation by others

image self neglect.

Assessing risk needs a systematic and holistic approach. There are questionnaires available to help in the assessment, but they are no substitute for taking a thorough history and detailed mental state examination, and carefully weighing up the various risk and protective factors that are present. The physical, psychological and social influences on the individual should be considered, along with the likelihood of them changing. Past history of high-risk behaviour is important, and if present the current risk should be considered to be greater. Assessing risk can be a difficult and highly skilled task. If you ever find yourself in doubt about the risk faced by a patient it is essential to seek advice from an experienced psychiatrist.


The emphasis here will be on assessing and managing risk of suicide and deliberate self harm. The principles of this form of risk assessment can be applied to assessing other risks. In particular, it is important to ask the patient directly about the risk faced by themselves or others, and to ask in detail about any incidents that have occurred.



Suicide and deliberate self harm


Suicide is deliberate self murder, and the cause of at least 1% of all deaths in the UK. The annual rate has steadily fallen to around 8.5 per 100,000 and is highest in men and the elderly. In the 1980s and 1990s there was a dramatic increase in the suicide rate in young men, however this trend is now reversing, and the suicide rates in this group are falling year on year. But suicide remains the second most common cause of death in 15- to 44-year-old men (accidental death is the most common cause). Over all ages men are three times more likely to die by suicide than women, and for the 20 to 24 years age group men are four times more likely than women to die in this way. Young Asian women have been identified as particularly vulnerable, with a suicide rate that is twice the national average. The method for committing suicide is determined to some extent by the availability of means. In the UK the commonest methods are hanging, self poisoning (most often painkillers or antidepressants), jumping and drowning. In the USA, firearms are the commonest means of suicide.


Deliberate self harm (DSH) is much more common than suicide. The annual rate is about 3 per 1000. In contrast with suicide, DSH is most common in young women, and drug overdose is the most frequently used method. A significant number of people who harm themselves go on to commit suicide, with 1% of those presenting to hospital following a suicide attempt dying by suicide in the following year, and 5% over the following 10 years.



Aetiology


Mental illness is by far the most important cause of suicide, present in about 90% of cases. In 70% of suicides the mental illness is depressive disorder. It is important to be aware that the early stage of recovery from depression is a vulnerable time as energy and motivation may return before the mood lifts, so the person is more able to act on continuing suicidal ideas. Up to 15% of people with severe mood disorders will kill themselves. About 20% of those dying by suicide are alcoholics, and alcoholics have a suicide rate of 10%. As schizophrenia is relatively uncommon it is present in only 2–3% of suicides but, of those suffering from schizophrenia, 10% die by suicide, with the greatest risk in the earlier stages of the illness when the patient is struggling to come to terms with the potentially devastating effects of the condition.


A number of social and medical factors are associated with suicide. These are listed in Table 1. They are not necessarily causes of suicide and are not present in all cases, but it is useful to bear them in mind when assessing a patient who may be at risk of committing suicide.


Table 1 Factors associated with suicide






image Male

image Older age – the greatest risk is in men over 75
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Related posts:

Mood stabilisers and ECT Old age psychiatry I Diagnosis and classification of schizophrenia Anxiety disorders – clinical presentation and aetiology Old age psychiatry II Personality disorders – introduction and classification

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Jul 12, 2016 | Posted by in PSYCHIATRY | Comments Off on Assessment of risk

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