Download Risk Assessment and Management

Clinical Risk Assessment and Management
in Psychiatry
Raquin Cherian
Specialty Registrar(ST4)
Sentil Soubramanian
Specialty Registrar(ST5)
PLAN
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Background
Definitions
Evidence base
Clinical Assessment
Tools for assessment
Limitations of Risk assessment
Case Examples
Background-how it all began!
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The concept of risk as we understand in psychiatry today,is
centuries old.(La logique,ou ‘Art de Penser,Pascal’s Pense’es1662)
1994, high-profile homicides by mental health patients
(Christopher Clunis, Michael Buchanan)
Public inquiries and data collection into homicide by mentally ill
under psychiatric care:Failing in risk management and poor
professional communication contributing to homicide
Risk assessment and management as central focus for mental
health policy and practice
Important guidelines e.g best clinical practice in the assessment
and management of risk (Royal College of Psychiatrists, 1996).
Background – past decade
• Risk moved to the forefront of mental health policy new legislation, changes in working practices and the
introduction of tools for assessing risk.
• Government policy (enshrined in the Care Programme
Approach (CPA) in England in 2000. stipulates that each
patient’s risk of harm should be routinely assessed by
specialist mental health services. -‘local’ risk
assessment tools designed internally by mental health
trusts (MHTs).
• Political focus and media commentary on the subject
+increasingly risk averse Society
Background :Where are we
• “Risk has become a central feature of modern life; a
veritable industry has grown up around its detection,
assessment and management. The risk posed by the
fraction of mentally ill people who offend has always
generated concern , but as care for the mentally ill
has moved out of the institutions into the gaze of an
increasingly risk- obsessed public, the intensity of the
reaction that it provokes has grown out of all
proportion to the actual risk involved.”(Rethinking
risk to others-Royal College of Psychiatrists Report
2008)
Definitions
• Risk:the likelihood of an adverse event.
• Risk Factors: features associated with increased risk.
• RiskAssessment:an estimation of the likelihood of
particular adverse events occurring under particular
circumstances within a specified period of time.
• RiskFormulation:organisation of the risk data to
facilitate risk management.
• Risk Management:organised attempts to minimise
the likelihood of adverse events
Types of risk assessment
• Clinical assessment
Unstructured
Structured (e.g. HCR 20)
• Actuarial approach
Actuarial tools
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Originated in the insurance industry
Use mathematical means to combine information
Use static(non-clinical) factors
Produce an estimate of risk derived from group
data.
• Predict the individual’s likely behaviour from the
behaviour of others in similar circumstances or
with similar profiles
• X%of those with similar profile would be violent
within Y years
Risk Assessment Tools
Structured Professional Judgement
• These tools take into account both static and
dynamic factors and combine current
clinicalevaluation with a review of historical
risk factors in a systematic way.
• Example:HCR 20
Clinical Assessment
• Person-specific,based upon history,mental
state and co-lateral information,
• Takes into account your relationship with the
individual and a thorough understanding of
his underlying thoughts, feelings and related
psychopathology.
• Difficulties can then be placed in the context
of adverse social problems and life events.
Cinical Assessment
Assessor characteristics
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Personal values
Own attitude towards risk
Work load at the time of the assessment
Time for the assessment
Clinical Assessment
Advantages
• Flexibility
• Emphasis upon violence prevention
• Can identify
a. Personality traits
b. Situational triggers
c. Motivation to commit risky acts
Clinical Assessment
Disadvantages
• Poor inter-rater reliability
• Failure to specify decision making process
• Poor predictive validity in comparison to
actuarial approaches
Risk assessment tools or clinical
assessment
• Tools(actuarial and Structured clinical tools) helps
to consider risk factors in a systematic way.
• Tools cannot be used to predict violence at an
individual level
• Can assist in identifying those high-risk subgroups
who require more resources and appropriate
management to reduce the risk.
• Neither should replace traditional clinical
assessment
Risk assessment
Best approach
The best approaches to risk assessment
combine actuarial and clinical judgements, the
former raising ‘an index of suspicion’ of risk,
while the latter employs rigorous clinical skills to
a complex arena. Risk will never be eliminated,
and responsibility for assessment of risk needs
to be multi- disciplinary.
Categories of risks
The broad categories are:
1 Suicide – inflicting of damage to self, with the intention of
relieving distress with an intended outcome of death.
2 Neglect – act of disregarding care for self, causing serious
risk to personal health and well being.
3 Aggression/violence – an expression of anger, fear or
despair, through anextreme and forceful delivery of actions and
emotions, inflicting harmful or damaging effects.Violence would
include actual physical assault on another individual, extreme
outpouring of verbal or written threats and damage to property.
Risk Categories
Others
• Other self-harm (e.g. eating disorders)
• Stated abuse by others
• Stated abuse of others
• Stated harassment by others (e.g. racial,
physical)
• Stated harassment of others
• Risks to child(ren)
Risk Categories
Others
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Stated exploitation by others (e.g. financial)
Stated exploitation of others
Culturally isolated situation
Non-violent sexual offence (e.g. exposure)
Arson (deliberate fire setting only)
Accidental fire risk
Other damage to property
Other
Risk Factors
Static factors
• Historical or fixed
• changeable but not by intervention (e.g.
age/marital status)
Strengths
– Provides risk estimate relative to others
– Facilitates resource allocation
Limitations
– Can’t change much
Risk Factors
Dynamic
E.g: Alcohol use
current mental state
Strengths
– Enhances predictive accuracy
– Identifies targets for treatment
– Engages offender in hopeful approach to the
future
Expressing the Risk
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Is there a risk of harm?
What sort of harm,
What degree?
Who is at risk?
How likely is it that harm will occur?
What is its immediacy?
How long will the risk last?
What are the factors which contribute to the risk?
How can the factors be modified or managed?
Define the risk
Severity:best predicted by prior violence
Imminence:best predicted by
– pattern of violence
– statements
– life circumstances.
Likelihood best predicted by actuarial models
Dvoskin and Heilbrun 2001
Violence
“Violence is relatively rare and consequently
accurate prediction is difficult”
So, why are we interested in them….
Violence and mental illness
Overwhelming evidence continues to point to an
increase in violence within populations with
mental illness specifically in those with
substance abuse, personality disorder or
psychopathy and psychotic disorders.
And….
Risk management
• Pharmacotherapy can reduce violence in those
whose prior violence was linked to psychotic
symptoms.
• Psychological interventions can specifically target
anger control, interpersonal skills and effective self
• Addressing dynamic risk factors may mean removing
access to lethal means, activating support systems or
involving other agencies
Violence Literature
McNeil et al 2003
• Clinical factors may be most relevant for the
estimation of short term risk in acutely ill
patients
• Historical factors may be most relevant for
estimating the long-term risk in treated
patients
Literature
ECA Study: Swanson 1990
• Major mental disorder: 5 fold increase in
violence compared to those without major
mental disorder (10- 13% verses 2%)
• Substance misuse:10fold increase in violence
compared to non-drug users (19-35% verses
2%)
Literature
MacArthur Violence Risk Assessment Study:
Steadman 1998
• Prospective 1 year follow up of 1000
discharged patients compared to community
controls for levels of violence
• No association found between mental illness
and violence
• May be indication of the success of risk
management
Violence Literature
• Birth Cohort Study: Hodgins (1992)
• Odds Ratio of 4 for violence among men with
major mental illness compared with controls
• Odds Ratio of 27 for violence among women
with major mental illness compared with
controls
Summary of violence literature
• Substance misuse is a major risk factor with or
without mental disorder
• Socio-demographic factors contribute
significantly
• Contribution of mental illness is relatively
small
Accuracy of clinical assessment
Link1993:predictions in emergency room
patients
– correct 1 in 2 attempts
– clinicians significantly under estimated risk in
women
– if used just the historical data on the same
patients the sensitivity increased at the expense
of the specificity
Accuracy of clinical assessment
• Mulvey and Lidz 1998
• Asked doctors to predict which of the patients
assessed in the ER would be violent
• The clinicians did reasonably well in
predicting place, target, severity of violence
and involvement of alcohol in violence
• Clinicians overestimated the influence of noncompliance and drug misuse upon risk of
violence
Summary of accuracy of clinical
prediction
Monahan1981“mental health predictions of
violence are wrong 2/3 of the time”
Lidz1993:Psychiatric predictions of violence better
than chance accuracy in male ER patients
Monahan1997:better than chance ability to predict
violence
Mulvey&Lidz1998
– clinicians generally right about the seriousness and
location of violence
– But overestimated the role of compliance and drug
misuse
Good risk assessment
Reviewed on a regular basis
Reviewed if there are new concerns
Multi-disciplinary
In collaboration with the patient and their carer
limitations of your assessment noted
Includes factors which reduce risk of future
violence
Only useful if disseminated
Informs the management plan.
Review risk
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First contact with service
Change or transfer of care
Change in legal status
Change in life events (e.g., loss)
Significant change in mental state
Change in environment
Violence:
Static Risk Factors
Increase
Decrease
Male
Over 35 years of age
Young
Stable/nurturing childhood
Disrupted /Abused Childhood
Good pre-morbid personality
Antisocial
Suspicious
Impulsive
Irritable
Sensible“
Violence:
Social and Interpersonal factors
Increase
Decrease
Poor social network
Good social network
Lack of Education
Stable accommodation
Lack of work skills
Employment
Rootless
A confidante
Poverty
Supportive intimate relationship
Homelessness
Violence
Mental Disorder
Increase
Decrease
Active symptoms
Absence of active symptoms
Poor compliance
Good compliance
Poor engagement with services
Good engagement
Treatment resistance
Good treatment response
Lack of insight
Good insight
Violence
Situational triggers
Increase
Availability of weapons
Loss
Demands and expectations
Change
Confrontation
Physical illness
Decrease
Violence
State of Mind
Increase
Anger/fear
Threats
Delusions
– Evoking fear
– Provoking indignation
– Provoking jealousy
– Involving jealousy
– Involving injury/threat from close
relative or companion
Clouding consciousness and confusion
Ideas of influence
Command hallucinations
Decrease
Amotivational
Violence
Substance Misuse
Increase
Decrease
Present
Absent
Risk assessment-limitations
All risk assessment processes will appear
inadequate if rare outcome measures are used.
Outcomes such as homicide and suicide are
statistically rare, so ‘numbers needed to treat’ in
order to avoid a single adverse outcome will
appear vast.
Risk assessment-limitation
• is not possible to identify and eliminate risk
entirely.
• Risk is dynamic, therefore, prediction may be
more accurate in the short term.
• Limited availability of info on which risk
assessment is based.
Risk assessment Framework
• Role of risk assessment may not be about an
accurate but about making informed
defensible decisions
• Content to vary depending on adverse
outcome being assessed.
Why things go wrong with risk
assessment(lipsedge,1995)
• Failure to lend sufficient weight to
carers/public’s reports about disturbed
behaviour
• Undue emphasis on civil liberties of patients
• Failure to implement MHA properly
• Tendency to take a cross sectional rather than
a long term view of risk
• Failure to share info in pts best interest
W v Egdell [1990]
• Duty of confidence to the patient is not
absolute
• Balance between the interest in
confidentiality and in public safety
Thoroughness
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Attention to detail
Accurate and detailed record keeping
Comprehensive history taking
Avoid minimising incidents
Linking incidents
“Asking the unaskable”
Too many decisions,too little timeThe “Bare minimum"
• Ask the patient about history of violence
• Ask the patient about current thoughts of
violence
• Attempt to contact an informant and ask about
any violence from the patient or history of
violence
• Request previous discharge summaries
Document that you have done these and the
outcome.
RISK Management
• adequate assessment and treatment – focussing
on compliance and engagement with services.
• Improved accommodation, and links to
programmes to improve social interaction-better
engagement
• The assessment and management of drug and
alcohol misuse among those with schizophrenia is
a major priority – its effective control is a
prerequisite for any other management
Risk management
• Pharmacotherapy can reduce violence in those
whose prior violence was linked to psychotic
symptoms.
• Psychological interventions can specifically target
anger control, interpersonal skills and effective self
• Addressing dynamic risk factors may mean removing
access to lethal means, activating support systems or
involving other agencies
CPA: risk management
Actions to minimise the hazards
Actions to enhance protective factors
Review date
Contingency plan to include
– Arrangements for when the co-coordinator is
unavailable
– Arrangements for when part of the care plan can
not be provided
Crisis plan to include
– Action to be taken if mental state is rapidly
deteriorating
Mullen’s clinical Engagement Model
for Risk in Schizophrenia
10% of pts with schizophrenia are responsible for
90% of the fear inducing and violent acts
This 10% will include nearly all of the smaller group
(perhaps 1%) who will commit potentially lethal or
seriously injurious behaviours
Thus by effectively identifying the 10% and
managing them appropriately the risk of serious
harm is also reduced
Multi Agency public protection
arrangements MAPPA
Offenders who pose a risk of serious harm to
others
– Level 1 Caused serious harm previously,
manageable by a single agency
– Level 2 Pose a serious risk to others but not an
imminent risk
– Level 3 Pose and imminent and serious risk
Risk management
• Clinical assessment is not primarily about
making an accurate prediction but about
making informed, defensible decisions"
(Grounds, 1995).
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The defensible decision
Take all reasonable steps
Use reliable assessment methods
Seek information you do not have
Thoroughly evaluate all relevant information
Stay within agency policies and procedures
Record and account for decision making
Communicate the plan to others involved
To conclude
• Patients with mental illness are at increased risk of
violence compared to the general population.
• High-risk subgroups are recognisable in advance and this
is greatly assisted by structured clinical assessment.
• This risk assessment approach is not perfect and does
not increase the ability to identify a particular individual
who may commit an act of serious violence, but it does
allow improved management of those at higher risk.
To Conclude
Only a few, even in these groups, will ever
commit serious acts of violence but
interventions targeted at the high risk group will
help to reduce serious episodes of violence.
To conclude
The ongoing prevention of future violence
requires approaches that target substance
misuse, control of positive psychotic symptoms,
personality factors, the need for employment
and/or structured activities, as well as
encouraging appropriate and supportive social
networks and relationships.
References
• Clinical risk assessment for general adult psychiatrists: A
Feeney(Rcpsych)
• Guidelineforclinicalriskassessmentandmanagement in mental
health services
• Ministry of Health (New Zealand) 1998
• Dangerousness,RiskandthePredictionofProbability.
• Mullen P. The New Oxford Textbook of Psychiatry. (Eds M.G. Gelder,
J.J. Lopez-Ibor and N.C. Andreasen). Chapter 11.4.3. Oxford.
• Thestateofcontemporaryriskassessmentresearch Norko MA and
Baranoski MV. Can J Psychiatry (50) 1, 18-26.
• BestPracticeinManagingRisk Department of Health June 2007
• …..to live without certainity and yet without
being paralysed by hesitation,is perhaps the
chief thing.(Bertrand Russell,1945)