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Slivinski A, Kaiser J, Perry A, Bradford JY, Camarda A, Gilmore L, Horigan AE, MacPherson-Dias R, Slifko A, Van Dusen K, Bishop-Royse J, Delao AM. ENA Clinical Practice Guideline Synopsis: Suicide Risk Assessment. J Emerg Nurs 2024; 50:296-300. [PMID: 38453343 DOI: 10.1016/j.jen.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 03/09/2024]
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Bossé Chartier G, Lam F, Bergmans Y, Lofchy J, Bolton JM, Klonsky ED, Zaheer J, Kealy D. "Psychotherapy in the Pressure Cooker": A Systematic Review of Single Session Psychosocial Interventions in Emergency Departments for Suicide-related Thoughts or Behaviors. J Psychiatr Pract 2023; 29:291-307. [PMID: 37449827 DOI: 10.1097/pra.0000000000000725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVES Up to 20% of individuals who die by suicide have visited an emergency department (ED) within 4 weeks of their death. Limited guidance is available regarding the modification of clinical outcomes following a psychosocial intervention in the ED for pediatric and adult populations. METHODS A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted to identify studies focused on single-session psychosocial interventions for pediatric and adult patients experiencing suicide-related thoughts or behaviors (SRTB) in the ED. Two reviewers independently screened articles identified using the key terms suicide/self-harm, emergency department, and interview. Medline, PubMed, Embase, PsycINFO, CINAHL, and CENTRAL were searched from inception to August 2018. RESULTS After screening 3234 abstracts, 29 articles were selected for full-text review and 14 articles, representing 8 distinct studies (N=782), were included. A high level of heterogeneity was present in the included articles, with 7 randomized-controlled trials, 2 nonrandomized-controlled trials, 2 cohort studies, 2 observational studies, and 1 feasibility study. Most of the included studies focused on adolescents (6 articles) or military veterans (7 articles). Strong statistical evidence of ED interventions improving outpatient service linkage was supported (χ2: 81.80, P<0.0001, 7 studies). CONCLUSIONS The findings of this study suggested promising outcomes for patients presenting to the ED with SRTB who receive a single-session psychosocial intervention. All of the studies that measured such outcomes found significantly increased follow-up care in the intervention arm. Further research is needed to strengthen the evidence base, provide better patient representation, and improve our understanding of the mechanisms by which the psychosocial intervention for SRTB in the ED ameliorates patient outcomes (CRD42020156496).
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Affiliation(s)
- Gabrielle Bossé Chartier
- BOSSÉ CHARTIER, LAM, and KEALY: Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; BERGMANS and ZAHEER: Department of Psychiatry, University of Toronto, Toronto, ON, Canada; LOFCHY: Adult Acute Care Psychiatry, St. Joseph's Health Centre and University of Toronto, Toronto, ON, Canada; BOLTON: Department of Psychiatry, University of Manitoba, and Shared Health Manitoba Crisis Response Centre, Winnipeg, MB, Canada; KLONSKY: Department of Psychology, University of British Columbia, Vancouver, BC, Canada
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Predicting suicide: A comparison between clinical suicide risk assessment and the Suicide Intent Scale. J Affect Disord 2020; 263:445-449. [PMID: 31969276 DOI: 10.1016/j.jad.2019.11.131] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/27/2019] [Accepted: 11/29/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND How suicide risk should be assessed is under discussion with arguments for both actuarial and clinical approaches. The aim of the present study was to compare the predictive accuracy of a clinical suicide risk assessment to that of the Suicide Intent Scale (SIS) in predicting suicide within one year of an episode of self-harm with or without suicidal intent. METHODS Prospective clinical study of 479 persons assessed in a psychiatric emergency department after an episode of self-harm. The clinical risk assessment and the SIS rating were made independently of each other. Suicides within one year were identified in the National Cause of Death Register. Receiver operating characteristic (ROC) curves were constructed, optimal cut-offs were identified and accuracy statistics were calculated. RESULTS Of 479 participants, 329 (68.7%) were women. The age range was 18-95 years. During one-year follow up, 14 participants died by suicide. The area under the curve (AUC) for the clinical risk assessment and the SIS score were very similar, as were the accuracy statistic measures at the optimal cut-offs of the respective methods. The positive predictive value (PPV) of each assessment method was 6%. LIMITATIONS The clinical suicide risk assessment is not standardized. The number of suicides is small, not allowing for stratification by e.g. gender or diagnosis. CONCLUSION Predictive accuracy was similar for a clinical risk assessment and the SIS, and insufficient to guide treatment allocation.
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Randall JR, Sareen J, Chateau D, Bolton JM. Predicting Future Suicide: Clinician Opinion versus a Standardized Assessment Tool. Suicide Life Threat Behav 2019; 49:941-951. [PMID: 29920749 DOI: 10.1111/sltb.12481] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 04/16/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the effectiveness of clinician prediction of risk to a standardized assessment of presentation status. METHODS All adult psychiatry emergency department consults in the two main hospitals in Winnipeg, Canada, were assessed using a standardized form (n = 5,376). This form includes two risk scales for a gestalt physician assessment of risk (Suicide Likelihood scale, suicide Attempt Likelihood scale) and the Columbia Classification Algorithm of Suicide Assessment (C-CASA). Regression determined whether assessments predicted future suicide attempts and deaths. The area under the curve (AUC) determined the prediction accuracy of these methods. RESULTS Although the regression results were significant, the AUCs were either moderate or poor. Clinician assessment was not effective at predicting deaths (AUC = .546, .36-.73), but moderately accurate at predicting future attempts (AUC = .728, .66-.79). C-CASA assessment was moderately accurate at predicting both attempts and deaths (AUC = .666 and .678). CONCLUSIONS Clinician assessment does not significantly outperform a simple assessment of the occurrence of suicidal thoughts and behaviors during presentation to the emergency department. Behavior-based standardized assessments should be further researched in this field. Assessment of suicidality at presentation using C-CASA or similar assessment should be standard for psychiatric patients assessed in the emergency department.
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Affiliation(s)
- Jason R Randall
- Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Manitoba Centre for Health Policy, Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Injury Prevention Centre, School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Jitender Sareen
- Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Psychiatry, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Dan Chateau
- Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Manitoba Centre for Health Policy, Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Injury Prevention Centre, School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - James M Bolton
- Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Manitoba Centre for Health Policy, Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Psychiatry, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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Woodford R, Spittal MJ, Milner A, McGill K, Kapur N, Pirkis J, Mitchell A, Carter G. Accuracy of Clinician Predictions of Future Self-Harm: A Systematic Review and Meta-Analysis of Predictive Studies. Suicide Life Threat Behav 2019; 49:23-40. [PMID: 28972271 DOI: 10.1111/sltb.12395] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 07/05/2017] [Indexed: 11/26/2022]
Abstract
Assessment of a patient after hospital-treated self-harm or psychiatric hospitalization often includes a risk assessment, resulting in a classification of high risk versus low risk for a future episode of self-harm. Through systematic review and a series of meta-analyses looking at unassisted clinician risk classification (eight studies; N = 22,499), we found pooled estimates for sensitivity 0.31 (95% CI: 0.18-0.50), specificity 0.85 (0.75-0.92), positive predictive value 0.22 (0.21-0.23), and negative predictive value 0.89 (0.86-0.92). Clinician classification was too inaccurate to be clinically useful. After-care should therefore be allocated on the basis of a needs rather than risk assessment.
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Affiliation(s)
- Rachel Woodford
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, NSW, Australia
| | - Matthew J Spittal
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Vic., Australia
| | - Allison Milner
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Vic., Australia
| | - Katie McGill
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, NSW, Australia.,Centre for Brain and Mental Health Research, University of Newcastle, Newcastle, NSW, Australia
| | - Navneet Kapur
- Centre for Suicide Prevention, University of Manchester, Manchester, UK
| | - Jane Pirkis
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Vic., Australia
| | - Alex Mitchell
- Cancer Studies & Molecular Medicine, University of Leicester, Leicester, UK
| | - Gregory Carter
- Centre for Brain and Mental Health Research, University of Newcastle, Newcastle, NSW, Australia
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Abstract
SummaryRisk assessment has been widely adopted in mental health settings in the hope of preventing harms such as violence to others and suicide. However, risk assessment in its current form is mainly concerned with the probability of adverse events, and does not address the other component of risk – the extent of the resulting loss. Although assessments of the probability of future harm based on actuarial instruments are generally more accurate than the categorisations made by clinicians, actuarial instruments are of little assistance in clinical decision-making because there is no instrument that can estimate the probability of all the harms associated with mental illness, or estimate the extent of the resulting losses. The inability of instruments to distinguish between the risk of common but less serious harms and comparatively rare catastrophic events is a particular limitation of the value of risk categorisations. We should admit that our ability to assess risk is severely limited, and make clinical decisions in a similar way to those in other areas of medicine – by informed consideration of the potential consequences of treatment and non-treatment.
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Quinlivan L, Cooper J, Meehan D, Longson D, Potokar J, Hulme T, Marsden J, Brand F, Lange K, Riseborough E, Page L, Metcalfe C, Davies L, O'Connor R, Hawton K, Gunnell D, Kapur N. Predictive accuracy of risk scales following self-harm: multicentre, prospective cohort study. Br J Psychiatry 2017; 210:429-436. [PMID: 28302702 PMCID: PMC5451643 DOI: 10.1192/bjp.bp.116.189993] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 10/05/2016] [Accepted: 11/13/2016] [Indexed: 11/23/2022]
Abstract
BackgroundScales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.AimsTo evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.MethodA multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.ResultsIn total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0-5) for the SAD PERSONS scale, to 97% (95% CI 93-99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2-47) for the Modified SAD PERSONS Scale to 47% (95% CI 41-53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50-0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69-0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P<0.001).ConclusionsRisk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.
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Affiliation(s)
- Leah Quinlivan
- Leah Quinlivan, PhD, Jayne Cooper, PhD, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, Manchester; Declan Meehan, RMN, Damien Longson, FRCPsych, Greater Manchester Mental Health and NHS Foundation Trust, Manchester; John Potokar, MRCPsych, Avon & Wiltshire Mental Health Foundation Trust, Bristol, University Hospitals Bristol, NHS Foundation Trust, Bristol and School of Social and Community Medicine, University of Bristol, Bristol; Tom Hulme, MSc, University Hospitals Bristol, NHS Foundation Trust, Bristol, Bristol; Jennifer Marsden, BA, Derbyshire Healthcare NHS Foundation Trust, Derby; Fiona Brand, RMN, Kezia Lange, MRCPsych, Oxford Health NHS Foundation Trust, Oxford; Elena Riseborough, RMN, Lisa Page, PhD, Sussex Partnership NHS Foundation Trust, Worthing; Chris Metcalfe, PhD, School of Social and Community Medicine, University of Bristol, Bristol; Linda Davies, Institute of Population Health, University of Manchester, Manchester; Rory O' Connor, PhD, Institute of Health and Wellbeing, University of Glasgow, Glasgow; Keith Hawton, DSc, Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford; David Gunnell, DSc, School of Social and Community Medicine, University of Bristol, Bristol; Nav Kapur, MBChB, MMedSci, MD, FRCPsych, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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Tanaka E, Tsutsumi A, Kawakami N, Kameoka S, Kato H, You Y. Long-term psychological consequences among adolescent survivors of the Wenchuan earthquake in China: A cross-sectional survey six years after the disaster. J Affect Disord 2016; 204:255-61. [PMID: 27544312 DOI: 10.1016/j.jad.2016.08.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 07/25/2016] [Accepted: 08/07/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Most epidemiological studies on adolescent survivors' mental health have been conducted within 2 years after the disaster. Longer-term psychological consequences remain unclear. This study explored psychological symptoms in secondary school students who were living in Sichuan province 6 years after the Wenchuan earthquake. METHODS A secondary data analysis was performed on data from a final survey of survivors conducted 6 years after the Wenchuan earthquake as part of the five-year mental health and psychosocial support project. A total of 2641 participants were divided into three groups, according to the level of traumatic experience exposure during the earthquake (0, 1, and 2 or more). ANCOVA was used to compare the mean scores of the Symptom Checklist-90 (SCL-90) among the three groups, adjusting for covariates such as age, gender, ethnicity, having a sibling, parents' divorce, and socio-economic status. Logistic regression analysis was used to identify relationships between the traumatic experiences and suicidality after the disaster. RESULTS Having two or more kinds of traumatic experiences was associated with higher psychological symptom scores on the SCL-90 (Cohen's d=0.23-0.33) and suicidal ideation (OR 1.98, 95% CIs:1.35-2.89) and attempts (OR 3.32, 95% CIs:1.65-6.68), as compared with having no traumatic experience. LIMITATIONS Causality cannot be inferred from this cross-sectional survey, and results may not generalize to other populations due to convenience sampling. CONCLUSIONS Severely traumatized adolescent survivors of the earthquake may suffer from psychological symptoms even 6 years after the disaster. Long-term psychological support will be needed for these individuals.
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Affiliation(s)
| | - Atsuro Tsutsumi
- Organization for Global Affairs, Kanazawa University, Kanazawa, Japan
| | - Norito Kawakami
- Department of Mental Health/Psychiatric Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Hiroshi Kato
- Hyogo Institute for Traumatic Stress, Kobe, Japan
| | - Yongheng You
- Institute of Teacher Education and Psychology, Sichuan Normal University, Chengdu, China
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Quinlivan L, Cooper J, Davies L, Hawton K, Gunnell D, Kapur N. Which are the most useful scales for predicting repeat self-harm? A systematic review evaluating risk scales using measures of diagnostic accuracy. BMJ Open 2016; 6:e009297. [PMID: 26873046 PMCID: PMC4762148 DOI: 10.1136/bmjopen-2015-009297] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 09/16/2015] [Accepted: 10/21/2015] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES The aims of this review were to calculate the diagnostic accuracy statistics of risk scales following self-harm and consider which might be the most useful scales in clinical practice. DESIGN Systematic review. METHODS We based our search terms on those used in the systematic reviews carried out for the National Institute for Health and Care Excellence self-harm guidelines (2012) and evidence update (2013), and updated the searches through to February 2015 (CINAHL, EMBASE, MEDLINE, and PsychINFO). Methodological quality was assessed and three reviewers extracted data independently. We limited our analysis to cohort studies in adults using the outcome of repeat self-harm or attempted suicide. We calculated diagnostic accuracy statistics including measures of global accuracy. Statistical pooling was not possible due to heterogeneity. RESULTS The eight papers included in the final analysis varied widely according to methodological quality and the content of scales employed. Overall, sensitivity of scales ranged from 6% (95% CI 5% to 6%) to 97% (CI 95% 94% to 98%). The positive predictive value (PPV) ranged from 5% (95% CI 3% to 9%) to 84% (95% CI 80% to 87%). The diagnostic OR ranged from 1.01 (95% CI 0.434 to 2.5) to 16.3 (95%CI 12.5 to 21.4). Scales with high sensitivity tended to have low PPVs. CONCLUSIONS It is difficult to be certain which, if any, are the most useful scales for self-harm risk assessment. No scales perform sufficiently well so as to be recommended for routine clinical use. Further robust prospective studies are warranted to evaluate risk scales following an episode of self-harm. Diagnostic accuracy statistics should be considered in relation to the specific service needs, and scales should only be used as an adjunct to assessment.
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Affiliation(s)
- L Quinlivan
- Centre for Mental Health and Safety, University of Manchester, Manchester, UK
| | - J Cooper
- Centre for Mental Health and Safety, University of Manchester, Manchester, UK
| | - L Davies
- Institute of Population Health, University of Manchester, Manchester, UK
| | - K Hawton
- Department of Psychiatry, Centre for Suicide Research, University, Warneford Hospital, Oxford, UK
| | - D Gunnell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - N Kapur
- Centre for Mental Health and Safety, University of Manchester, Manchester, UK
- Manchester Mental Health and Social Care Trust, Manchester, UK
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Peyron PA, David M. Les outils cliniques d’évaluation du risque suicidaire chez l’adulte en médecine générale. Presse Med 2015; 44:590-600. [DOI: 10.1016/j.lpm.2014.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 11/28/2014] [Accepted: 12/10/2014] [Indexed: 11/24/2022] Open
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Larkin C, Di Blasi Z, Arensman E. Risk factors for repetition of self-harm: a systematic review of prospective hospital-based studies. PLoS One 2014; 9:e84282. [PMID: 24465400 PMCID: PMC3896350 DOI: 10.1371/journal.pone.0084282] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 11/22/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Self-harm entails high costs to individuals and society in terms of suicide risk, morbidity and healthcare expenditure. Repetition of self-harm confers yet higher risk of suicide and risk assessment of self-harm patients forms a key component of the health care management of self-harm patients. To date, there has been no systematic review published which synthesises the extensive evidence on risk factors for repetition. OBJECTIVE This review is intended to identify risk factors for prospective repetition of self-harm after an index self-harm presentation, irrespective of suicidal intent. DATA SOURCES PubMed, PsychInfo and Scirus were used to search for relevant publications. We included cohort studies which examining factors associated with prospective repetition among those presenting with self-harm to emergency departments. Journal articles, abstracts, letters and theses in any language published up to June 2012 were considered. Studies were quality-assessed and synthesised in narrative form. RESULTS A total of 129 studies, including 329,001 participants, met our inclusion criteria. Some factors were studied extensively and were found to have a consistent association with repetition. These included previous self-harm, personality disorder, hopelessness, history of psychiatric treatment, schizophrenia, alcohol abuse/dependence, drug abuse/dependence, and living alone. However, the sensitivity values of these measures varied greatly across studies. Psychological risk factors and protective factors have been relatively under-researched but show emerging associations with repetition. Composite risk scales tended to have high sensitivity but poor specificity. CONCLUSIONS Many risk factors for repetition of self-harm match risk factors for initiation of self-harm, but the most consistent evidence for increased risk of repetition comes from long-standing psychosocial vulnerabilities, rather than characteristics of an index episode. The current review will enhance prediction of self-harm and assist in the efficient allocation of intervention resources.
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Affiliation(s)
- Celine Larkin
- National Suicide Research Foundation, Cork, Ireland
- * E-mail:
| | - Zelda Di Blasi
- School of Applied Psychology, University College Cork, Cork, Ireland
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Chesin M, Stanley B. Risk assessment and psychosocial interventions for suicidal patients. Bipolar Disord 2013; 15:584-93. [PMID: 23782460 PMCID: PMC3835446 DOI: 10.1111/bdi.12092] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 04/28/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Suicide is a leading cause of death in the USA. Although factors elevating long-term risk for suicide are known and include bipolar disorder, signs of imminent suicide risk are difficult to study and not well specified. Acute risk determinations must be made to determine the appropriate level of care to safeguard patients. To increase safety among at-risk patients in the short term and to decrease risk over time, psychosocial interventions to prevent suicide have been developed and tested in acute care and outpatient settings. METHODS A narrative review of studies of imminent risk factors for suicide, suicide risk decision-making, and psychosocial suicide prevention interventions was conducted. RESULTS Although some long-term risk factors of suicide have been established, accurate identification of individuals at imminent risk for suicide is difficult. Therefore, prevention efforts targeting individuals at high suicide behavior risk discharging from acute care settings tend to be generic and focus on psychoeducation and supportive follow-up contact. Data regarding the effectiveness of brief interventions (i.e., those not requiring more than one individualized treatment session) are mixed, showing better outcomes in the shorter term and when the incidence of suicidal behavior or ideation is the outcome. With respect to longer-term suicide prevention interventions (i.e., those with a minimum of ten sessions), Dialectical Behavior Therapy has the largest evidence base. CONCLUSIONS To improve suicide prevention efforts, more rigorous study of imminent risk factors and psychosocial interventions is needed. Adaptations specific to individuals with bipolar disorder are possible and needed.
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Affiliation(s)
- Megan Chesin
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York, NY, USA
- Division of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, USA
| | - Barbara Stanley
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York, NY, USA
- Division of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, USA
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Can repetition of deliberate self-harm be predicted? A prospective multicenter study validating clinical decision rules. J Affect Disord 2013; 149:253-8. [PMID: 23453675 DOI: 10.1016/j.jad.2013.01.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 01/23/2013] [Accepted: 01/25/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Clinical decision rules have been developed to help identify patients at high risk of repeating deliberate self-harm actions. The objective of this study was to prospectively validate the clinical decision rules', Södersjukhuset Self-Harm Rule and Manchester Self-Harm Rule, ability to predict repetition of deliberate self-harm (DSH). METHODS A consecutive series of 325 patients attending two large emergency departments in Stockholm, Sweden due to DSH were included and followed for six months. Predictive factors were collected from hospital charts at the emergency department. A nationwide register-based follow-up of new DSH within six months was used. We calculated the sensitivity and specificity to evaluate the different decision rules' ability to identify repetition of DSH. Main outcome measure repeated DSH within six months. RESULTS The cumulative incidence for patients repeating within six months was 24.6% (95% CI: 19.9-29.3). Application of Södersjukhuset Self-Harm Rule yielded a sensitivity of 89% (95%CI: 79.2-94.4) and a specificity of 11% (95%CI: 7.9-16.2). Application of Manchester Self-Harm Rule to our material yielded a sensitivity of 94% (95%CI: 85.4-97.7) and a specificity of 18% (95%CI: 13.8-23.9). LIMITATIONS If data regarding predictive factors were missing it was not possible to investigate this further and in the statistical analysis missing data was classified as no. This would imply that the predicted risks may be underestimated. CONCLUSION Clinical decision rules could be used as a compliment providing important additional information regarding risk of repetition in an ED setting when focusing on high sensitivity.
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Steeg S, Kapur N, Webb R, Applegate E, Stewart SLK, Hawton K, Bergen H, Waters K, Cooper J. The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT Self-Harm Rule. Psychol Med 2012; 42:2383-2394. [PMID: 22394511 DOI: 10.1017/s0033291712000347] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Self-harm is a common reason for Emergency Department (ED) attendance. We aimed to develop a clinical tool to help identify patients at higher risk of repeat self-harm, or suicide, within 6 months of an ED self-harm presentation. METHOD The tool, the ReACT Self-Harm Rule, was derived using multicentre data from a prospective cohort study. Binary recursive partitioning was applied to data from two centres, and data from a separate centre were used to test the tool. There were 29 571 self-harm presentations to five hospital EDs between January 2003 and June 2007, involving 18 680 adults aged ⩾16 years. We estimated sensitivity, specificity and positive and negative predictive values to measure the performance of the tool. RESULTS A self-harm presentation was classified as higher risk if at least one of the following factors was present: recent self-harm (in the past year), living alone or homelessness, cutting as a method of harm and treatment for a current psychiatric disorder. The rule performed with 95% sensitivity [95% confidence interval (CI) 94-95] and 21% specificity (95% CI 21-22), and had a positive predictive value of 30% (95% CI 30-31) and a negative predictive value of 91% (95% CI 90-92) in the derivation centres; it identified 83/92 of all subsequent suicides. CONCLUSIONS The ReACT Self-Harm Rule might be used as a screening tool to inform the process of assessing self-harm presentations to ED. The four risk factors could also be used as an adjunct to in-depth psychosocial assessment to help guide risk formulation. The use of multicentre data helped to maximize the generalizability of the tool, but we need to further verify its external validity in other localities.
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Affiliation(s)
- S Steeg
- Psychiatry Research Group, University of Manchester, UK
| | - N Kapur
- Psychiatry Research Group, University of Manchester, UK
| | - R Webb
- Psychiatry Research Group, University of Manchester, UK
| | - E Applegate
- Psychiatry Research Group, University of Manchester, UK
| | - S L K Stewart
- Psychiatry Research Group, University of Manchester, UK
| | - K Hawton
- The University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - H Bergen
- The University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - K Waters
- Resource Centre, Derbyshire Royal Infirmary, Derby, UK
| | - J Cooper
- Psychiatry Research Group, University of Manchester, UK
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Bilén K, Ponzer S, Ottosson C, Castrén M, Pettersson H. Deliberate self-harm patients in the emergency department: who will repeat and who will not? Validation and development of clinical decision rules. Emerg Med J 2012; 30:650-6. [DOI: 10.1136/emermed-2012-201235] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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16
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Does a decision aid help physicians to detect chronic obstructive pulmonary disease? Br J Gen Pract 2012; 61:e674-9. [PMID: 22152850 DOI: 10.3399/bjgp11x601398] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Numerous decision aids have been developed recently, but the value they add above that of the initial clinical assessment is not well known. AIM To quantify whether a formal decision aid for chronic obstructive pulmonary disease (COPD) adds diagnostic information, above the physician's clinical assessment. DESIGN AND SETTING Subanalysis of a diagnostic study in Dutch primary care. METHOD Sixty-five primary care physicians included 357 patients who attended for persistent cough and were not known to have COPD. The physicians estimated the probability of COPD after short history taking and physical examination. After this, the presence or absence of COPD was determined using results of extensive diagnostic work-up. The extent to which an 8-item decision aid for COPD, which included only symptoms and signs, added diagnostic value above the physician's estimation was quantified by the increase of the area under the receiver operating characteristic curve (ROC area), and the improvement in diagnostic risk classification across two classes: 'low probability of COPD' (<20%) and 'possible COPD' (≥20%). RESULTS One hundred and four patients (29%) had COPD. Adding the decision aid to the clinical assessment increased the ROC area from 0.75 (95% confidence interval [CI] = 0.70 to 0.81) to 0.84 (95% CI = 0.80 to 0.89) (P<0.005), and improved the diagnostic risk classification of the patients, such that 35 fewer patients needed spirometry testing and eight fewer COPD cases were missed. CONCLUSION A short decision aid for COPD added diagnostic value to the physician's clinical assessment.
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How do methods of non-fatal self-harm relate to eventual suicide? J Affect Disord 2012; 136:526-33. [PMID: 22127391 DOI: 10.1016/j.jad.2011.10.036] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 10/24/2011] [Accepted: 10/24/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND Methods used at an index episode of non-fatal self-harm may predict risk of future suicide. Little is known of suicide risk associated with most recent non-fatal method, and whether or not change in method is important. METHODS A prospective cohort of 30,202 patients from the Multicentre Study of Self-harm in England presenting to six hospitals with self-harm, 2000-2007, was followed up to 2010 using national death registers. Risks of suicide (by self-poisoning, self-injury, and all methods) associated with recent method(s) of non-fatal self-harm were estimated using Cox models. RESULTS Suicide occurred in 378 individuals. Cutting, hanging/asphyxiation, CO/other gas, traffic-related and other self-injury at the last episode of self-harm were associated with 1.8 to 5-fold increased risks (vs. self-poisoning) of subsequent suicide, particularly suicide involving self-injury. All methods of self-harm had similar risks of suicide by self-poisoning. One-third who died by suicide used the same method for their last self-harm and for suicide, including 41% who self-poisoned. No specific sequences of self-poisoning, cutting or other self-injury in the last two non-fatal episodes were associated with suicide in individuals with repeated self-harm. LIMITATIONS Data were for hospital presentations only, and lacked a suicide intent measure. CONCLUSIONS Method of self-harm may aid identification of individuals at high risk of suicide. Individuals using more dangerous methods (e.g. hanging, CO/other gas) should receive intensive follow-up. Method changes in repeated self-harm were not associated with suicide. Our findings reinforce national guidance that all patients presenting with self-harm, regardless of method, should receive a psychosocial assessment.
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Randall JR, Rowe BH, Colman I. Emergency department assessment of self-harm risk using psychometric questionnaires. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2012; 57:21-8. [PMID: 22296964 DOI: 10.1177/070674371205700105] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine several potential predictive screening tools for emergency department assessment of risk of self-harm. METHODS Adult patients presenting with self-harm or suicidal ideation were enrolled at 2 emergency departments at large teaching hospitals in Edmonton, Alberta. Patients completed a brief interview assessing demographics and psychiatric history and several questionnaires (the Beck Hopelessness Scale, the Barrett Impulsiveness Scale [BIS], and the Brief Symptom Inventory [BSI]) and drug and alcohol abuse screens (Drug Abuse Screening Test [DAST-10] and the Cut down, Annoyed, Guilt, Eye-opener [commonly referred to as CAGE] Questionnaire). At 3 months, patients were followed up via telephone and electronic health records to ascertain self-harm outcome. Questionnaires and their subscales were assessed using logistic regression. Receiver operating characteristic (ROC) analysis was performed on the results. RESULTS Among the 157 patients enrolled, 49% were women and 36% (of the total) were aged 18 to 29 years. Several of the subscales of the BSI and BIS as well as the DAST-10 were significant predictors of self-harm (P < 0.05). ROC analysis showed that none of the scales in isolation were very strong predictors. Hierarchical regression analysis that combined the significant scales with clinical risk factors that were significantly related to self-harm (that is, age, education level, history of self-harm, and whether they presented with self-harm or only suicidal ideation) indicated that the BIS and DAST-10 questionnaires each added significantly to the predictive ability of a model with these risk factors. CONCLUSIONS While many of the questionnaires and their related constructs are related to future self-harm, none of them are particularly strong and their diagnostic usefulness is limited.
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Affiliation(s)
- Jason R Randall
- Alberta Centre for Injury Control and Research, School of Public Health, University of Alberta, Edmonton, Alberta
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Schiepek G, Fartacek C, Sturm J, Kralovec K, Fartacek R, Plöderl M. Nonlinear dynamics: theoretical perspectives and application to suicidology. Suicide Life Threat Behav 2011; 41:661-75. [PMID: 22145825 DOI: 10.1111/j.1943-278x.2011.00062.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite decades of research, the prediction of suicidal behavior remains limited. As a result, searching for more specific risk factors and testing their predictive power are central in suicidology. This strategy may be of limited value because it assumes linearity to the suicidal process that is most likely nonlinear by nature and which can be more adequately described and analyzed with nonlinear dynamics. The goal of moving nonlinear dynamics from theory to practice and to real-world phenomena can now be realized with Internet-based monitoring systems such as the Synergetic Navigation System.
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Affiliation(s)
- Günter Schiepek
- Institute of Synergetics and Psychotherapy Research, Paracelsus Medical University Salzburg, Austria
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Randall JR, Colman I, Rowe BH. A systematic review of psychometric assessment of self-harm risk in the emergency department. J Affect Disord 2011; 134:348-55. [PMID: 21658779 DOI: 10.1016/j.jad.2011.05.032] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Accepted: 05/17/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND Assessment of self harm risk is both a common and difficult task in emergency room settings. Psychometric measures have been developed to help with this assessment but it is uncertain how well these measures perform and which are clinically useful for assessment in this setting. METHOD Two reviewers independently assessed studies for relevance, inclusion, and study quality. Included studies classified mostly adult patients at risk for self-harm treated in an ED. The outcome variables selected were recurrence of self-harm/suicidal ideation or hospitalization. Only cohort study designs with follow-up were eligible. RESULTS From 556 potentially relevant abstracts, 12 studies were identified for inclusion in the review. Overall, the risk of bias was considered moderate to low in this review. Of the included studies reporting future self harm as an outcome measure, only the scales that are part of the Manchester self harm project, the Implicit Associations Test and the Violence and Suicide Assessment Form were found to successfully predict self harm. The four studies that assessed admission as an outcome utilized eight different actuarial methods. Of the scales assessed, six were found to be significant predictors of admission. LIMITATIONS It was not possible to perform a meta-analysis with the studies detected and it is uncertain whether publication bias or selection bias within the reviewed studies affected the results. CONCLUSION Overall, while many methods used in the ED to assess suicidal and parasuicidal patients have strong psychometric properties, there is little clinical evidence supporting their use.
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Affiliation(s)
- Jason R Randall
- Department of Public Health Sciences, School of Public Health, University of Alberta, Edmonton, Canada
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21
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Lopez-Castroman J, Perez-Rodriguez MDLM, Jaussent I, Alegria AA, Artes-Rodriguez A, Freed P, Guillaume S, Jollant F, Leiva-Murillo JM, Malafosse A, Oquendo MA, de Prado-Cumplido M, Saiz-Ruiz J, Baca-Garcia E, Courtet P. Distinguishing the relevant features of frequent suicide attempters. J Psychiatr Res 2011; 45:619-25. [PMID: 21055768 DOI: 10.1016/j.jpsychires.2010.09.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Revised: 09/10/2010] [Accepted: 09/29/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND In spite of the high prevalence of suicide behaviours and the magnitude of the resultant burden, little is known about why individuals reattempt. We aim to investigate the relationships between clinical risk factors and the repetition of suicidal attempts. METHODS 1349 suicide attempters were consecutively recruited in the Emergency Room (ER) of two academic hospitals in France and Spain. Patients were extensively assessed and demographic and clinical data obtained. Data mining was used to determine the minimal number of variables that blinded the rest in relation to the number of suicide attempts. Using this set, a probabilistic graph ranking relationships with the target variable was constructed. RESULTS The most common diagnoses among suicide attempters were affective disorders, followed by anxiety disorders. Risk of frequent suicide attempt was highest among middle-aged subjects, and diminished progressively with advancing age of onset at first attempt. Anxiety disorders significantly increased the risk of presenting frequent suicide attempts. Pathway analysis also indicated that frequent suicide attempts were linked to greater odds for alcohol and substance abuse disorders and more intensive treatment. CONCLUSIONS Novel statistical methods found several clinical features that were associated with a history of frequent suicide attempts. The identified pathways may promote new hypothesis-driven studies of suicide attempts and preventive strategies.
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Affiliation(s)
- Jorge Lopez-Castroman
- Department of Psychiatry at Fundacion Jimenez Diaz Hospital and Autonoma University, Avenida Reyes Católicos 2, 28040, Madrid, Spain.
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Large MM, Ryan CJ, Singh SP, Paton MB, Nielssen OB. The predictive value of risk categorization in schizophrenia. Harv Rev Psychiatry 2011; 19:25-33. [PMID: 21250894 DOI: 10.3109/10673229.2011.549770] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Risk assessment is increasingly used to inform decisions regarding the psychiatric treatment of patients with schizophrenia and other serious mental disorders. AIMS To examine the theoretical limits of risk assessment and risk categorization as applied to a range of harms known to be associated with schizophrenia. METHODS Using known rates of suicide, homicide, self-harm, and violence in schizophrenia, a hypothetical tool with an unrealistically high level of accuracy was used to calculate the proportion of true- and false-positive risk categorizations. RESULTS Risk categorization incorrectly classified a large proportion of patients as being at high risk of violence toward themselves and others. CONCLUSION Risk assessment and categorization have severe limitations. A large proportion of patients classified as being at high risk will not, in fact, cause or suffer any harm. Unintended consequences of inaccurate risk categorization include unwarranted detention for some patients, failure to treat others, misallocation of scarce health resources, and the stigma arising from patients' being labeled as dangerous.
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Affiliation(s)
- Matthew M Large
- University of New South Wales, Prince of Wales Hospital, Sydney, Australia.
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Ryan C, Nielssen O, Paton M, Large M. Clinical decisions in psychiatry should not be based on risk assessment. Australas Psychiatry 2010; 18:398-403. [PMID: 20863176 DOI: 10.3109/10398562.2010.507816] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Risk assessments that place patients in high or low risk categories have been widely adopted by mental health services in an attempt to reduce the harms associated with psychiatric disorders. This paper examines the effects of categorization based on the results of a risk assessment. METHODS The violence prediction instrument derived from the MacArthur Study of Mental Disorder and Violence was used to illustrate the nature and effects of risk assessment and the consequent categorization of patients. RESULTS The majority of patients categorized as being at high risk will not commit any harmful acts. CONCLUSIONS Patients who are classified as high risk share the cost of efforts to reduce harm in the form of additional treatment and restrictions, although the majority will not go on to commit a harmful act. Clinical decisions made on the basis of risk assessment also divert resources away from patients classified as low risk, even though a significant proportion do go on to a commit harmful act. We argue that psychiatric professionals should discuss the risks of treatment and of non-treatment with patients (or with their substitute decision-makers) and should maintain a duty to warn about the consequences of not having treatment. However, assessment of risk of harm should not form the basis for clinical decision making. We should aim to provide optimal care according to the treatment needs of each patient, regardless of the perceived risk of adverse events.
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Affiliation(s)
- Christopher Ryan
- Discipline of Psychiatry and the Centre for Values, Ethics and the Law in Medicine, University of Sydney and Westmead Hospital, Westmead, NSW, Australia
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