Screening for risk

Screening for risk is a routine part of all assessments. Screening for suicide risk will be used as the example to describe the process. The assessment of suicidal risk is one of the most common and basic procedures in psychiatry.² It is probably the purest example of a risk assessment as the process requires close interaction with the patient, is incremental in that the next question is based on the response to the previous question, and interventions will be based on both treating the underlying illness and preventing the risk behaviour from occurring.

Unless the patient spontaneously comments that they are considering suicide, the clinician will need to prompt for it. An index of suspicion should be present for any patient with mood symptoms. If the primary problem is another problem such as psychosis, the mood symptoms may be hidden but the screening questions should still be asked. The first screening question may lead on to an in-depth assessment of the risk or may be sufficient to allow the clinician to determine that the current risk is negligible or absent.

After working towards the questions about suicidality with a question such as, ‘How bad have things been?’, it will be possible to move on to an initial screening question such as, ‘Have you ever felt that life is no longer worth it?’ or ‘Have you ever felt that you can’t carry on?’

If the verbal and/or non-verbal response to these opening questions is positive, the clinician will then continue to ask more probing questions until the extent of the preoccupation with suicide is apparent. From there, in conjunction with the rest of the assessment, management decisions will be made. For suicide,

because of the acuity which may be present, it is not uncommon for a full assessment to be conducted during the first meeting to determine the level of risk. This is less likely to be the case for violence where the focus is more often on preventing future episodes.

Suicide assessment is incorporated into the body of the clinical assessment. For other risks such as violence and self-harm the process is the same but the index of suspicion may not be as high on the part of the clinician. Suicide is an easily recognised complication of mood disorders whilst other risks such as violence and sexual predation are more likely to be hidden; there may be more shame or a fear that disclosure will be punished in some way, such as incarceration. Violence may be a complication of several different disease processes and may occur even when there is no disease process. A clinician should, however, always include a basic screening for violence. Sexual predation is unlikely to be part of routine general mental health screening unless an index of suspicion is raised in the assessment.

Static factors in the history which make the propensity for violence greater should be considered. These should emerge during the routine questioning of the childhood and personality development. The patient’s response to dynamic factors should be explored. A classical example would be an exploration of the patient’s likelihood of acting on command hallucinations.

When there is uncertainty about how detailed the risk assessment should be, the rule of thumb should be — do a complete assessment.

There are screening tools available (one is included in Chapter 15, risk of violence) but a useful rule of thumb is to consider a more detailed assessment if:

The decision about the level of detail required within the assessment will also be based on the following question; ‘What is the likelihood and imminence of the risk behaviour occurring and what will the consequences be if it occurs?’

As the patient becomes better known and treatment continues, the assessment of the risk will continue alongside the continuing assessment of the patient’s clinical condition.

Assessment and documentation exercise

The first exercise in this section starts the process of assessing and documenting risk. Often, the first presentation is a phone call or an assessment in the Emergency Department (ED). Information may be limited but a start needs to be made. The initial identification of the risk may also create anxiety on the part of the clinician. The process of simply documenting what is known creates a degree of objectivity which will immediately reduce anxiety. The purpose of the following exercise is to simply practise documenting identified risk and consider to whom, when, where and what means might be used. Practising the exercises will give you an opportunity to get used to the routine questions which are central to any risk assessment. With practice, there will be increasing familiarity which is a risk management skill in its own right. Familiarity with the process can reduce risk by a factor of 17.⁵

For each of the examples below answer the following questions.

Try and write your answers in narrative form. Imagine that this information is being communicated to a colleague who will be seeing the patient after hours.

Exercise 1 — Monique

Monique is a 28-year-old woman with schizophrenia. Her boyfriend has recently left her and staff in the supported accommodation home in which she lives report that she is tearful, distraught and withdrawn. They wonder if she is going to kill herself. The staff phone you and your task is to complete the risk documentation on the triage form. Refer to the template in Figure 9.1. The completed form appears in Appendix 3.

Figure 9.1 Risk assessment and management template

Comment on the completed form

For Monique, she will need to be seen relatively urgently for a more complete assessment. The staff in the supported accommodation are anxious and part of the task of the assessment will be to manage this anxiety. Hopefully, she will already have a risk management plan which will make the process easier. This is how the risk may be documented in a triage form written by a duty worker receiving the call from the supported accommodation home. See Appendix 1 for an example of a triage form, including a place for documenting risk.