Risk factors and risk equations

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Chapter 3 Risk factors and risk equations

To recap:

Risk = the likelihood of an adverse outcome.

It is now necessary to examine the group of two factors that, when considered together, help determine the likelihood of the event occurring.

Measuring the likelihood of the event occurring is a combination of the static risk factors and the dynamic risk factors. Or put mathematically:

Likelihood = static risk factors + dynamic risk factors

Risk factors1

Risk factor: Something in the patient’s history or current environment or mental state which makes the adverse event more likely to occur.

Risk factors can be divided into two main categories:

1. static factors (also referred to as enduring, stable or historic factors)

2. dynamic factors (also referred to as current or variable factors).

In some forensic settings, static factors are referred to as enduring factors and dynamic factors are referred to as variable factors.

Static risk factors are factors that do not change. They are usually laid down either as a result of the patient’s developmental history or are related to the patient’s past external environment. Static factors give an indication of an individual’s longer term propensity for the risk.

A comprehensive analysis of static risk factors can help ensure that clinicians take account of historical material and consider pre-existing vulnerabilities for (violence) risk when planning long-term treatment strategies.2

Some examples of static factors include:

• For violence: previous episodes of violence, conduct disorder and alcohol and drug history.

• For suicide: previous attempts, family history of suicide, history of mental illness.

Lists of risk factors for violence and suicide can be found in Chapter 9 (Tables 9.1 and 9.2, pp 80, 84).

The static factors set the context in which a clinician works.3 Empirically it makes sense that the closer the patient is to these factors in time, the greater the influence they will have. However there is currently no literature available to support this. An extreme example would be of a man who was repeatedly violent in his youth but is now presenting at the age of 75. The weighting given to these factors is likely to be less than had he presented at the age of 25.

Dynamic risk factors are those factors which are more likely to change:

• as a result of alterations in the patient’s mental state such as a lowering of mood (internal) and/or

• changes in the patient’s external environment (situational) such as the dissolution of a relationship or loss of job.

Dynamic factors capture the fluctuating nature of risk. Dynamic factors may change in both duration and intensity. A single event may cause changes to a number of dynamic risk factors creating a change to the overall risk. Assessing the dynamic factors is essential for considering the particular conditions, patterns and circumstances that place individuals at special risk. Hanson and Harris (2000)4 distinguished between stable and acute dynamic factors. Stable dynamic factors (e.g. traits of impulsivity or hostility) are unlikely to change over short periods of time, but can change gradually. In contrast, acute dynamic factors (e.g. drug use and mental state) can change daily or even hourly.

Further understanding of risk factors comes from knowing that certain risk factors are more likely to be relevant to certain types of risks. This knowledge is of immense importance in risk assessment as commonly occurring factors can be looked for. These factors are being refined with increasing research.

It is not sufficient to consider risk factors in isolation and manage them individually. Risk factors can affect each other in various ways. For example, one risk factor may moderate the effect of another or a second risk factor may only become relevant if the first risk factor is present. There are many possible permutations which will need to be formulated by clinicians for each patient. Whenever there are more than two causal risk factors these issues must be considered.5 (A causal risk

BOX 3.1 THE NATURE OF RISK

Practice points

• Risk in a mental health setting is never static.

• The likelihood of the risk behaviour occurring is often linked to the severity of the illness.

• The nature of a patient’s risk doesn’t usually change; it is the likelihood and context which changes.

• The likelihood of the risk changes most with changes of the dynamic factors.

• Given the fluctuation of dynamic risk factors in patients, measures of the level of risk may have little value other than stating what it was on that particular day.

• If there is a heavy weighting of static risk factors, this is worth highlighting as the tipping point into the risk behaviour may be reached quickly.

factor is one that can be changed by manipulation and when changed can be shown to alter the risk.)

Finally, there will be risk factors that will be specific to individual patients. These have been termed ‘signature risk signs’ by Fluttert (2005). She states:

In some persons with mental or personality disorder and a history of violence or self-harm, a highly specific, ‘signature’ set of patterns or signs may be identified (e.g. a preoccupation with certain people, or a change to a behaviour pattern), as a ‘calling card’ for their mental illness and the potential risk for violence to self or others.6

These personal signature risk signs and patterns of behaviour can be useful concepts for clinicians to consider when assessing patients. The concept of ‘signature risk signs’ has been incorporated into the thinking behind ‘START’, an assessment tool currently being evaluated.7 Along similar lines, the concept of ‘critical risk factors’ is also worth considering. These are 2–3 risk factors which will be of great importance for specific individuals and can be highlighted in management plans as flags for rapid intervention.

Looked at diagrammatically, risk factors can be presented as shown in Figure 3.1.8

image

Figure 3.1 Diagramatic representation of risk factors

When it comes to documenting the risk, this diagram can be referred to. The risk documentation framework used in the book is to a large degree based on this model.

BOX 3.2 CLINICAL TIP

• When assessing risk, look for patterns of risk factors which repeat themselves in the history. When the same risk factors occur repeatedly, the same risk behaviour is more likely to occur.

• Look for ‘signature risk signs’ that are specific to the patient.

Example 1 — violence risk factors

Jimmy was brought up in a violent household (static factor). He was diagnosed with conduct disorder when 11 (static factor). He is currently experiencing command auditory hallucinations (dynamic factor — mental state) and wants to kill the Prime Minister. He lives down the road from Parliament (dynamic factor — situational) and has stopped his medication (dynamic factor — situational).

When knowledge of the static risk factors is combined with that of the dynamic risk factors, an estimation of the likelihood of the risk occurring can be made. This can be used to help plan an intervention in the here and now. Efforts can then be made to reduce the likelihood of dynamic risk factors occurring again or if they do, early interventions can be implemented.

The synthesis of the static and dynamic risk factors combines to give the current ‘risk state’.9, 10 The risk state is a term used in some literature to describe the likelihood of the risk occurring at a given time.

BOX 3.3 RISK FACTORS

• Static factors are static and stable and do not usually change. They indicate the individual’s propensity for the risk.

• Dynamic factors can be related to either the mental state (internal) or the external environment (situational). Dynamic factors account for the fluctuating level of risk.

The graphs in Figures 3.2 and 3.3 help describe the idea of risk being a synthesis of static and dynamic factors. The second graph also shows how the likelihood of the risk occurring can change quickly.

image

Figure 3.2 Chronic high risk due to static risk factors

image

Figure 3.3 Rapid onset and partial resolution of dynamic risk factors

Example 211

Figure 3.2 shows graphically a patient with chronic depression. The patient is a 54-year-old woman who has had recurring episodes of major depression throughout her adult life. Treatment has included antidepressants, supportive psychotherapy and electroconvulsive therapy (ECT). On three occasions she has attempted to kill herself. On the last occasion she was found accidentally by a hunter as she was gassing herself in her car, which was parked deep in the woods. She has a lot of static risk factors: three previous suicide attempts, physical illness, sexual abuse as a child, family history of mental disorder and her own history of mental illness. These leave her especially vulnerable to the risk of relapse and further suicidality if there is a small change in her dynamic factors. This needs to be considered when assessing and managing the risk.

Precipitating events can ‘tip the balance’12 easily into a risk event and may only need to be minor in this example. It may be necessary to review the patient frequently as it will only take a small change in the dynamic factors for the pathway into suicide to be completed. Being mindful of the weighting given to each of the static and dynamic factors is going to be important in the assessment of what it takes for a patient’s suicidal intent to be realised. For individual patients, there are likely to be specific releasing factors (signature risk signs) clustered into two or three critical risk factors that tip the patient over into the risk behaviour.

Example 3

Figure 3.3 shows a very different scenario. This patient is a young man of 25 who is ‘happily married’. He has no previous history of mental illness but does drink in a binge pattern. Over the course of 10 days, he loses his job on day 1, his father has a heart attack on day 5 and his wife confesses she has been having an affair with his brother on day 8! This patient has very few static factors for suicide which would usually pose little risk but over the period of a few days, he has a series of life events which destabilise his mental state and raise the risk of suicide substantially. He has dynamic risk factors of loss, recent adverse events, rage and feeling abandoned. On day 9 the risk peaks and by day 10 there has been some resolution of the dynamic factors and the risk rapidly reduces. In Chapter 9 there is a list of risk factors for suicide (Table 9.1, p 80) which will help when doing assessments.

In this example, the path towards a possible suicide attempt is clear and rapid: close levels of observation and support will be required. In the longer term, however, once the acute episode has settled, it is unlikely that the patient will need the frequency of review which was necessary in example 2.

One of the difficulties in assessing risk within a mental health context is that the likelihood of the event happening (the risk state) is never static. The likelihood will vary with any change in the risk factors.

Thus the word ‘likelihood’ in the equation

Risk = the likelihood of an adverse outcome.

is NOT a constant at all but can change daily and even hourly. The likelihood of the risk behaviour occurring will fluctuate with time, context and intervention.

EXAMPLE OF THE LIKELIHOOD (RISK STATE) CHANGING

Andrew is usually a mild mannered, placid person who wouldn’t harm a fly. He decides to try some methamphetamine (speed) and within an hour is feeling very violent and aggressive. Four hours later the likelihood of violence lessens as the drug wears off.

Although the nature of the risk (e.g. in this case violence) is unlikely to change, the likelihood can change enormously. When assessing risk, it is a little bit like making a diagnosis: a diagnosis is only a snapshot in time. A risk assessment is similarly a snapshot in time and its predictive quality weakens with every passing hour and day. A risk assessment will give the indicators and patterns of what makes the risk behaviour more likely to occur. Risk management involves an assessment of the current circumstances whenever the patient is seen. This includes a review of the patient’s mental state and the patient’s external environment; that is, no different to routine and usual clinical practice.

Level of risk

Level of risk = likelihood × severity of consequences

Sometimes clinicians have to work in environments or situations when the levels of risk are described as being high. It is useful not to forget that there can be rewards even when the risks are high; for example, ‘She risked her life to save a friend’. Good treatment may involve living with high levels of risk.

To understand levels of risk, consider an outcome with a very, very low likelihood such as a meteor falling onto earth. This could have very severe consequences (the death of millions). If one was to add the likelihood which is very low and the consequences which are very high, the level would immediately be seen as extreme but when the two factors are multiplied, the event would still be seen as being a low to moderate risk rather than an extreme risk. This is important to understand in mental health work. Many of the risks which occur in this field have substantial consequences but the likelihood of them occurring is often quite low. The ‘base rates’ (the frequency in which an event occurs in a given population) of suicide and violence are both low in the general population and even within the population of mental health patients they are still quite low.

Table 3.1 demonstrates the changeability of the level of risk with fluctuations of likelihood and consequences.

Table 3.1 Changes in level of risk

image

An example from clinical practice is nausea which is a common side effect of the drug naltrexone. The likelihood may be moderate but the consequences are minor so the level of risk is felt to be low.

It is useful at this stage to consider the various components of the level of risk which will lead to a clinician trying to determine whether it is high, moderate or low.

How imminent is the risk?

The number of static risk factors that the patient has will only have a small effect on the imminence of the risk. The static risk factors relate more to the propensity for the risk behaviour. A rule of thumb is that the more static factors a patient has, the lower the threshold will be for the risk behaviour to occur. However, this is invariably trumped by the dynamic risk factors which in the here and now are of much more relevance.

For example, when a student believes that people are plotting against him, feels threatened and develops a delusional belief that the world will end if he does not kill his teacher, the imminence is much greater than when the patient’s psychosis has been adequately treated. The other component to this dilemma of imminence is the environment which the patient is in. Imminence is often greater within acute psychiatric units than the community as a result of both the environment of inpatient units and the degree of illness. However, in the example of the student, the imminence may be greater in the classroom or the teacher’s home.

Each time a patient is seen, an assessment will be made of the imminence of the risk occurring. On an inpatient unit this may occur every 5 minutes. In an outpatient setting, the judgment may only occur every 6 months. The greater the number of risk factors, especially critical risk factors, which are present at any given time, the greater the likelihood that the risk is imminent.

What are the consequences?

If the consequence is considered minor — for example, a mild headache for a few hours when taking a new medication — but the likelihood is high, there is little cause for concern. If the consequence is a suicide but the likelihood is moderate, everyone worries more.

High, moderate or low risk?

To recap: when a risk is designated as having a certain level — high, moderate or low — this is a product of the likelihood of it occurring and the consequences of it occurring.

BOX 3.4 CLINICAL TIP

A common cause for the level of risk changing acutely is anything which can change levels of consciousness. This can include:

• delirium

• evening time for patients with dementia

• disinhibiting effects of substances, especially alcohol.

Assessments of the level of risk are frequently made in forensic settings when predictions are made for the future. They can also be used in everyday practice to indicate the level in the here and now. Once an assessment is completed, the documentation of the level of the risk can become a big problem. For example, if a patient is described as being a high risk, that may be true one day but not the next. The changeability of dynamic factors is of greatest relevance here. (Obviously, if Andrew from the example on page 24 takes methamphetamine again, the aggressive feelings are likely to return and the level of risk will be higher for a few hours.) Alternatively, a patient with a lot of static risk factors may be a high risk of displaying the risk behaviour at some time in the future and may need closer monitoring. When levels of risk are used in routine documentation, this should automatically generate a degree of monitoring with specified review dates built in to ensure that the level is reviewed. This is routine practice in acute psychiatric units and for a lot of forensic patients. If levels of risk are not clearly defined and standardised, neither the clinicians nor their family will be able to give any meaning to them. One person’s definition will differ from another’s which will lead to confusion.

Using levels of risk may cause problems, however. If a patient is described as being high risk, the label tends to stick and may cause stigma to the patient and prejudice for clinicians; never mind the problems that may arise later when efforts are made to explain management decisions if there is a bad outcome. If a patient is termed high risk, the risk thereafter is of staff being held responsible if the patient converts their risk factors into action. This tends to lead to defensive practice which is not without its own risk. It is important for clinicians to remember to involve the patient and their family in the management of the risk. By designating the risk as being high, there is a tendency for clinicians to take the responsibility away from the patient. This must be guarded against.

Describing a patient as high risk may not be conducive to developing a therapeutic alliance as there will be a tendency to be rejecting of patients. Compliance with treatment will be less likely. The stigma attached to patients if they are categorised as being high risk should be avoided where possible. Another argument to be made against using a focus on level of risk is that resources may be diverted towards those deemed to be at highest risk and away from those with other mental illnesses.13

Risk assessment and management plans should be explicit about the time period for which they are made. To set a valid schedule for assessing and monitoring risk state, a clinician must have a sense for the speed at which an individual’s most important dynamic factors will change.14

Documenting a patient as being ‘high, moderate or low risk’ is an absolute measurement. Using a risk management plan which makes an argument for a certain degree of monitoring when certain conditions are met is more qualitative and relative. Given the ever-changing likelihood of the event occurring, this approach may well be considered to be more useful to general mental health clinicians than absolute statements of level of risk.

BOX 3.5 PRACTICE TIP

High risk usually refers to the imminence of the risk behaviour occurring or to the seriousness and/or consequences of the behaviour occurring. Often the documentation of the level of risk is limited to a tick box which provides no useful information to anybody and simply puts the clinician at risk.

A simple and effective way of documenting the level of risk for the future is to utilise a narrative form of documentation to qualify terms such as ‘high’ and ‘low’ along the lines of:

The patient will pose a higher risk when he is acutely psychotic and perceives himself to be threatened by others. At these times his impulsivity is greatly increased and he will have a low threshold for violence, especially as he has utilised violence repeatedly in the past.

The essence of these two sentences is a description of the patient’s individual dynamic risk factors taking past patterns into account. This can be used for future assessments and in generating treatment for his psychosis.

Using standardised tools such as the Historical/Clinical/Risk Management 20-item (HCR 20)15 help identify the level of risk but will not necessarily add anything to the meaning of the risk behaviour for the patient, which will be specific to them.

Finally, clinicians, their managers and health trusts run the risk of using levels of risk to become agents of social control.

If the interests of the patient are given primacy, there is little problem. However, violence risk assessment processes may be utilised with public protection as the primary goal. This is ethically troubling territory for the mental health professional, even more so where the processes rely entirely on static risk factors that are not open to therapeutic change.16

It is sometimes too easy to say that the patient is high risk and needs to be detained involuntarily without pursuing other options. This is sometimes used as an anxiety reduction tool for clinicians (secondary risk management). The obverse side of this coin is to treat the patient in the least restrictive setting and ignore the risk. Good risk management practice will minimise the likelihood of either of these polarities being taken unwittingly. Remember:

• ‘primary risk management’ is the term for managing risk as it pertains to the patient

• ‘secondary risk management’ is the term used to describe risk management undertaken to reduce clinician anxiety but not reduce the risk for the patient.17

Summary

• Levels of risk can be useful in setting up systems for regular monitoring of patients.

• Levels of risk need to be clearly defined for each risk group and possibly for different settings in order to be meaningful.

• Levels of risk can identify patients from whom the public needs to be protected. (Some people suggest that this is using risk management to be an agent of social control.)

• Using levels of risk can help identify patients who need greater numbers of resources. The risk here is that other patients miss out.

• Documentation of level of risk may cause stigma to the patient.

Exercise — level of risk changing over time

Richard is a 42-year-old man with a severe depressive illness. He presents to the crisis team clutching a knife and tells you that his family would be better off without him.

1. What is the likelihood of Richard committing suicide tonight?

Two days later, Richard is an inpatient in the psychiatric unit. He is beginning to question whether his family would be better off without him.

2. Has the likelihood of risk changed?

Three weeks later, Richard is less depressed. You have had a meeting with Richard’s family and discussed his prognosis and the likelihood of him having a relapse of his depressive illness in the future and the possibility of him committing suicide at some stage in the future.

3. Has the likelihood of risk changed?

4. Has the nature of the risk changed?

Refer to Appendix 3 for possible answers.

BOX 3.6 PRACTICE TIPS

• A narrative approach indicating in which situations a patient may be at higher or lower risk is useful. It allows for identification of times of increased risk and for interventions to be planned.

• If the risk is documented as high, moderate or low, frequency and levels of monitoring need to be specified and review dates included. To set a valid schedule for assessing and monitoring risk state, a clinician must have a sense for the speed at which an individual’s most important dynamic factors will change.

• The decision whether to document level of risk may be made for you by your managers. If not, think carefully about the clinical usefulness of documenting a level of risk at this time and whether it will help your patient. It is always useful to ask the question ‘Is the risk being rated as high for the benefit of the patient or the protection of the public?’

Note: It should not be forgotten that to ignore the seriousness of the potential for the risk behaviour is also poor practice and must be avoided. It should not be forgotten that clinicians also do patients a disservice if they are allowed to pose a threat to the public.

BOX 3.7 SUMMARY OF RISK EQUATIONS

• Risk = the likelihood of an adverse outcome.

• Likelihood = static risk factors + dynamic risk factors.

• Level of risk = likelihood × severity of consequences.

Notes

1 Bouch J., Marshall J.J. Suicide Risk: structured professional judgment. Advances in Psychiatric Treatment. 2005;11:84–91.

2 Mullen P. Dangerousness, risk and the prediction of probability. In: Gelder M., Lopez-Ibor J.J., Andreasen N.C. New Oxford Textbook of Psychiatry. Oxford: Oxford University Press; 2000:2066–2078.

3 Maden A. Treating Violence: a guide to risk management in mental health. Oxford: Oxford University Press; 2007.

4 Hanson R.K., Harris A.J.R. Where should we intervene? Dynamic predictors of sexual offense recidivism. Criminal Justice and Behavior. 2000;27:6–35.

5 Kraemer H.C. Current concepts of risk in psychiatric disorders. Current Opinion in Psychiatry. 2003;16(4):421–430.

6 Fluttert F. Nursing study of personal based ‘early recognition and early intervention’ schemes in forensic care. Melbourne: Paper presented at 5th Annual Conference, International Association of Forensic Mental Health Services; 2005. April.

7 Webster C.D., Nicholls T.L., Martin M.L., Desmarais S.L., Brink J. Short-Term Assessment of Risk and Treatability (START): The case for a New Structured Professional Judgment Scheme. Behavioural Science and the Law. 2006;24:747–766.

8 Adapted from: New Zealand Ministry of Health 2006 Assessment and Management of Risk to Others Guidelines; Development of Training Toolkit; and Trainee Workbook. New Zealand Ministry of Health. Online. Available: www.mhwd.govt.nz (accessed 12 Oct 2009).

9 Skeem J.L., Mulvey E. Monitoring the violence potential of mentally disordered offenders being treated in the community. In: Buchanan A., ed. Care of the Mentally Disordered Offender in the Community. New York: Oxford Press; 2002:111–142.

10 Douglas K.S., Skeem J.L. Violence risk assessment. Getting specific about being dynamic. Psychology, Public Policy and Law. 2005;11(3):347–383.

11 Adapted from Bouch J., Marshall J.J. Suicide risk: structured professional judgment. Advances in Psychiatric Treatment. 2005;11:84–91.

12 New Zealand Ministry of Health. Guidelines for Clinical Risk Assessment and Management in Mental Health Services. New Zealand Ministry of Health, 1998. p 17.

13 Szmukler G. Risk Assessment: ‘numbers’ and values. Psychiatric Bulletin. 2003;27:205–207.

14 Douglas & Skeem, above, n 10.

15 Webster C.D., Douglas K.F., Eaves D., et al. HCR-20: Assessing Risk of Violence (version 2). Vancouver: Mental Health Law and Policy Institute, Simon Fraser University; 1997.

16 Carroll A. Are violence risk assessment tools clinically useful? Australian and New Zealand Journal of Psychiatry. 2007;41:301–307.

17 Undrill G. The risks of risk assessment. Advances in Psychiatric Treatment. 2007;13:291–297.

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