Risk Assessment

Risk assessment tends to focus on the risk of physical harm to the patient or to others, but other aspects of risk should also be considered, including neglect of any dependents, victimization by others, nonadherence to treatment and absconding. Prompt and regular formal risk assessments are required, and the results should be communicated to other staff and carers involved in treatment and supervision. New patients are ''unknown quantities'' for clinicians, and the first priority is to ensure that the patient and his or her environment are safe [42].


The importance of assessing suicide risk in the first interview cannot be overstated [42]. Up to 23% of patients with first-episode psychosis experience suicidal thoughts and about 15% have attempted suicide in the past. The risk persists in patients with chronic psychotic illness. Suicide is the leading cause of premature death in patients with schizophrenia, and the incidence of completed suicide among patients with schizophrenia is 10-13% [11].

The early stages of a psychotic disorder are a time of high risk. During the assessment process, suicidal thoughts and intent can often be explored near the end of the interview once some rapport has been established. For example:

• Explore how distressing the patient's experiences have been.

• How does the person usually cope with emotional distress?

• Ask whether the patient has ever considered life unbearable.

• Discuss the factors that can motivate suicide in psychosis, and how they can be reduced by effective treatment.

• Negotiate ways for patients to seek help should they become suicidal.

Suicidal thoughts are often transient and therefore need constant monitoring. Thoughts of suicide are the best predictor of a subsequent suicide attempt. It is vital to note that:

• There is a greater risk of suicide following, rather than preceding, the active phase of the illness, perhaps associated with greater awareness of the illness that has been experienced and its potential consequences. This is why a positive and optimistic attitude to prognosis is crucial at this stage.

• Hopelessness can still occur when the rest of the mental state is restored to a relatively normal state.

Suicide is influenced by a broad range of social, biological and psychological factors. Table 2.8 outlines some specific general risks and protective factors to consider during the assessment process.

Patients considered at high risk for suicide should be hospitalized, with precautions such as close, 24-hour one-to-one observation, and removal of any means of self-harm. It is important to optimize the treatment of psychotic and depressive symptoms, and to address suicidal thoughts directly with an empathic and supportive approach. Among outpatients, the frequency of visits may need to be increased (even to daily home visits)

Table 2.8 Factors to consider in assessing suicide risk in early psychosis

Recent experience of suicide

• Recent death of a relative or close friend by suicide.

• Recent history of suicidal behaviour (particularly in the last 6 months).

Suicide-related cognitions

• Detail and lethality of plans to self-harm.

• Preparations and access to lethal means.

• Regards suicide as the only "logical" solution.

Mental status factors

• Self-destructive command hallucinations.

• Nihilistic delusions.

• Delusions and hallucinations which result in dangerous behaviours or a desire to escape, such as a belief in an ability to fly or that one is indestructible, delusions of guilt, delusions of persecution.

• Recent deterioration in mental state.

• Degree of subjective distress and level of hopelessness.

• Severity of depression or anxiety, including symptoms such as self-criticism.

• Alcohol and drug abuse.

• Increasing insight into the nature of the illness.

Withdrawal and isolation

• May be influenced by severity of illness.

Recent significant stressors

• Multiple stressors or ongoing exposure to stressors.

• Recent discharge from an inpatient unit.

Supports and help-seeking capacity

• Availability of supervision and support.

• Potential for compliance with medications or with protective management plans.

• Degree of openness with carers and the clinician about current mental state.

• Capacity to self-manage impulses.

Reasons for living and barriers to self-harm

• Potential of future goals and success.

• Ongoing responsibilities to others, e.g. children.

• Cultural and religious factors.

• Fear of death and physical suffering/pain.

Protective mental state features

• Disorganized thinking which limits the ability to implement actions for suicide.

• Lack of insight which can reduce the distress associated with symptoms.

during higher-risk periods, including the time shortly after discharge from hospital. Other useful strategies may include:

• providing frequent reassurance and encouragement;

• providing clear explanations and feedback about the temporary nature of the distressing experiences;

• ensuring consistency of messages from staff;

• ensuring continuity of care.

Aggression and Violence

The risks of aggression and violence associated with psychosis are probably overestimated by the community. However, such risks do exist and cannot be ignored [48]. Aggressive or highly agitated behaviour is sometimes the key factor which finally motivates families and others to seek help, and an appropriate response by mental health services is vital.

The clinical features of the episode of acute psychosis, including the degree of agitation and the nature of hallucinations and delusions, should be considered in assessing the risk of violence. General risk factors for violence in psychotic disorders include a history of violence in the past, substance abuse and the presence of neurological impairment [12]. However, clinical features of the illness are a better short-term predictor of violence in the acute episode.

The use of safety precautions, such as the availability of extra staff, is essential in dealing with potentially violent people. Outlined below are some issues in managing crisis situations before a full assessment is possible, and in community settings, which are less secure than a hospital environment.

A history of prior violence is one of the best predictors of future violence. Gaining as much history as possible from other sources before approaching the patient, for example family, friends and police, is an important step [49]. Check for specific current threats or evidence of impulsivity, whether there is an obvious precipitant to this episode, the individual's main concerns or needs, and whether he or she has access to a weapon or other means of causing harm.

A number of behaviours can suggest actual or impending aggression, including:

• loud, clipped or angry speech;

• angry facial expression;

• refusal to communicate;

• threats or gestures;

• physical or mental agitation;

• restlessness;

• persecutory ideation;

• delusions or hallucinations with violent content;

• people themselves reporting violent feelings.

Some useful techniques in first dealing with an agitated young person who may be experiencing an episode of acute psychosis or other disturbed behaviour are outlined in Table 2.9.

Once the situation has eased and some rapport has been established, it may be possible to start assessing the immediate risks that the individual will attempt to harm himself or herself, or harm others.

Knowledge of local mental health legislation will be required in these circumstances, particularly if a judgement is made that the individual requires involuntary hospital admission.

At this time of crisis it is important to consider establishing a productive relationship with the family, if present, and use them constructively in resolving the situation. If their presence exacerbates the situation, then they should be asked tactfully to withdraw.

Table 2.9 Approaching an acutely agitated young person with early psychosis

• Ensure that adequate back-up is available in case the situation escalates. Alert police or other security personnel if appropriate and, if possible, have them located unobtrusively close by.

• If your safety or that of others is directly threatened, then withdraw rather than persist.

• Maintain as much privacy as is possible while ensuring a safe environment.

• If in a room, ensure you can reach the door but do not block the exit from the young person (angry people may rather leave than resort to violence).

• Consider removing clothing (such as ties or necklaces) which could be used to grasp you, or items such as pens or other objects which could be used as weapons.

• Approach in a calm, confident manner.

• Avoid sudden or violent gestures and adopt a relaxed, non-threatening posture.

• Avoid prolonged eye contact (staring).

• Do not confront the person physically or ''tower over them'' (for example, if they are seated).

• Do not humiliate or ignore the person.

• Allow the individual ample ''personal space''.

• Use an empathic, non-confronting manner, emphasizing your desire to help.

• Focus on the immediate situation - the ''here and now'' - and the immediate needs of the individual, rather than dwelling on the past.

• Try not to give ultimatums.

Unintentional Harm to Others

People experiencing an acute psychotic illness might cause unintentional harm to others, particularly by neglecting the physical or emotional needs of children or others under their care. Assistance may be needed from child protection or family welfare services.

Neglect and Death

Other causes of illness and death in young people with psychosis include [42]:

• exposure to high-risk lifestyles such as homelessness, with a greater risk of accidental death, assault or murder;

• exposure to human immunodeficiency virus (HIV) infection;

• excess cigarette smoking;

• substance abuse.

Death from physical complications of early psychosis is rare, but it is necessary to monitor physical status, including nutritional status and hydration.

Victimization by Others

There is a need to protect inpatients (and outpatients if possible) against violence, intimidation, harassment or exploitation by others. Younger people are more vulnerable, and harassment and intimidation may be subtle and unreported. Highly vulnerable patients should be identified from the outset and protected, for example by one-to-one care.

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