Risk assessment

Determining the risk of harm to the patient, and sometimes to others, is an essential part of a psychiatric assessment. It is useful to know what questions to ask whether you’re at the hospital front door or on an inpatient psychiatric ward.

Self-harm/suicide risk assessment

The aim is to assess acute risk for a patient at that moment in time. Often this will tie in with a psychiatric history and you should still ask about any associated symptoms and screen for psychosis. The ‘before-during-after’ proforma allows you to capture a timeline of events and can be used in presentations of self-harm or overdose. It is useful to start these consultations with rapport building.

“I understood you took some tablets last night. I’m sorry things got that bad for you. I would like to reassure you that we would like to help you”

Before
  • Prior events: “If you don’t mind me asking, did anything happen to lead you to feel you and to harm yourself/end it all?”
  • Planning: “What plans did you make?” “How long did you plan to do this?”
  • Precautions: “Did you try to make sure you wouldn’t get caught?”
  • Preparation: “Did you write a note, or make a will?”
During
  • Sequence: “Can you talk through what happened?” (how, where, when)
  • Substances: “Did you take anything else? (any alcohol or drugs)
  • Expectations: “What did you want to happen?” “Did you expect to die?”
After
  • Regret: “How do you feel now, do you regret what happened?”
  • Lingering thoughts: “What would you do if you left today?”
  • Future: “What does the future look like?” “What would you like to happen now?”
urn cambridge.org id binary 22069 20160510085846500 0872 87926tbl3 2
‘SADpersons’ scale to determine suicide risk – ≥6 may require psychiatric assessment

Screening for risk in psychiatric disorders

Depression
  • Self-harm or suicide – “Sometimes when people low, thoughts of self-harm can creep in, has this happened to you?”
  • Hopelessness – “When you look to the future, how do you feel?”
  • Worthlessness – “How do you feel about your life?”
Psychosis
  • Command hallucinations – “Do the voices ever give you instructions?”
Mania/hypomania
  • Self-neglect (sleep, eating, hygiene) – “You sound busy, have you had time to sleep?”
  • Risky behaviours (spending, drug use, risky sexual behaviours)
Substance misuse
  • Impact on physical health (accidents, seizures, overdoses, abscesses, BBV)
  • Financial cost
  • Harm to others (e.g. driving under the influence)
Old age
  • Self-neglect
  • Falls
  • Wandering
  • Financial exploitation
  • Aggression to/from carers
  • Vulnerability

References and further reading

  • Chapter 3 – Suicide Assessments, Emergency Psychiatry 2013, Cambridge University Press

Written by Dr Muhammad Zain Haq, Psychiatry Lead (FY2)
Reviewed by Dr Patrick Ezeani (Consultant Psychiatrist)

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