Transcript The Principles and Practice of mental health risk

Dr Paul Rogers
RMN, PG Cert ENB 650 (CBT), PG Dip (CBT), MSc (Econ), PhD, MRCPsych
(Hon), M.EWI, M.ISRA
CBT Therapist and Medico Legal Expert Witness
[email protected]
What is “risk assessment” within mental health
What “risks” are we trying to “assess”
How have we tended to do it
How good are we (Judgement vs Actuarial vs Structured)
What are the main guidelines that inform practice
What are the issues with such guidelines
10 Considerations of an expert when examining risk
assessment
Psychiatric Risk Assessment involves the –
1. Specification of the behaviour of concern
2. Estimation of the probability that the behaviour will
occur……. and under what circumstances (over a
given time period)
3. Determination of the potential damage or harm from
the behaviour
Scott (1977)
Historically:Violence
Suicide
Self Harm
In last 5-10 years:Self Neglect
Disengagement with Services
Exploitation by others
Chart 1: Proportion of incidents in mental health settings by quarter,
October 2009 - September 2010
Patient accident
Disruptive, aggressive behaviour
Self-harming behaviour
Access, admission, transfer, discharge (including missing patient)
Medication
Other
Infrastructure (including staffing, facilities, environment)
Oct 2009 - Dec 2009
Documentation (including records, identification)
Jan 2010 - Mar 2010
Treatment, procedure
Apr 2010 - Jun 2010
Patient abuse (by staff / third party)
Jul 2010 - Sep 2010
Consent, communication, confidentiality
Implementation of care and ongoing monitoring / review
Infection Control Incident
Clinical assessment (including diagnosis, scans, tests, assessments)
Medical device / equipment
0
5
10
15
Percent
20
25
30
35
Probability
is a measure
…………………of the likeliness
……………….…………….………that an event
.............................................................will occur
And here lie the issues!
Version 1: “The very basic version”
Risk of Violence
Risk of Suicide
Risk of Self-harm
Risk of X
Risk of Y
YES
YES
NO
NO
√
√
√
√
√
Version 2: “Only a little bit better than the very basic
version”
RATING
Risk of Violence
0
Risk of Suicide
2
Risk of Self-harm
4
Risk of X
1
Risk of Y
2
0=None; 1=Slight; 2=Moderate; 3=High; 4=Severe
Version 1 & 2 – (meaningless)
RATING
Risk of Violence
Risk of Suicide
√
Risk of Self-harm
√
Risk of X
Risk of Y
0=None; 1=Slight; 2=Moderate; 3=High; 4=Severe
Probability
is a measure
…………………of the likeliness
……………….…………….………that an event
.............................................................will occur
Here lies the issue - Likeliness is a JUDGEMENT!
“Linda is 31 years old, single, outspoken and very bright.
She majored in philosophy. As a student, she was deeply
concerned with the issue of discrimination and social
justice, and also participated in antinuclear
demonstrations.
Which of the following is more probable:
1. Linda is a bank teller
2. Linda is a bank teller and is active in the feminist
movement
Tversky and Kahneman (1974)
Which of the following is more probable:
1. Linda is a bank teller
2. Linda is a bank teller and is active in the feminist movement
The LINDA test is a famous experiment, the results
of which provided a significant contribution in the
field of probability judgment.
The conclusion being that:
Generally humans tend to argue irrational or
biased (by personal, societal, or cultural) reasoning.
Steadman & Cocozza (1974; 1976) Baxtrom study
Johnnie K. BAXSTROM v. HEROLD (US SUPREME COURT NEW YORK 1966)
Baxstrom was a prisoner in a prison in a psychiatric hospital
Civilly committed at end of his sentence to a hospital
Left in hospital even though his sentence had ended and
he had no release / discharge date.
Writs were dismissed, transfer requests denied
Supreme Court ruling:
Commitment beyond term without judicial review
violated his rights
He should be released
Other civilly committed patients in prisons had right to
hearing
Steadman & Cocozza (1974; 1976) & the Baxtrom study
As a result of the Baxtrom ruling, 966 detained patients
in New York Maximum Security Hospital were released.
All were considered a high and immediate risk to
others / society
Of interest, Steadman & Cocozza followed all 966 up
after 4 years and examined their reconvictions……..
Steadman & Cocozza (1974; 1976) & the Baxtrom study, 4
years on:-
ONLY 20% had been reconvicted of any offence
ONLY 2% had been reconvicted for a violent offence!
Steadman & Cocozza (1974; 1976) & the Baxtrom study.
Prior to release - All 966 were being detained due the
immediate danger they posed to others! The findings
cast ……………….
“serious doubt on the ability of clinicians to predict
dangerous behaviour at all”
1. Generally speaking, clinicians are poor at
predicting risk and shouldn’t be relying on their
clinical opinion alone to predict risk. Yet they
repeatedly do!
2. Furthermore, research repeatedly shows that
when we try to predict risk based upon specific
psychiatric factors (e.g., depression, command
hallucinations, delusions, etc.) these can be very
poor predictors of risk and therefore cannot be
relied upon
Humans are bad at it
Too many variables to weigh up.
Not knowing how to weight the variables
Tendency to weigh bizarre and unusual factors heavily
and neglect everyday but important factors (gender).
Professions “slow to revise their judgement despite a
mounting body of evidence” (Munro, 1999).
Our experience is usually blind to outcomes
Positive association
No association
Scores on risk instruments
Poor employment adjustment
Hx juvenile delinquency
Adult criminal history
Dysfunctional family background
Antisocial personality disorder
Age
Hospital admissions
Violent offense history
Poor Institutional adjustment
Single
Clinical judgment
Substance abuse problems
Violent index offense
Index sex offense
Psychosis
Mood disorder
Intelligence
-.
Overwhelming evidence that we can not predict
future risk using our professional judgement
We need to turn to techniques that can help us
These techniques should be proven by
controlled experimental studies
Based upon statistical formula to quantify the
likelihood of a negative outcome occurring
Avoids rater bias
Does not need any clinical skills
Fast
Don’t take into account individual circumstances. e.g.
ignores “rich” case specific information (e.g., previous
violence, self harm or suicide may have been due to
untreated psychosis)
They are static factors that do not change or do not change
easily (being male, historical suicide attempts, where
you live).
They provide no advice on how to manage risk as the
factors are largely “unchangeable”
Actuarial factors in predicting suicide
Source: World Health Organization (WHO)
1. Self-harm: The short-term physical and psychological management
and secondary prevention of self-harm in primary and secondary
care (NICE, 2004) http://publications.nice.org.uk/self-harm-cg16 *
2. Self-harm: Longer term management (NICE, 2011)
http://www.nice.org.uk/guidance/cg133
3. Violence: The short-term management of disturbed/violent
behaviour in in-patient psychiatric settings and emergency
departments (NICE, 2005) http://guidance.nice.org.uk/CG25
4. Best Practice in Managing Risk: Principles and evidence for best
practice in the assessment and management of risk to self and
others in mental health services (DoH, 2007)
http://www.nmhdu.org.uk/silo/files/managing-risk-best-practice.pdf *
Self-harm: longer term management
(NICE, 2011)
Self-harm:
longer-term management
Implementing NICE guidance
November 2011
NICE clinical guideline 133
Self-harm: longer term management
(NICE, 2011) – Background
Self-harm does not often result from the wish
to die. Those who self-harm may do so to
communicate, to secure help and care or to
obtain relief from an overwhelming situation.
Service provision for self-harm is varied.
About half of those presenting at an emergency
department after an incident of self-harm are
assessed by a mental health professional.
Self-harm: longer term management
(NICE, 2011) - Training
Health and social care professionals should:
• Be trained in the assessment, treatment and
management of self-harm, and
• Be educated about the stigma and discrimination
usually associated with self-harm and the need to
avoid judgemental attitudes.
Have routine access to senior colleagues for supervision,
consultation and support should be provided for
professionals who work with people who self-harm.
Self-harm: longer term management
(NICE, 2011) - Risk assessment: 1
When assessing the risk of repetition of self-harm or
risk of suicide, identify and agree the person’s specific
risks, taking into account:
methods and frequency of current and past selfharm
current and past suicidal intent
depressive symptoms
any psychiatric illness
the personal and social context and any other
specific factors preceding self-harm.
Self-harm: longer term management
(NICE, 2011) - Risk assessment: 2
Also take into account:
• specific risk and protective factors that may
increase or decrease the risks associated with
self-harm
• coping strategies
• significant relationships that may either be
supportive or represent a threat
• immediate and longer-term risks.
Self-harm: longer term management (NICE,
2011) - Risk assessment tools and scales
Do not use risk assessment tools and scales to predict
future suicide or repetition of self-harm.
Do not use risk assessment tools and scales to
determine who should and should not be offered
treatment or who should be discharged.
Risk assessment tools may be considered to help
structure risk assessments as long as they include the
areas identified in recommendation 1.3.6
Self-harm: longer term management (NICE,
2011) - Risk assessment tools and scales
Do not use risk assessment tools and scales to
predict future suicide or repetition of selfharm.
In 2011, there were 11.8 per 100,000
From a research and risk prediction
perspective, they are - “Too Rare to be
Usefully Predicted”
Best Practice in Managing Risk: Principles
and evidence for best practice in the
assessment and management of risk to self
and others in mental health services
http://www.nmhdu.org.uk/silo/files/managing-risk-best-practice.pdf
Identifies six potential evidence based tools for suicide
or self harm
Two are actually tools for assessing pre and post
training outcomes and not risk assessment tools!
The four left are –
1.
2.
3.
4.
The Beck Hopeless Scale (BHS)
Sad-persons (SP)
Suicidal Intent Scale (SIS)
Scale for Suicidal Ideation (SSI)
TOOL
EVIDENCE BASE
BHS
There is an extensive international evidence base including testing of the tool’s
structure and support for hopelessness as a risk factor for completed suicide.
Some of the available evidence is derived from the UK.
SP
The available evidence is based on American samples and indicates that
the tool is adequate as one part of an overall assessment. One review has
criticised the lack of evidence indicating acceptable reliability and validity. There
is a lack of evidence based on UK samples.
SIS
An American review concluded that the SIS score was not a risk factor
for completed suicide over several years among in-patients hospitalised for
attempted suicide. There is a lack of evidence based on UK samples.
SSI
A major American review Found evidence of an association between
scores on the interview (but not the self report) version of this scale and
completed suicide in outpatients. There is a lack of evidence based on UK
samples.
NICE explains, in a document on the legal context of its guidance
(2004) that:
"Once NICE guidance is published, health professionals are
expected to take it fully into account when exercising their clinical
judgment. However, NICE guidance does not override the individual
responsibility of health professionals to make appropriate decisions
according to the circumstances of the individual patient in
consultation with the patient and/or their guardian/carer".
Thus, while professionals have a duty to be "familiar with relevant
guidelines and developments that affect your work" (GMC, Good
Medical Practice, paragraph 12) this does not mean that they
cannot depart from guidance in specific situations when they
consider it is in the patient’s interests to do so.
The MDU guidance on guidance!
“You must be prepared to explain and justify your
decisions and actions, especially if you depart from
guidelines produced by a nationally recognised body, such
as NICE. It is also important to keep a record of the
reasons for your decision and your discussions with the
patient”.
http://www.themdu.com/learn-and-develop/case-studies/must-doctors-comply-withguidelines#sthash.Kkh0Zrna.dpuf
Anyone experiencing mental health problems is entitled
to an assessment of their needs with a mental healthcare
professional, and to have a care plan that's regularly
reviewed by that professional. Someone might get CPA support if they:
are diagnosed as having a severe mental disorder
are at risk of suicide, self harm, or harm to others
tend to neglect themselves and don't take treatment regularly
Are vulnerable. This could be for various reasons, such as physical or emotional
abuse, financial difficulties because of their mental illness or cognitive impairment
have misused drugs or alcohol
have learning disabilities
rely significantly on the support of a carer, or have their own caring responsibilities
have recently been detained under the Mental Health Act.
have parenting responsibilities
have a history of violence or self-harm
What CPA should provide
It's recommended that the person who needs CPA support is
involved in the assessment of their own needs and in the
development of the plan to meet those needs.
There should be a formal written care plan that outlines any risks
and includes details of what should happen in an emergency or
crisis.
A CPA care co-ordinator should be appointed to co-ordinate the
assessment and planning process. The co-ordinator is usually a
nurse, social worker or occupational therapist.
The care co-ordinator should also make sure that the care plan is
reviewed regularly. A formal review is made at least once a year.
The review will consider whether CPA support is still needed.
1.
2.
3.
What were the patient’s known risks? How recent were they?
What do the organisations policies say should be done?
Is risk within the CPA policy? Or standalone? If standalone, how do the 2 policies
compare and contrast? Are there any contradictions?
4. What do the policies say should happen? Were the policies reasonable? When were
they last updated? Was this when they should have been updated?
5. Were the policies followed?
6. Did staff have the necessary training? What training did they have? How was this
recorded? Are there records of training attendance available for the person
conducting the risk assessments? How often should such training be refreshed? Did
this happen?
7. How was the risk assessment recorded? Was it recorded correctly? Was it completed
at the times that it stated it should have?
8. Was the assessment of risk accurate and reasonable given what was known about
the patient at that time? If not, how did it falter?
9. Was a plan to manage those risks developed? By whom? Was it reasonable? Was it
followed? Was it recorded properly?
10. Why did the event happen? Was the risk reasonably foreseeable?
Dr Paul Rogers
RMN, PG Cert ENB 650 (CBT), PG Dip (CBT), MSc (Econ), PhD, MRCPsych
(Hon), M.EWI, M.ISRA
CBT Therapist and Medico Legal Expert Witness
[email protected]