Clinical Risk Assessment in Psychiatry – Part 1

What Is Clinical Risk Assessment?

Risk assessment in medicine is the conscientious evaluation of all relevant factors that help the clinician predict an adverse event or outcome. In psychiatry, risk assessment primarily — though not exclusively — concerns the prediction of suicide and serious self-harm in a given social circumstance. It also includes the assessment of risk to others (aggression, violence, and harm to identified third parties).

The prediction of suicide at a specified point in time, even after years of training and experience in this field, is extremely difficult. This is due to the large number of variables and their complex relationships, which are at play at any given time. How these varied factors influence an individual who ultimately takes their own life is unique to that individual. Furthermore, from an innate psychological perspective, deliberate self-destruction is contrary to the survival instinct.

There are well-researched and painstakingly evaluated published studies that have highlighted specific factors which should alert all clinicians to the possibility of an adverse outcome. However, prediction based only on the presence or absence of risk factors has a very low sensitivity and specificity. No risk assessment tool can reliably predict who will and who will not die by suicide. What is useful is an understanding of what circumstances are likely to lead to increased risk, and how that risk can be minimised through active, collaborative management.

Risk assessment for suicide requires the clinician's willingness to conduct a detailed assessment of physical and mental health; financial circumstances; the social context in which particular behaviours have arisen; and an understanding of effective and ineffective interventions in the past. A risk assessment is only useful if it leads to a better and agreed management plan among all concerned individuals and professionals. Above all, faithful implementation of the agreed plan is the essential step for safe, appropriate, and effective care.

Key Risk Factors for Suicide

The following are the key factors that should alert a clinician to a probable suicide attempt. These are divided into static risk factors (which do not change) and dynamic risk factors (which are modifiable):

Demographic and Static Factors

• Male gender (men are approximately three times more likely to die by suicide than women in the UK, although women make more attempts)
• Single, widowed, or divorced status
• Older age in men; younger age in women
• Social isolation
• History of previous attempted self-harm (the single strongest predictor of future suicide)
• History of alcohol or drug misuse and dependence with physical complications and loss of social status
• Impulsive or aggressive personality traits

Clinical and Dynamic Factors

• Presence of suicidal intent or ideation — active plans for suicide are of greater concern than passive ideation ("I wish I was dead")
• Recent adverse life events: loss of employment, partner, or financial security; loss of family or community role
• Pervasive feelings of hopelessness — often a stronger predictor than the severity of depression alone
• Depressive illness and other psychiatric disorders with ongoing relapsing patterns, particularly psychotic depression
• Presence of physical illness and chronic pain
• Recent discharge from psychiatric hospital (the first two weeks after discharge carry significantly elevated risk)
• Religious, spiritual, or personal belief system about life and death (can be protective or, in some circumstances, a risk factor)

The Process of Risk Evaluation

The following are essential steps in conducting a thorough risk assessment:

1. The doctor should set aside enough time to complete the assessment in a sympathetic and unhurried fashion. The clinical environment should be private and as calm as possible.
2. It is always useful to invite another health professional to join you — a community nurse or a senior ward nurse who knows the patient well and has been involved in their clinical management is very helpful, both for safety and to provide additional clinical information.
3. It is also important to invite a member of the patient's family, with the patient's consent, to join you or to interview them separately after the initial patient interview.
4. Conduct a systematic review of the patient's personal history — particularly recent losses (financial, relationship, social status) and their significance from the patient's perspective.
5. Review the relevant past medical, psychiatric, and family history.
6. Assess the current medical and mental health issues, the prescribed treatment, and the patient's perception of their prognosis.
7. Conduct a detailed evaluation of depressive symptoms, attitude towards life, feelings of being a burden to others, guilt, and thoughts of suicidal intent.
8. Differentiate clearly between passive suicidal ideation ("I wish I was dead") and active plans for self-harm or suicide (specific method, intent, and plan).
9. Ask about religious, spiritual, or personal beliefs about life and death. Many patients with extreme hardship and very little left to live for will not consider suicide because of strongly held personal beliefs — these are protective factors and should be recognised and documented.
10. Enquire about other protective factors. Almost all patients, except those with severe psychotic depression or other psychotic disorders, will acknowledge some reasons to continue living. Identifying and reinforcing these is a valuable component of management.
11. Speak to other relevant health professionals — with the patient's consent — who have known the patient in the past, including the GP and community nursing staff.
12. Consider completing a validated suicide risk scale. The Columbia Suicide Severity Rating Scale (C-SSRS) is now widely recommended in NHS settings for structured assessment of suicidal ideation and behaviour. The Beck Suicide Intent Scale (Beck, 1974) and Pierce's Modified Objective Intent Scale (BJP, 1977) are also used to translate the seriousness of a recent suicide attempt into a numerical format. However, no scale replaces a thorough clinical assessment — a very high or very low score does not always predict the ultimate outcome.

Limits of Risk Assessment

1. It is not possible to identify and eliminate risk entirely.
2. Risk fluctuates from day to day and sometimes from hour to hour; therefore, prediction is more accurate in the short term and even then is never one hundred percent accurate.
3. The clinician will often not have access to all the essential facts at the time of assessment.
4. A good risk assessment depends on reliable information from the patient and other informants — family, friends, colleagues. If the patient provides a misleading account, even the most thorough assessment may underestimate the risk.
5. A comprehensive assessment of risk should incorporate the views of all relevant health professionals currently and previously involved in the patient's care, including the GP, hospital specialists, senior nursing staff, clinical psychologists, community nursing staff, and — where relevant — information from police and courts.

These limitations underline why risk assessment is a clinical process, not a predictive algorithm. The goal is not to achieve certainty — which is impossible — but to gather as much relevant information as possible, to reason carefully about it, and to make a defensible, well-documented clinical decision about management.

Formulation and Management of Risk

Once the assessment is complete, the risk should be formally formulated — summarised and categorised — as follows:

1. Summarise the relevant personal details: age, gender, marital history, and past medical and psychiatric history.
2. Identify the current stress factors and how they differ from previous circumstances. Note the precipitating factors of the current clinical state, including:
   • Recent bereavement
   • Recent relationship breakdown
   • Recent discharge from hospital or change in legal status
   • Anniversaries or reminders of the deaths of loved ones
   • Recent loss or threat of loss of employment
   • Financial loss or reputational damage
   • Threat of criminal charges or imprisonment
   • Unwanted pregnancy or peer suicide (particularly in adolescence)
3. Classify the patient into a risk category to guide management planning and help minimise the risk of an adverse event.

Risk Categories

Category 1: Minimum Risk of Future Adverse Event

Key factors:

1. First episode of deliberate self-harm with no evidence of:
   • Mental disorder
   • Continuing suicidal ideation or intent
   • History of drug or alcohol misuse
2. Evidence that the triggering crisis has been resolved
3. Presence of one or more of the following protective factors:
   • Strong social support network
   • Supportive partner, parents, or others
   • Stable personality
   • Optimistic outlook; positive religious, spiritual, or personal belief system
   • Sense of responsibility towards parents, children, or others
   • Willingness to receive medical and other help

Category 2: Moderate Risk of Future Adverse Event

Key factors:

• Evidence of psychiatric disorder (depression, schizophrenia, or significant personality difficulties)
• Presence of depressive delusions, ideas of reference, or command hallucinations in other psychotic disorders
• Alcohol or drug misuse
• Previous history of self-harm
• Chronic physical health problems
• Active suicidal ideation
• Limited protective factors

Category 3: Severe (Serious) Risk of Future Adverse Event

Key factors:

• All factors listed in Category 2
• Plus a recent serious suicide attempt using a high-lethality method:
  • Gunshot wound
  • Attempted hanging
  • Carbon monoxide poisoning
  • Jumping from a height or in front of a vehicle
• Active suicidal ideation with plans for a further attempt
• Poor response to prescribed treatment for mental and physical health disorders
• Presence of chronic pain
• Absence of almost all protective factors

Conclusion: Clinical Decisions Following Risk Assessment

Once the assessment has been completed, all risk factors evaluated, understood, and documented, the following decisions must be made:

1. Can the patient be safely discharged from hospital and treated in the community?
2. Should the patient be admitted or transferred to a psychiatric inpatient unit?
3. Who else needs to be involved to complete the risk assessment?
4. When, where, and by whom will the risk assessment be reviewed?

The management of the suicidal patient and deliberate self-harm, and consent for treatment, are dealt with in Clinical Risk Assessment in Psychiatry – Part 2.