The following document was written by Dr Satvir Singh FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry) Kent & Medway NHS and Social Care Partnership Trust Canterbury, Kent in Dec 2007.
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CLINICAL RISK ASSESSMENT IN PSYCHIATRY - 3

This section should be read in conjunction with the articles on Clinical Risk Assessment in Psychiatry – 1 & 2.

As outlined in articles 1 & 2, you have gone through the assessment of the patient either in A & E or in Community (GP practice or at the patient’s home) and you have identified patients who are at Moderate or Serious Risk of further self-harm. Such patients should be assessed by the Specialist Nurse/Psychiatrist who may arrange an admission to a psychiatric unit for further evaluation of their mental state, social circumstances and treatment.

In fact, it is always easier to manage patients that you have identified for psychiatric assessment and probably admission to psychiatric unit. Sometimes the patient may require to be admitted under the appropriate mental health Act and again, the psychiatric team will arrange this.

Rarely, you may need to hold a patient, who is already an in-patient, but refuses to stay and, in your opinion, is in need of further psychiatric evaluation. You can do this under Section 5(2) of the Mental Health Act 1983, for a maximum of 72 hours. You may need help of the nursing and/or security staff to keep the patient on the ward until such time the psychiatric team members arrive. Very rarely you may have to notify the police about someone who has left the A & E without psychiatric assessment and you are concerned about their safety.

The next few paragraphs briefly repeat the key factors that you should be aware of and which should alert you to seek help from the psychiatric team, especially regarding those suffering from mental disorders.

In cases of major depression, assess for recent changes in living arrangements leading to isolation and self-neglect, hopelessness, excessive guilt and self-blame, alcohol abuse, suicidal intent and lack of social support.

While in cases of schizophrenia, be aware of the following factors, which increase the risk of suicide:

• Recently diagnosed young male
• Recent discharge from psychiatric unit
• Current and past history of depression
• Non-compliance to prescribed psychiatric treatment
• Social isolation
• Suicidal intent

In cases of older persons:

• Male gender
• Single/separated or widowed
• History of depression and suicidal intent
• Recent changes in living arrangements
• Co-morbid physical illness
• Chronic pain

Next is the management of a patient who has been brought to the A & E department following an episode of deliberate self-harm and is not suffering from major depression, schizophrenia or other mental disorders.

The examining doctor should assess and be aware of:

1. Patient’s capacity to consent
2. What treatment in what circumstances can be given without the patient’s consent. (See section on Consent in Clinical Risk Assessment in Psychiatry – 2).

Then the patient is medically examined, investigated, treated accordingly and considered to be physically fit for psychosocial assessment. Before undertaking the psychosocial assessment, it is always helpful to have the contact details of the following, which would be helpful in managing the patient effectively and efficiently.

1. Local social services and housing department
2. Crisis Assessment Team
3. Voluntary services such as Help Line and Samaritans
4. Community based resources such as Day Hospital, Day Centres, Walk in Clinics, etc.

The following information should be obtained from the patient and/or a family member/friend (with the patient’s consent):

• Patient’s intention at the time of self-harm


• How he/she feels about it now


• Who can help and support the patient immediately after discharge from the A & E and what arrangements should be made for essential support in any crisis for the next 3 months.


• Employment status


• Current financial problems, if any


• Details of debts, if any


• Accommodation issues


• Any eviction notices due to non-payment of rent and/or any other reasons


• Relationship problems, if any


• Children and their current physical and mental health


• Pregnancy, wanted/unwanted


• Issues with drugs and alcohol, petty crimes, etc


• Any pending court cases


• Driving offences and pending fines


• Fear of losing custody of children and the reasons.


• Fear of imprisonment and the reasons


• Falling out from extended members of family


• Loneliness and inability to cope with current social and financial circumstances

The episode of self-harm, may often be the only way of coping with the daily grind of overwhelming poor socio-economic conditions, relationship difficulties and limited/absent social support network. Also, such patients may have problems with their organisational skills, ability to solve problems, control their anger, etc.

Before you plan to discharge the patient from the A & E department or the hospital, make sure that you have excluded any treatable underlying physical and mental health disorders. Also make sure that the crisis that precipitated the self-harm has abated and the patient is no more expressing any suicidal intent.

The following must be done in almost all cases of deliberate self-harm prior to the discharge from the hospital:

• That a responsible adult has been contacted who will assume the responsibility of the patient’s immediate safety and general welfare


• The patient’s GP has been notified and the relevant details given with the advice to see the patient within the next 72 hours.


• Refer the patient to appropriate department, such as Social Services and Housing Department for the essential support and advice.


• If necessary, arrange the community based psychiatric services to see the patient as soon as possible, preferably within 72 hours.


• If necessary, an appointment with a psychiatrist should be arranged by the Community Psychiatric Services.

Finally, as the patient leaves the hospital, make sure that you have given the following information to the patient/family/friend:

• Your own contact details in case any other health professional needs further details regarding the patient


• Appointment time and date with the GP if you have been able to arranged it


• Contact details of Social Services, Housing Department, if relevant.


• Appointment arrangements with the Crisis Assessment Team, if necessary


• Contact details of the Help Line and Samaritans, in case of emergency

Ideally, each A & E department should have an agreed protocol to be followed, step by step incorporating most of the above suggestions.

Author:
Dr Satvir Singh
FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS
Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry)
Kent & Medway NHS and Social Care Partnership Trust
Canterbury, Kent

References:

1. Shorter Oxford Textbook of Psychiatry, Fifth Edition, M Gelder et al, 2006
2. Department of Health - Consent

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