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 Ė 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 patientís 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:


In cases of older persons:


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. Patientís capacity to consent
  2. What treatment in what circumstances can be given without the patientís consent. (See section on Consent in Clinical Risk Assessment in Psychiatry Ė 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 patientís consent):



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:

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

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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