Involving carers in risk assessment: a study of a structured dialogue between mental health nurses and carers

Factors within the clinical encounter that impact upon risk assessment within child and adolescent mental health services: a rapid realist synthesis

Background

Risk assessment is a key process when a child or adolescent presents at risk for self-harm or suicide in a mental health crisis or emergency. Risk assessment by a healthcare professional should be included within a biopsychosocial assessment. However, the predictive value of risk-screening tools for self-harm and suicide in children and adolescents is consistently challenged. A review is needed to explore how best to undertake risk assessment and the appropriate role for tools/checklists within the assessment pathway.

Aims

To map research relating to risk assessment for child and adolescent mental health and to identify features that relate to a successful risk assessment.

Objectives

To review factors within the clinical encounter that impact upon risk assessments for self-harm and suicide in children and adolescents: i. to conduct a realist synthesis to understand mechanisms for risk assessment, why they occur and how they vary by context ii. to conduct a mapping review of primary studies/reviews to describe available tools of applicability to the UK.

Data sources

Databases, including MEDLINE, PsycINFO®, EMBASE, CINAHL, HMIC, Science and Social Sciences Citation Index and the Cochrane Library, were searched (September 2021). Searches were also conducted for reports from websites.

Review methods

A resource-constrained realist synthesis was conducted exploring factors that impact upon risk assessments for self-harm and suicide. This was accompanied by a mapping review of primary studies/reviews describing risk-assessment tools and approaches used in UK child and adolescent mental health. Following piloting, four reviewers screened retrieved records. Items were coded for the mapping and/or for inclusion in the realist synthesis. The review team examined the validity and limitations of risk-screening tools. In addition, the team identified structured approaches to risk assessment. Reporting of the realist synthesis followed RAMESES guidelines.

Results

From 4084 unique citations, 249 papers were reviewed and 41 studies (49 tools) were included in the mapping review. Eight reviews were identified following full-text screening. Fifty-seven papers were identified for the realist review. Findings highlight 14 explanations (programme theories) for a successful risk assessment for self-harm and suicide. Forty-nine individual assessment tools/approaches were identified. Few tools were developed in the UK, specifically for children and adolescents. These lacked formal independent evaluation. No risk-screening tool is suitable for risk prediction; optimal approaches incorporate a relationship of trust, involvement of the family, where appropriate, and a patient-centred holistic approach. The objective of risk assessment should be elicitation of information to direct a risk formulation and care plan.

Limitations

Many identified tools are well-established but lack scientific validity, particularly predictive validity, or clinical utility. Programme theories were generated rapidly from a survey of risk assessment.

Conclusions

No single checklist/approach meets the needs of risk assessment for self-harm and suicide. A whole-system approach is required, informed by structured clinical judgement. Useful components include a holistic assessment within a climate of trust, facilitated by family involvement.

Study registration

This study is registered as PROSPERO CRD42021276671.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135079) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 1. See the NIHR Funding and Awards website for further award information.

Interventions that support unpaid carers of adult mental health inpatients: a scoping review

BACKGROUND

Unpaid carers of adult mental health inpatients often lack support for their well-being and feel excluded from decisions about patient care.

AIMS

This scoping review aimed to: synthesise the peer-reviewed literature evaluating the outcomes of brief interventions for unpaid carers of adult mental health inpatients, identify transferable lessons for evidenced-informed practice, and establish future research priorities.

METHODS

PRISMA scoping review guidelines were followed to search 12 databases using predefined search terms. Two reviewers independently screened papers and applied exclusion/inclusion criteria. Studies were included if they evaluated the impact or outcomes of interventions. Two reviewers extracted data and assessed study quality. Data were synthesised to categorise types of interventions and evidence for their outcomes.

RESULTS

16 papers met the inclusion criteria, and five types of interventions were identified: those that aimed to (1) increase carer involvement in inpatient care; (2) facilitate organisational change to increase carer support and involvement; (3) provide carers with support; (4) deliver psychoeducation and offer support; and (5) reduce carer stress and improve coping skills.

CONCLUSIONS

Whilst evidence of intervention effectiveness was promising, the quality of studies was generally weak. More research is needed to develop an evidence-informed approach to supporting carers during inpatient stays.

Suicide risk assessment in UK mental health services: a national mixed-methods study

BACKGROUND

Risk assessments are a central component of mental health care. Few national studies have been done in the UK on risk assessment tools used in mental health services. We aimed to examine which suicide risk assessment tools are in use in the UK; establish the views of clinicians, carers, and service users on the use of these tools; and identify how risk assessment tools have been used with mental health patients before suicide.

METHODS

We did a mixed-methods study involving three components: collection and content analysis of risk assessment tools used by UK mental health services; an online survey of clinicians, service-users, and carers; and qualitative telephone interviews with clinicians on their use of risk assessment tools before a suicide death and their views of these tools. The online survey was advertised through the National Confidential Inquiry into Suicide and Safety in Mental Health's (NCISH) website and social media, and it included both quantitative and open-ended qualitative questions, and respondents were recruited through convenience sampling. For the telephone interviews, we examined the NCISH database to identify clinicians who had been responsible for the care of a patient who died by suicide and who had been viewed as being at low or no immediate risk of suicide.

FINDINGS

We obtained 156 risk assessment tools from all 85 National Health Service mental health organisations in the UK, and 85 (one per each organisation) were included in the analysis. We found little consistency in use of these instruments, with 33 (39%) of 85 organisations using locally developed tools. Most tools aimed to predict self-harm or suicidal behaviour (84 [99%] of 85), and scores were used to determine management decisions (80 [94%]). Clinicians described positive aspects of risk tools (facilitating communication and enhancing therapeutic relationships) but also expressed negative views (inadequate training in the use of tools and their time-consuming nature). Both patients and carers reported some positive views, but also emphasised little involvement during risk assessment, and a lack of clarity on what to do in a crisis.

INTERPRETATION

Assessment processes need to be consistent across mental health services and include adequate training on how to assess, formulate, and manage suicide risk. An emphasis on patient and carer involvement is needed. In line with national guidance, risk assessment should not be seen as a way to predict future behaviour and should not be used as a means of allocating treatment. Management plans should be personalised and collaboratively developed with patients and their families and carers.

FUNDING

The Healthcare Quality Improvement Partnership.