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Connors MH, Large MM. Calibrating violence risk assessments for uncertainty. Gen Psychiatr 2023; 36:e100921. [PMID: 37144159 PMCID: PMC10151861 DOI: 10.1136/gpsych-2022-100921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/26/2023] [Indexed: 05/06/2023] Open
Abstract
Psychiatrists and other mental health clinicians are often tasked with assessing patients' risk of violence. Approaches to this vary and include both unstructured (based on individual clinicians' judgement) and structured methods (based on formalised scoring and algorithms with varying scope for clinicians' judgement). The end result is usually a categorisation of risk, which may, in turn, reference a probability estimate of violence over a certain time period. Research over recent decades has made considerable improvements in refining structured approaches and categorising patients' risk classifications at a group level. The ability, however, to apply these findings clinically to predict the outcomes of individual patients remains contested. In this article, we review methods of assessing violence risk and empirical findings on their predictive validity. We note, in particular, limitations in calibration (accuracy at predicting absolute risk) as distinct from discrimination (accuracy at separating patients by outcome). We also consider clinical applications of these findings, including challenges applying statistics to individual patients, and broader conceptual issues in distinguishing risk and uncertainty. Based on this, we argue that there remain significant limits to assessing violence risk for individuals and that this requires careful consideration in clinical and legal contexts.
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Affiliation(s)
- Michael H Connors
- Centre for Healthy Brain Ageing, University of New South Wales, Sydney, New South Wales, Australia
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew M Large
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia
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2
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Effectiveness of Artificial Intelligence Methods in Personalized Aggression Risk Prediction within Inpatient Psychiatric Treatment Settings—A Systematic Review. J Pers Med 2022; 12:jpm12091470. [PMID: 36143255 PMCID: PMC9501805 DOI: 10.3390/jpm12091470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/12/2022] [Accepted: 08/27/2022] [Indexed: 11/17/2022] Open
Abstract
Aggression risk assessments are vital to prevent injuries and morbidities amongst patients and staff in psychiatric settings. More recent studies have harnessed artificial intelligence (AI) methods such as machine learning algorithms to determine factors associated with aggression in psychiatric treatment settings. In this review, using Cooper’s five-stage review framework, we aimed to evaluate the: (1) predictive accuracy, and (2) clinical variables associated with AI-based aggression risk prediction amongst psychiatric inpatients. Databases including PubMed, Cochrane, Scopus, PsycINFO, CINAHL were searched for relevant articles until April 2022. The eight included studies were independently evaluated using critical appraisal tools for systematic review developed by Joanna Briggs Institute. Most of the studies (87.5%) examined health records in predicting aggression and reported acceptable to excellent accuracy with specific machine learning algorithms employed (area under curve range 0.75–0.87). No particular machine learning algorithm outperformed the others consistently across studies (area under curve range 0.61–0.87). Relevant factors identified with aggression related to demographic and social profile, past aggression, forensic history, other psychiatric history, psychopathology, challenging behaviors and management domains. The limited extant studies have highlighted a potential role for the use of AI methods to clarify factors associated with aggression in psychiatric inpatient treatment settings.
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Martinho SM, Santa-Rosa B, Silvestre M. Where the public health principles meet the individual: a framework for the ethics of compulsory outpatient treatment in psychiatry. BMC Med Ethics 2022; 23:77. [PMID: 35879800 PMCID: PMC9309603 DOI: 10.1186/s12910-022-00814-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background Compulsory treatments represent a legal means of imposing treatment on an individual, usually with a mental illness, who refuses therapeutic intervention and poses a risk of self-harm or harm to others. Compulsory outpatient treatment (COT) in psychiatry, also known as community treatment order, is a modality of involuntary treatment that broadens the therapeutic imposition beyond hospitalization and into the community. Despite its existence in over 75 jurisdictions worldwide, COT is currently one of the most controversial topics in psychiatry, and it presents significant ethical challenges. Nonetheless, the ethical debate regarding compulsory treatment almost always stops at a preclinical level, with the different ethical positions arguing for or against its use, and there is little guidance to support for the individual clinicians to act ethically when making the decision to implement COT. Main body The current body of evidence is not clear about the efficacy of COT. Therefore, despite its application in several countries, evidence favouring the use of COT is controversial and mixed at best. In these unclear circumstances, ethical guidance becomes paramount. This paper provides an ethical analysis of use of COT, considering the principlist framework established by Ross Upshur in 2002 to justify public health interventions during the 2002–2004 severe acute respiratory syndrome outbreak. This paper thoroughly examines the pertinence of using the principles of harm, proportionality, reciprocity, and transparency when considering the initiation of COT. Conclusion Ross Upshur’s principlist model provides a useful reflection tool for justifying the application of COT. This framework may help to inform sounder ethical decisions in clinical psychiatric practice.
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Affiliation(s)
- Sérgio M Martinho
- Bioethics Institute, Faculty of Medicine, University of Coimbra, Azinhaga de Santa Comba, Celas, 3000-548, Coimbra, Portugal.
| | - Bárbara Santa-Rosa
- Bioethics Institute, Faculty of Medicine, University of Coimbra, Azinhaga de Santa Comba, Celas, 3000-548, Coimbra, Portugal.,National Institute of Legal Medicine and Forensic Sciences, North Branch, Porto, Portugal
| | - Margarida Silvestre
- Bioethics Institute, Faculty of Medicine, University of Coimbra, Azinhaga de Santa Comba, Celas, 3000-548, Coimbra, Portugal.,Reproductive Medicine Department, Coimbra Hospital and University Centre, Coimbra, Portugal
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4
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Hospital-Based Suicides: Challenging Existing Myths. Psychiatr Q 2022; 93:1-13. [PMID: 33169312 DOI: 10.1007/s11126-020-09856-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2020] [Indexed: 10/23/2022]
Abstract
Myths are widely held and often based on false beliefs. To improve patient safety and speed the translation of research to clinical practice, we highlight and then debunk 10 common myths regarding the assessment, treatment, and management of hospitalized patients at risk for suicide. Myths regarding hospital-based suicides are examined and empirical evidence that counters each myth is offered. Ten common myths regarding hospital-based suicides are found to be untrue or unsupported based on existing empirical evidence. Rethinking common beliefs and practices that lack empirical support and seeking alternatives based on research evidence is consistent with an emphasis on evidence-based practices leading to improved patient care and protection.
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Suicide after contact with a national digital mental health service. Internet Interv 2022; 28:100516. [PMID: 35251939 PMCID: PMC8891694 DOI: 10.1016/j.invent.2022.100516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 02/18/2022] [Accepted: 02/20/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The safety of mental health care provided remotely via the internet, in particular, the probability of suicide after contact, is not known. METHOD An observational cohort study of patients registered with the MindSpot Clinic an Australian national digital mental health service (DMHS), linked to the National Death Index. Measures included demographic information, the nature of contact, duration between last contact and death, scores on measures of psychological distress (K-10), depression (PHQ-9) and anxiety (GAD-7), and responses to questions about suicidal thoughts or plans for patients who died by suicide within two years of last contact with the service. RESULTS Sixty-four (0.11%) of 59,033 patients registered with the MindSpot Clinic between 1 January 2013 and 31 December 2016 died from suicide within two years of last contact. The mean time between last contact and death was 344 days. Fourteen patients died within 90 days of last contact, and 4 of 285 who were urgently referred for crisis service intervention at the time of contact or soon afterwards died within 2 years. Suicidal thoughts (OR: 2.59), a suicide plan (OR: 10.8), and a score of "3" to item 9 of the PHQ9 (OR: 16.4) were significantly associated with subsequent suicide. Patients who died by suicide were more likely to be male (OR: 3.2), middle-aged (35-45; OR: 2.3), separated or divorced (OR: 3.1), unemployed (OR: 3.1) or receiving disability benefits (OR: 5.1). Enrolling in an online treatment course was associated with reduced risk (OR: 0.38). CONCLUSIONS Although DMHS provide services to patients with severe symptoms of depression, only a small proportion died by suicide, and only a small number of those referred for urgent care, which suggests that the safety protocols of the clinic are relatively effective.
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Terzioğlu C, Doğan S. The Effects of a Psychodrama-Based Risk Management Training Program on the Knowledge and Practices of Turkish Nurses in Psychiatric Clinics. Issues Ment Health Nurs 2022; 43:76-82. [PMID: 34232839 DOI: 10.1080/01612840.2021.1933279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This study aimed to assess the effects of a psychodrama-based risk management training program on nurses' knowledge and practices. This study used a mixed methods design; quantitative and qualitative methods were used together with a single group pretest, post-test, and follow-up. The training program, in which the nurses took part, comprised six lessons that were designed using psychodrama methods. The result showed that risk management scores increased significantly after the training. Thus, this training is effective for improving the knowledge and practices of mental health nurses for risk management.
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Affiliation(s)
- Candan Terzioğlu
- Nursing Department, Faculty of Health Science, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Selma Doğan
- Nursing Department, Faculty of Health Science, Üsküdar University, Istanbul, Turkey
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Morales S, Barros J. Mental Pain Surrounding Suicidal Behaviour: A Review of What Has Been Described and Clinical Recommendations for Help. Front Psychiatry 2021; 12:750651. [PMID: 35153847 PMCID: PMC8828913 DOI: 10.3389/fpsyt.2021.750651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 12/21/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To conduct a comprehensive review of scientific publications related to mental pain and suicide risk in order to deepen relevant aspects to guide clinical interventions. METHOD Using a text analysis tool, we collected the terms most frequently linked with that situation in published results of research using various tools to evaluate mental pain or psychache. DISCUSSION We propose clinical interventions for the clinical conditions most commonly associated with mental pain.
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Affiliation(s)
- Susana Morales
- Psychiatry Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.,Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile
| | - Jorge Barros
- Psychiatry Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.,Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile
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8
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Dong X, Bergren S, Wang B, Kozlov E. The associations between social support and negative social interaction with suicidal ideation in US Chinese older adults. Aging Ment Health 2021; 25:94-98. [PMID: 31650846 DOI: 10.1080/13607863.2019.1680953] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/08/2019] [Indexed: 10/25/2022]
Abstract
To examine associations between social support and negative social interaction with past suicidal ideation (SI) at multiple time intervals. The study used cross-sectional data collected from 3157 US Chinese older adults in Chicago to assess past 2-week, 1-month, 1-year, and lifetime SI. Self-perceived social support and negative social interaction were measured. Multiple logistic regression analyses were used to examine the associations. People perceived more social support and less negative social interaction were 17-19% less likely to have SI. People perceived more social support were 14-20% less likely to have SI. Meanwhile, people perceived more negative social interaction were 28-37% more likely to have SI. The independent associations between different social interaction and SI are significant regardless of the time intervals. Research should pay attention not only to bolstering perceptions of social support, but also to strategies that help individuals cope with the influence of negative social interactions.
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Affiliation(s)
- Xinqi Dong
- Health Care Policy and Aging Research, Rutgers University, Institute for Health, New Brunswick, New Jersey, USA
| | - Stephanie Bergren
- Health Care Policy and Aging Research, Rutgers University, Institute for Health, New Brunswick, New Jersey, USA
| | - Bei Wang
- Health Care Policy and Aging Research, Rutgers University, Institute for Health, New Brunswick, New Jersey, USA
| | - Elissa Kozlov
- Health Care Policy and Aging Research, Rutgers University, Institute for Health, New Brunswick, New Jersey, USA
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9
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Graney J, Hunt IM, Quinlivan L, Rodway C, Turnbull P, Gianatsi M, Appleby L, Kapur N. Suicide risk assessment in UK mental health services: a national mixed-methods study. Lancet Psychiatry 2020; 7:1046-1053. [PMID: 33189221 DOI: 10.1016/s2215-0366(20)30381-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/30/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Jane Graney
- National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK.
| | - Isabelle M Hunt
- National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK
| | - Leah Quinlivan
- National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre, Manchester, UK
| | - Cathryn Rodway
- National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK
| | - Pauline Turnbull
- National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK
| | - Myrsini Gianatsi
- National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK
| | - Louis Appleby
- National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK
| | - Nav Kapur
- National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK; National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre, Manchester, UK; Greater Manchester Mental Health National Health Service Foundation Trust, Manchester, UK
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10
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Florisse EJR, Delespaul PAEG. Monitoring risk assessment on an acute psychiatric ward: Effects on aggression, seclusion and nurse behaviour. PLoS One 2020; 15:e0240163. [PMID: 33007027 PMCID: PMC7531854 DOI: 10.1371/journal.pone.0240163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 09/22/2020] [Indexed: 11/29/2022] Open
Abstract
Evidence of risk assessment procedures is scarce and inconclusive. The aim of this study is to evaluate the effects of risk assessment on aggression and the use of coercive interventions in an acute psychiatric admission setting. In addition, we evaluated nurse behaviour before and after the use of risk assessment. To take the fluctuations with regard to aggression and coercive interventions into account, we allowed 26 weeks for baseline measurements, followed by a 26 weeks steady-state period after the implementation of the risk assessment instrument. Contrary to expectations, no positive effects of risk assessment were found on aggression or on coercive interventions. Time spent in seclusion increased significantly with more than 10 hours on average after implementation. Furthermore, there were only negative effects on nurse behaviour and experiences. Among other things, they felt more stressed, spent more time on administration tasks and spent less time with patients after the implementation. In conclusion, there is insufficient evidence to use structured short-term risk assessment to reduce aggression or coercive interventions.
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Affiliation(s)
| | - Philippe A. E. G. Delespaul
- Mondriaan Mental Health Care, Heerlen, The Netherlands
- Department of Psychiatry and Psychology, School of Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
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11
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Wilson MP, Moutier C, Wolf L, Nordstrom K, Schulz T, Betz ME. ED recommendations for suicide prevention in adults: The ICAR2E mnemonic and a systematic review of the literature. Am J Emerg Med 2020; 38:571-581. [DOI: 10.1016/j.ajem.2019.06.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 01/28/2023] Open
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12
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Randall JR, Sareen J, Bolton JM. Suicide and all-cause mortality in a high-risk cohort: A latent class approach. Gen Hosp Psychiatry 2020; 63:62-67. [PMID: 30529067 DOI: 10.1016/j.genhosppsych.2018.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 10/08/2018] [Accepted: 11/20/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To use latent class analysis to group patients consulted to an emergency psychiatry consultation service and assess occurrence of suicide attempts and all-cause mortality across groups. METHOD Latent class analysis was used to classify individuals assessed by psychiatry in the emergency department of the two teaching hospitals in Winnipeg, Canada. A second latent class analysis was done on individuals presenting with a suicide attempt. Indicators variables included a variety of clinically assessed factors, such as presentation suicidality and occurrence of anxiety/depression/psychosis, and prior medical treatment. Two post-treatment indicators were used; suicide attempt hospitalizations and all-cause mortality within 12 months of assessment. RESULTS Latent class analysis identified 8 classes for all presentations (n = 5292) and 3 classes for the attempter subgroup (n = 730). Although there is considerable overlap in indicators among the classes certain indicators differentiated between the groups: suicide attempt presentation, prior psychiatric treatment, psychotropic medication polypharmacy, childhood abuse, and addictions. Although the presence of deaths and future attempts varied between the identified groups, there were no groups with a >10% proportion of individuals with either of these outcomes. CONCLUSIONS Potential exists for latent class-based assessments, but additional samples with better indicators are needed.
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Affiliation(s)
- Jason R Randall
- Injury Prevention Centre, School of Public Health, University of Alberta, Edmonton, AB, Canada; Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
| | - Jitender Sareen
- Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada; Manitoba Centre for Health Policy, Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada; Department of Psychiatry, College of Medicine, Faculty of Health Sciences, University of Manitoba, Canada
| | - James M Bolton
- Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada; Manitoba Centre for Health Policy, Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada; Department of Psychiatry, College of Medicine, Faculty of Health Sciences, University of Manitoba, Canada
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13
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Ng L, Zeng I, Kalinowski C, Watson P. Documenting psychiatric risk: more than ticking boxes. Australas Psychiatry 2019; 27:625-629. [PMID: 31241347 DOI: 10.1177/1039856219859272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of this study was to audit the completion of risk assessment documentation by staff working within an acute adult mental health setting. METHOD Fifty risk assessment forms in a district health board's acute adult mental health service were audited for completion. Clinicians provided verbal feedback on the audit results. RESULTS Risk assessment forms were completed in 58.3% of cases. A risk formulation statement was completed in 43.8% of cases. Rates of completion varied between senior medical officers, registrars and nurses. CONCLUSION Accurate risk formulation and safety planning are more important than ensuring all boxes are ticked on a form. Optimising the design of electronic forms may enhance access to information about historical risk.
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Affiliation(s)
- Lillian Ng
- Department of Psychological Medicine, The University of Auckland, New Zealand, and; Counties Manukau District Health Board, Auckland, New Zealand
| | - Irene Zeng
- Mental Health and Addictions Services, Counties Manukau District Health Board, Auckland, New Zealand
| | - Coni Kalinowski
- Acute Mental Health and Addictions Services, Counties Manukau District Health Board, Auckland, New Zealand
| | - Peter Watson
- Mental Health and Addictions Services, Counties Manukau District Health Board, Auckland, New Zealand
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14
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Maguire T, Daffern M, Bowe SJ, McKenna B. Evaluating the impact of an electronic application of the Dynamic Appraisal of Situational Aggression with an embedded Aggression Prevention Protocol on aggression and restrictive interventions on a forensic mental health unit. Int J Ment Health Nurs 2019; 28:1186-1197. [PMID: 31290238 DOI: 10.1111/inm.12630] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2019] [Indexed: 01/04/2023]
Abstract
Risk assessment is a pre-requisite for violence prevention in mental health settings. Extant research concerning risk assessment and nursing intervention is limited and has focused on the predictive validity of various risk assessment approaches and instruments, with few attempts to elucidate and test interventions that might prevent aggression, and reduce reliance on coercive interventions. The integration of risk assessment and violence prevention strategies has been neglected. The aim of this feasibility study was to test a novel Aggression Prevention Protocol designed to prioritize the instigation of less restrictive interventions on an acute forensic mental health unit for female patients. A prospective quasi-experimental study was designed to test an Aggression Prevention Protocol, linked to an electronic application of the Dynamic Appraisal of Situational Aggression (DASA). Following introduction of the DASA and Aggression Prevention Protocol, there were reductions in verbal aggression, administration of Pro Re Nata medication, the rate of seclusion, and physical and mechanical restraint. There was also an increase in documented nursing interventions. Overall, these results support further testing of the electronic application of the DASA and the Aggression Prevention Protocol.
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Affiliation(s)
- Tessa Maguire
- Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Victoria, Australia.,Victorian Institute of Forensic Mental Health, Forensicare, Melbourne, Victoria, Australia
| | - Michael Daffern
- Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Victoria, Australia.,Victorian Institute of Forensic Mental Health, Forensicare, Melbourne, Victoria, Australia
| | - Steven J Bowe
- Faculty of Health, Biostatistics Unit, Deakin University, Melbourne, Victoria, Australia
| | - Brian McKenna
- Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Victoria, Australia.,Auckland University of Technology, Auckland, New Zealand
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15
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Corsico P. The risks of risk. Regulating the use of machine learning for psychosis prediction. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 66:101479. [PMID: 31706401 DOI: 10.1016/j.ijlp.2019.101479] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/21/2019] [Accepted: 07/24/2019] [Indexed: 06/10/2023]
Abstract
Recent advances in Machine Learning (ML) have the potential to revolutionise psychosis prediction and psychiatric assessment. This article has two objectives. First, it clarifies which aspects of English Law are relevant in order to regulate the use of ML in clinical research on psychosis prediction. It is argued that its lawful implementation will depend upon the legal requirements regarding the balance between potential harms and benefits, particularly with reference to: (i) any additional risks introduced by the use of ML for data analysis and outcome prediction; and (ii) the inclusion of vulnerable research populations such as minors or incapacitated adults. Second, this article investigates how clinical prediction via ML might affect the practice of risk assessment under mental health legislation, with reference to English Law. It is argued that there is a potential for virtuous applications of clinical prediction in psychiatry. However, reaffirming the distinction between psychosis risk and risk of harm is paramount. Establishing psychosis risk and assessing a person's risk of harm are discrete practices, and so should remain when using artificial intelligence for psychiatric assessment. Evaluating whether clinical prediction via ML might benefit individuals with psychosis will depend on which risk we try to assess and on what we try to predict, whether this is psychosis transition, a psychotic relapse, self-harm and suicidality, or harm to others.
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Affiliation(s)
- Paolo Corsico
- Centre for Social Ethics and Policy, Department of Law, School of Social Sciences, The University of Manchester, United Kingdom.
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16
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Randall JR, Sareen J, Chateau D, Bolton JM. Predicting Future Suicide: Clinician Opinion versus a Standardized Assessment Tool. Suicide Life Threat Behav 2019; 49:941-951. [PMID: 29920749 DOI: 10.1111/sltb.12481] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 04/16/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the effectiveness of clinician prediction of risk to a standardized assessment of presentation status. METHODS All adult psychiatry emergency department consults in the two main hospitals in Winnipeg, Canada, were assessed using a standardized form (n = 5,376). This form includes two risk scales for a gestalt physician assessment of risk (Suicide Likelihood scale, suicide Attempt Likelihood scale) and the Columbia Classification Algorithm of Suicide Assessment (C-CASA). Regression determined whether assessments predicted future suicide attempts and deaths. The area under the curve (AUC) determined the prediction accuracy of these methods. RESULTS Although the regression results were significant, the AUCs were either moderate or poor. Clinician assessment was not effective at predicting deaths (AUC = .546, .36-.73), but moderately accurate at predicting future attempts (AUC = .728, .66-.79). C-CASA assessment was moderately accurate at predicting both attempts and deaths (AUC = .666 and .678). CONCLUSIONS Clinician assessment does not significantly outperform a simple assessment of the occurrence of suicidal thoughts and behaviors during presentation to the emergency department. Behavior-based standardized assessments should be further researched in this field. Assessment of suicidality at presentation using C-CASA or similar assessment should be standard for psychiatric patients assessed in the emergency department.
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Affiliation(s)
- Jason R Randall
- Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Manitoba Centre for Health Policy, Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Injury Prevention Centre, School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Jitender Sareen
- Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Psychiatry, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Dan Chateau
- Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Manitoba Centre for Health Policy, Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Injury Prevention Centre, School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - James M Bolton
- Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Manitoba Centre for Health Policy, Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Psychiatry, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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Jasmin K, Walker A, Guthrie E, Trigwell P, Quirk A, Hewison J, Murray CC, House A. Integrated liaison psychiatry services in England: a qualitative study of the views of liaison practitioners and acute hospital staffs from four distinctly different kinds of liaison service. BMC Health Serv Res 2019; 19:522. [PMID: 31345212 PMCID: PMC6659268 DOI: 10.1186/s12913-019-4356-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/17/2019] [Indexed: 02/06/2023] Open
Abstract
Background Liaison psychiatry services provide mental health care for patients in physical healthcare (usually acute hospital) settings including emergency departments. Liaison work involves close collaboration with acute hospital staff so that high quality care can be provided. Services however are patchy, relatively underfunded, heterogeneous and poorly integrated into acute hospital care pathways. Methods We carried out in-depth semi-structured interviews with 73 liaison psychiatry and acute hospital staff from 11 different acute hospitals in England. The 11 hospitals were purposively sample to represent hospitals in which four different types of liaison services operated. Staff were identified to ensure diversity according to professional background, sub-specialism within the team, and whether they had a clinical or managerial focus. All interviews were audio-recorded and transcribed. The data were analysed using a best-fit framework analysis. Results Several key themes emerged in relation to facilitators and barriers to the effective delivery of integrated services. There were problems with continuity of care across the secondary-primary interface; a lack of mental health resources in primary care to support discharge; a lack of shared information systems; a disproportionate length of time spent recording information as opposed to face to face patient contact; and a lack of a shared vision of care. Relatively few facilitators were identified although interviewees reported a focus on patient care. Similar problems were identified across different liaison service types. Conclusions The problems that we have identified need to be addressed by both liaison and acute hospital teams, managers and funders, if high quality integrated physical and mental health care is to be provided in the acute hospital setting. Electronic supplementary material The online version of this article (10.1186/s12913-019-4356-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Keeble Jasmin
- Department of Digital, Media, Culture and Sport, London, UK
| | - Andrew Walker
- Clinical Research Network National Coordinating Centre, National Institute of Health Research Clinical Research Network, Leeds, UK
| | - Elspeth Guthrie
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Peter Trigwell
- National Inpatient Centre for Psychological Medicine, Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Alan Quirk
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Jenny Hewison
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Allan House
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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18
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Assessing interpersonal and mood factors to predict trajectories of suicidal ideation within an inpatient setting. J Affect Disord 2019; 252:315-324. [PMID: 30999088 DOI: 10.1016/j.jad.2019.04.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/06/2019] [Accepted: 04/07/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND A limited amount of research has assessed how suicide risk changes over time, and how changes can be predicted. The current study assessed suicidal ideation and risk factors throughout inpatient visits to a psychiatric facility to refine prediction of suicide risk. METHOD In total, 491 patients (73% Female; mean age = 39.21) at a psychiatric inpatient facility self-reported the frequency of their suicidal thoughts, perceived burdensomeness, thwarted belongingness, hopelessness, depression, and anxiety in the prior 24 h on a daily basis. Levels of suicidal ideation and risk factors at each quarter of an inpatient's stay were identified, and latent class growth analysis used to identify common patterns of change over time. RESULTS Changes in mood and interpersonal factors were associated with changes in suicidal ideation over days and weeks. Further, they contributed to the prediction of future levels of suicidal ideation. Thwarted belongingness at admission predicted whether patients had pervasively high suicidal thoughts over the course of inpatient visits or showed marked improvements, while perceived burdensomeness predicted which patients would develop suicidal thoughts during their visit. LIMITATIONS The use of single item measures may limit specificity of measurement of suicide risk factors. Hourly, rather than daily measurement used in the current study, may more accurately identify suicide risk. CONCLUSIONS Change in suicidal ideation is associated with changes in a number of psychological risk factors. Regular assessment of interpersonal risk factors may identify warning signs and aid clinical interventions in reducing suicidal thoughts and associated self-injurious behaviours.
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19
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Teismann T, Forkmann T, Glaesmer H. Risikoabschätzung bei suizidalen Patienten: Geht das überhaupt? VERHALTENSTHERAPIE 2019. [DOI: 10.1159/000493887] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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20
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SanSegundo MS, Ferrer-Cascales R, Bellido JH, Bravo MP, Oltra-Cucarella J, Kennedy HG. Prediction of Violence, Suicide Behaviors and Suicide Ideation in a Sample of Institutionalized Offenders With Schizophrenia and Other Psychosis. Front Psychol 2018; 9:1385. [PMID: 30131743 PMCID: PMC6091276 DOI: 10.3389/fpsyg.2018.01385] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 07/17/2018] [Indexed: 11/13/2022] Open
Abstract
This study examined the predictive validity of the Spanish version of the Suicide Risk Assessment Manual (S-RAMM) and the Historical-Clinical-Risk Management-20 (HCR-20) in a sample of violent offenders with schizophrenia and other psychosis, who had committed violent crimes and had been sentenced to compulsory psychiatric treatment by the criminal justice system. Patients were prospectively monitored within the institution for 18 months. During the follow-up period, 25% of offenders were involved in any suicidal behavior including acts of self-harm, suicidal ideation and suicide attempts and 34% were physically or verbally violent. The S-RAMM and HCR-20 risk assessment tools were strongly correlated and were able to predict suicidal behavior and violence with a moderate-large effect size (AUCs = 0.81-0.85; AUCs = 0.78-0.80 respectively). Patients scoring above the mean on the S-RAMM (>20-point cut-off) had a five times increased risk of suicide related events (OR = 5.05, 95% CI = 2.6-9.7) and sevenfold risk of violence in the HCR-20 (>21-point cut-off) (OR = 7.13, 95% CI = 2.0-21.2) than those scoring below the mean. Offenders at high risk for suicide and violence had significantly more suicide attempts (p < 0.001) and more prior sentences for violent crimes (p < 0.001). These results support the use of the S-RAMM and HCR-20 for clinical practice by providing evidence of the utility of these measures for predicting risk for suicidal and violent behavior in mentally disordered offenders.
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Affiliation(s)
| | | | - Jesús H. Bellido
- Department of Psychology, Alicante Forensic Psychiatric Hospital, Alicante, Spain
| | - Mar P. Bravo
- Department of Psychiatry, Institute of Legal Medicine, Alicante, Spain
| | | | - Harry G. Kennedy
- Department of Psychiatry, Trinity College, University of Dublin, Dundrum, Ireland
- Central Mental Hospital, Dublin, Ireland
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21
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Lockertsen Ø, Procter N, Vatnar SKB, Faerden A, Eriksen BMS, Roaldset JO, Varvin S. Screening for risk of violence using service users' self-perceptions: A prospective study from an acute mental health unit. Int J Ment Health Nurs 2018; 27:1055-1065. [PMID: 29171702 DOI: 10.1111/inm.12413] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 11/26/2022]
Abstract
Service users' self-perception of risk has rarely been emphasized in violence risk assessments. A recent review pointed to the importance of a multidisciplinary approach, because different perspectives may provide a deeper and improved understanding of risk assessment. The aim of this study was to investigate service users' perceptions of their own risk of committing violence, using a self-report risk scale, to determine the feasibility and efficacy of this potential violence risk marker during acute mental health hospitalization. All service users admitted to a psychiatric emergency hospital in Norway during one calendar year were included (N = 512). Nearly 80% self-reported no risk or low risk; only seven (1.4%) reported moderate risk or high risk. Service users who reported moderate risk, high risk, don't know, or won't answer were more likely to be violent (OR = 4.65, 95% CI = 2.79-7.74) compared with those who reported no risk or low risk. There was a significant gender interaction with higher OR for women on both univariate and multivariate analyses. Although the OR was higher for women, women's violence rate (11.0%) was almost half that of men (21.8%). For women, sensitivity and specificity were 0.55 and 0.88, respectively; corresponding values for men were 0.40 and 0.80. Inclusion of self-perception of violence risk is the first step towards service users' collaborative involvement in violence prediction; these results indicate that self-perception can contribute to violence risk assessments in acute mental health settings. Findings also indicate that there are gender differences in these assessments.
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Affiliation(s)
- Øyvind Lockertsen
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo and Akershus University of Applied Sciences, Oslo, Norway.,Division of Mental Health and Addiction, Acute Psychiatric Section, Oslo University Hospital, Oslo, Norway
| | - Nicolas Procter
- School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia
| | - Solveig Karin Bø Vatnar
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo and Akershus University of Applied Sciences, Oslo, Norway.,Centre for Research and Education in Forensic Psychiatry, Oslo University Hospital, Oslo, Norway
| | - Ann Faerden
- Division of Mental Health and Addiction, Acute Psychiatric Section, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, Oslo, Norway
| | - Bjørn Magne S Eriksen
- Division of Mental Health and Addiction, Acute Psychiatric Section, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, Oslo, Norway
| | - John Olav Roaldset
- Centre for Research and Education in Forensic Psychiatry, Oslo University Hospital, Oslo, Norway.,Møre & Romsdal Health Trust, Psychiatric Department, Ålesund Hospital, Ålesund, Norway
| | - Sverre Varvin
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo and Akershus University of Applied Sciences, Oslo, Norway
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22
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Lundahl A, Helgesson G, Juth N. Psychiatrists' motives for practising in-patient compulsory care of patients with borderline personality disorder (BPD). INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2018; 58:63-71. [PMID: 29853014 DOI: 10.1016/j.ijlp.2018.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/27/2018] [Accepted: 03/05/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Patients with BPD are often subjected to compulsory care. However, as compulsory care restricts liberty and may have negative effects, it is recommended that it be used sparingly. In this study, we investigate psychiatrists' motives for practising compulsory care of BPD patients. METHOD Semi-structured interviews with twelve Swedish psychiatrists from Stockholm County. These interviews were analysed according to descriptive qualitative analysis. RESULTS The qualitative data from our study resulted in three themes: (1) BPD patients are perceived as difficult: interpersonally, in clinical and legal management, and due to suicide risk; (2) there are medical and non-medical motives for compulsory care of BPD patients, and its consequences can vary; and (3) BPD patients have decision competence and sometimes demand to be taken into compulsory care. CONCLUSION The interviewed psychiatrists' own judgements and values, rather than clinical and legal directions, were decisive in their practice of compulsory care. For the BPD patients, this can result in vast differences in the mental healthcare offered, depending on which individual psychiatrist they encounter. Socio-political expectations and psychiatrists' personal views seem to lead to more compulsory care of BPD patients than is clinically recommended and legally sanctioned.
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Affiliation(s)
- Antoinette Lundahl
- Norra Stockholms Psykiatri (Psychiatry of Northern Stockholm), S:t Görans sjukhus (S:t Görans Hospital), Stockholm, Sweden.
| | - Gert Helgesson
- Stockholm Centre for Healthcare Ethics (CHE), Karolinska Institutet, LIME, 17177 Stockholm, Sweden.
| | - Niklas Juth
- Stockholm Centre for Healthcare Ethics (CHE), Karolinska Institutet, LIME, 17177 Stockholm, Sweden.
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23
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Abstract
SummaryRisk assessment has been widely adopted in mental health settings in the hope of preventing harms such as violence to others and suicide. However, risk assessment in its current form is mainly concerned with the probability of adverse events, and does not address the other component of risk – the extent of the resulting loss. Although assessments of the probability of future harm based on actuarial instruments are generally more accurate than the categorisations made by clinicians, actuarial instruments are of little assistance in clinical decision-making because there is no instrument that can estimate the probability of all the harms associated with mental illness, or estimate the extent of the resulting losses. The inability of instruments to distinguish between the risk of common but less serious harms and comparatively rare catastrophic events is a particular limitation of the value of risk categorisations. We should admit that our ability to assess risk is severely limited, and make clinical decisions in a similar way to those in other areas of medicine – by informed consideration of the potential consequences of treatment and non-treatment.
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24
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Abstract
SummaryAssessment and management of the risk of violence in psychiatry inevitably and appropriately draws on emotionally laden ‘intuitive’ modes of thought, as well as deliberative analytic thinking. This article discusses the concept of ‘intuition’ and proposes a brief set of guidelines, derived from work by the cognitive psychologist Robin Hogarth, by which intuitive thinking may be applied by clinicians when undertaking risk assessment work. The guidelines are: consider the learning structure relevant to the risk assessment task; use your own emotions as a source of data; impose ‘circuit breakers' such as cost–benefit analyses and validated structured risk assessment tools; and use a narrative approach to develop formulations. The guidelines are intended to provide a framework for ongoing reflective practice in assessing and managing risk.
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25
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Abstract
SummaryTaking risks is a fundamental part of the human experience that supports personal growth. Therapeutic risk-taking enables patients to make decisions about their level of safety and to pursue goals. Promoting therapeutic risk-taking can be complex. Professionals can experience tension striving for a balance between the interests of the individual and societal pressures to control risk. This article examines therapeutic risk-taking, recognising the challenges to supporting it in practice and debating how they may be overcome.Learning Objectives• Be able to explain what therapeutic risk-taking is and discuss its application to psychiatric practice• Understand the factors that challenge and enable therapeutic risk-taking in psychiatric practice• Describe the association between therapeutic risk-taking and recovery
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26
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Bhugra D, Tasman A, Pathare S, Priebe S, Smith S, Torous J, Arbuckle MR, Langford A, Alarcón RD, Chiu HFK, First MB, Kay J, Sunkel C, Thapar A, Udomratn P, Baingana FK, Kestel D, Ng RMK, Patel A, Picker LD, McKenzie KJ, Moussaoui D, Muijen M, Bartlett P, Davison S, Exworthy T, Loza N, Rose D, Torales J, Brown M, Christensen H, Firth J, Keshavan M, Li A, Onnela JP, Wykes T, Elkholy H, Kalra G, Lovett KF, Travis MJ, Ventriglio A. The WPA-Lancet Psychiatry Commission on the Future of Psychiatry. Lancet Psychiatry 2017; 4:775-818. [PMID: 28946952 DOI: 10.1016/s2215-0366(17)30333-4] [Citation(s) in RCA: 184] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 07/28/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Dinesh Bhugra
- Department of Health Services and Population Research, King's College London and South London and Maudsley NHS Foundation Trust, London, UK; World Psychiatric Association, Geneva, Switzerland.
| | - Allan Tasman
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA
| | - Soumitra Pathare
- Centre for Mental Health Law and Policy, Indian Law Society, Pune, India
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development, Queen Mary University of London, London, UK
| | - Shubulade Smith
- Department of Forensic and Neurodevelopmental Science, King's College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - John Torous
- Department of Psychiatry and Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Melissa R Arbuckle
- Department of Psychiatry, Columbia University Medical Center, New York, NY, USA; New York State Psychiatric Institute, New York, NY, USA
| | - Alex Langford
- Psychological Medicine Service, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Renato D Alarcón
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN, USA; Department of Psychiatry, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Helen Fung Kum Chiu
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Michael B First
- Department of Psychiatry, Columbia University Medical Center, New York, NY, USA; New York State Psychiatric Institute, New York, NY, USA
| | - Jerald Kay
- Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Charlene Sunkel
- SA Federation for Mental Health, Johannesburg, South Africa; Movement for Global Mental Health, Johannesburg, South Africa
| | - Anita Thapar
- Child & Adolescent Psychiatry Section, Division of Psychological Medicine and Clinical Neuroscience, MRC Centre for Neuropsychiatric Genetics & Genomics, School of Medicine, Cardiff University, Cardiff, UK
| | - Pichet Udomratn
- Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Florence K Baingana
- Mental Health Lead Basic Package of Essential Health Services Cluster, WHO Sierra Leone Country Office, Freetown, Sierra Leone
| | - Dévora Kestel
- Mental Health and Substance Use Unit, Pan American Health Organization/World Health Organization, Washington DC, USA
| | | | - Anita Patel
- Centre for Primary Care & Public Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Livia De Picker
- Collaborative Antwerp Psychiatric Research Institute, University of Antwerp, Antwerp, Belgium
| | - Kwame Julius McKenzie
- Wellesley Institute, Toronto, Ontario, Canada; General Psychiatry and Health Systems, Centre for Addictions and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Driss Moussaoui
- Ibn Rushd University Psychiatric Center, Casablanca, Morocco
| | - Matt Muijen
- Danish Mental Health Association, Copenhagen, Denmark
| | - Peter Bartlett
- School of Law and Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Sophie Davison
- State Forensic Mental Health Service, Department of Health, Clinical Research Centre, Mount Claremont, WA, Australia; School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, WA, Australia
| | - Tim Exworthy
- Department of Forensic and Neurodevelopmental Science, King's College London and South London and Maudsley NHS Foundation Trust, London, UK; Cygnet Healthcare, Stevenage, UK
| | | | - Diana Rose
- Service User Research Enterprise, King's College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - Julio Torales
- Department of Psychiatry, National University of Asunción, San Lorenzo, Paraguay
| | | | - Helen Christensen
- Black Dog Institute, University of New South Wales, Sydney, NSW, Australia
| | - Joseph Firth
- NICM, School of Science and Health, University of Western Sydney, Sydney, NSW, Australia
| | - Matcheri Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ang Li
- Department of Psychology, Beijing Forestry University, Beijing, China
| | - Jukka-Pekka Onnela
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Til Wykes
- Institute of Psychiatry, Psychology & Neuroscience, King's College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - Hussien Elkholy
- World Psychiatric Association, Geneva, Switzerland; Institute of Psychiatry, Neurology and Psychiatry Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Gurvinder Kalra
- Flynn Adult Inpatient Psychiatric Unit, Latrobe Regional Hospital Mental Health Services (LRH-MHS), Traralgon, VIC, Australia; School of Rural Health (La Trobe Valley & West Gippsland), Monash University, VIC, Australia
| | | | - Michael J Travis
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Antonio Ventriglio
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
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Crane MF, Phillips JK, Karin E. "I've Been a Long Time Leaving": The Role of Limited Skill Transferability in Increasing Suicide-Related Cognitions and Behavior in Veterinarians. Suicide Life Threat Behav 2017; 47:309-320. [PMID: 27404267 DOI: 10.1111/sltb.12279] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 05/04/2016] [Indexed: 11/30/2022]
Abstract
Barriers to occupational mobility were investigated to determine whether they increased reported suicide-related cognitions and behavior over 12 months. This was explored in a two-wave longitudinal study. Intention to leave, depression, perceived skill transferability, and suicide-related cognitions and behavior was measured at both time points approximately 12 months apart. Results indicated that when there was a high intention to leave at T1, reported suicide-related cognitions and behavior increased over 12 months only when skill transferability to other professions was perceived to be limited. Findings support the role of limited occupational mobility in suicide-related cognitions and behavior.
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Affiliation(s)
- Monique F Crane
- Department of Psychology, Macquarie University, North Ryde, Sydney, NSW, Australia
| | | | - Eyal Karin
- Department of Psychology, eCentreClinic, Macquarie University, Sydney, NSW, Australia
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28
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Morales S, Barros J, Echávarri O, García F, Osses A, Moya C, Maino MP, Fischman R, Núñez C, Szmulewicz T, Tomicic A. Acute Mental Discomfort Associated with Suicide Behavior in a Clinical Sample of Patients with Affective Disorders: Ascertaining Critical Variables Using Artificial Intelligence Tools. Front Psychiatry 2017; 8:7. [PMID: 28210230 PMCID: PMC5289061 DOI: 10.3389/fpsyt.2017.00007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 01/11/2017] [Indexed: 12/30/2022] Open
Abstract
AIM In efforts to develop reliable methods to detect the likelihood of impending suicidal behaviors, we have proposed the following. OBJECTIVE To gain a deeper understanding of the state of suicide risk by determining the combination of variables that distinguishes between groups with and without suicide risk. METHOD A study involving 707 patients consulting for mental health issues in three health centers in Greater Santiago, Chile. Using 345 variables, an analysis was carried out with artificial intelligence tools, Cross Industry Standard Process for Data Mining processes, and decision tree techniques. The basic algorithm was top-down, and the most suitable division produced by the tree was selected by using the lowest Gini index as a criterion and by looping it until the condition of belonging to the group with suicidal behavior was fulfilled. RESULTS Four trees distinguishing the groups were obtained, of which the elements of one were analyzed in greater detail, since this tree included both clinical and personality variables. This specific tree consists of six nodes without suicide risk and eight nodes with suicide risk (tree decision 01, accuracy 0.674, precision 0.652, recall 0.678, specificity 0.670, F measure 0.665, receiver operating characteristic (ROC) area under the curve (AUC) 73.35%; tree decision 02, accuracy 0.669, precision 0.642, recall 0.694, specificity 0.647, F measure 0.667, ROC AUC 68.91%; tree decision 03, accuracy 0.681, precision 0.675, recall 0.638, specificity 0.721, F measure, 0.656, ROC AUC 65.86%; tree decision 04, accuracy 0.714, precision 0.734, recall 0.628, specificity 0.792, F measure 0.677, ROC AUC 58.85%). CONCLUSION This study defines the interactions among a group of variables associated with suicidal ideation and behavior. By using these variables, it may be possible to create a quick and easy-to-use tool. As such, psychotherapeutic interventions could be designed to mitigate the impact of these variables on the emotional state of individuals, thereby reducing eventual risk of suicide. Such interventions may reinforce psychological well-being, feelings of self-worth, and reasons for living, for each individual in certain groups of patients.
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Affiliation(s)
- Susana Morales
- Facultad de Medicina, Departamento de Psiquiatría, Depression and Suicidality Research Group, Pontificia Universidad Católica de Chile, Santiago, Chile
- Millennium Institute for Research in Depression and Personality (MIDAP), Depression and Suicidality Research Group, Santiago, Chile
| | - Jorge Barros
- Facultad de Medicina, Departamento de Psiquiatría, Depression and Suicidality Research Group, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Orietta Echávarri
- Facultad de Medicina, Departamento de Psiquiatría, Depression and Suicidality Research Group, Pontificia Universidad Católica de Chile, Santiago, Chile
- Millennium Institute for Research in Depression and Personality (MIDAP), Depression and Suicidality Research Group, Santiago, Chile
| | - Fabián García
- Independent researcher, Avenida José Manso de Velasco 6968, Santiago, Chile
| | - Alex Osses
- Independent researcher, Isla Darwin 8726, Santiago, Chile
| | - Claudia Moya
- Millennium Institute for Research in Depression and Personality (MIDAP), Depression and Suicidality Research Group, Santiago, Chile
- School of Nursery, Universidad San Sebastián, Santiago, Chile
| | - María Paz Maino
- Facultad de Medicina, Departamento de Psiquiatría, Depression and Suicidality Research Group, Pontificia Universidad Católica de Chile, Santiago, Chile
- Millennium Institute for Research in Depression and Personality (MIDAP), Depression and Suicidality Research Group, Santiago, Chile
| | - Ronit Fischman
- Millennium Institute for Research in Depression and Personality (MIDAP), Depression and Suicidality Research Group, Santiago, Chile
| | - Catalina Núñez
- Millennium Institute for Research in Depression and Personality (MIDAP), Depression and Suicidality Research Group, Santiago, Chile
| | - Tita Szmulewicz
- Facultad de Medicina, Departamento de Psiquiatría, Depression and Suicidality Research Group, Pontificia Universidad Católica de Chile, Santiago, Chile
- Millennium Institute for Research in Depression and Personality (MIDAP), Depression and Suicidality Research Group, Santiago, Chile
| | - Alemka Tomicic
- Millennium Institute for Research in Depression and Personality (MIDAP), Depression and Suicidality Research Group, Santiago, Chile
- School of Psychology, Universidad Diego Portales, Santiago, Chile
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Ryan CJ, Callaghan S. The impact on clinical practice of the 2015 reforms to the New South Wales Mental Health Act. Australas Psychiatry 2017; 25:43-47. [PMID: 27558219 DOI: 10.1177/1039856216663738] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The Mental Health Act 2007 (NSW) ( MHA) was recently reformed in light of the recovery movement and the United Nations Convention on the Rights of Persons with Disabilities. We analyse the changes and describe the impact that these reforms should have upon clinical practice. CONCLUSIONS The principles of care and treatment added to the MHA place a strong onus on clinicians to monitor patients' decision-making capacity, institute a supported decision-making model and obtain consent to any treatment proposed. Patients competently refusing treatment should only be subject to involuntary treatment in extraordinary circumstances. Even when patients incompetently refuse treatment, clinicians must make every effort reasonably practicable to tailor management plans to take account of any views and preferences expressed by them or made known via friends, family or advance statements.
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Affiliation(s)
- Christopher James Ryan
- Clinical Associate Professor and Consultation-Liaison Psychiatrist, Discipline of Psychiatry and the Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, NSW, Australia
| | - Sascha Callaghan
- Lecturer, Sydney Law School and the Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, NSW, Australia
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Affiliation(s)
- Matthew Large
- School of PsychiatryUniversity of New South WalesSydneyNSWAustralia
| | - Olav Nielssen
- Faculty of Medicine and Health SciencesMacquarie UniversityNorth RydeNSWAustralia
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Hagen J, Hjelmeland H, Knizek BL. Relational Principles in the Care of Suicidal Inpatients: Experiences of Therapists and Mental Health Nurses. Issues Ment Health Nurs 2017; 38:99-106. [PMID: 27901635 DOI: 10.1080/01612840.2016.1246631] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This study explored and compared therapists' and mental health nurses' experiences of caring for suicidal inpatients in light of ethics of care and ethics of justice. Analysis of interview data from eight therapists and eight mental health nurses indicates two approaches: "connection and care" and "duty and control," reflecting aspects of both ethical perspectives. There are some differences between the two professional groups, and sometimes there might be conflicts between the two approaches and ethical perspectives. Clinical practice is increasingly shaped by standardization and guidelines, and it is important to promote professionals' efforts to provide relational-emotional care for suicidal patients.
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Affiliation(s)
- Julia Hagen
- a Norwegian University of Science and Technology (NTNU) , Department of Social Work and Health Science , Trondheim , Norway
| | - Heidi Hjelmeland
- a Norwegian University of Science and Technology (NTNU) , Department of Social Work and Health Science , Trondheim , Norway
| | - Birthe Loa Knizek
- b Norwegian University of Science and Technology (NTNU) , Department of Applied Social Science , Trondheim , Norway
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The promise and the reality: a mental health workforce perspective on technology-enhanced youth mental health service delivery. BMC Health Serv Res 2016; 16:562. [PMID: 27724951 PMCID: PMC5057226 DOI: 10.1186/s12913-016-1790-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 09/24/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Digital technologies show promise for reversing poor engagement of youth (16-24 years) with mental health services. In particular, mobile and internet based applications with communication capabilities can augment face-to-face mental health service provision. The literature in this field, however, fails to adequately capture the perspectives of the youth mental health workforce regarding utility and acceptability of technology for this purpose. METHODS This paper describes results of in-depth qualitative data drawn from various stakeholders involved in provision of youth mental health services in one Australian rural region. Data were obtained using focus groups and semi-structured interviews with regional youth mental health clinicians, youth workers and support/management staff (n = 4 focus groups; n = 8 interviews) and analysed via inductive thematic analysis. RESULTS Results question the acceptability of technology to engage clients within youth mental health services. Six main themes were identified: young people in a digital age, personal connection, power and vulnerability, professional identity, individual factors and organisational legitimacy. CONCLUSIONS These findings deepen the understanding of risks and challenges faced when adopting new technologies in mental healthcare. Recommendations for technology design and implementation in mental health services are made.
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Hawgood J, De Leo D. Suicide Prediction - A Shift in Paradigm Is Needed. CRISIS 2016; 37:251-255. [PMID: 27809591 DOI: 10.1027/0227-5910/a000440] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Jacinta Hawgood
- 1 Australian Institute for Suicide Research and Prevention (AISRAP) and WHO Collaborating Centre for Research and Training in Suicide Prevention, Griffith University, Brisbane, Australia
| | - Diego De Leo
- 1 Australian Institute for Suicide Research and Prevention (AISRAP) and WHO Collaborating Centre for Research and Training in Suicide Prevention, Griffith University, Brisbane, Australia
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Abstract
OBJECTIVES Existing research on Community Treatment Orders (CTOs) questions what purposes they serve, for whom and for how long. This study aimed to identify demographics of the CTO population, differences between individuals who require short CTOs from those who require repeat CTO and clinician-determined factors which influence these decisions. METHODS Using a cross-sectional snapshot method, 301detailed audits were analysed for frequencies and relationships between variables. RESULTS People on CTOs (n = 301) comprised 9% of the community mental health population (n = 3268); 21% (n = 62) having it be their first CTO, 50% (n = 149) on repeat CTOs (continuous) and 29% (n = 85) on second episode or more of CTOs (non-continuous). There were 82% (n = 231) of people on a CTO who had a primary diagnosis of schizophrenia. There was a higher occurrence of males with co-existing factors of aggression and current substance misuse. Age had a relationship with length of actual and predicted CTOs. CONCLUSIONS Men of middle age, with a diagnosis of schizophrenia, a history of aggression, current substance misuse and reported previous CTO efficacy are the primary individuals predicted to require ongoing CTOs. Improving CTO efficacy should focus on providing targeted intervention for this group and a closer analysis of the use of CTOs in other groups.
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Affiliation(s)
- Sophie Isobel
- Clinical Nurse Consultant, Quality and Research, Mental Health, Sydney Local Health District, Sydney, NSW, Australia
| | - Paul Clenaghan
- Community and Partnerships Manager, Mental Health, Sydney Local Health District, Sydney, NSW, Australia
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Lawn S, Delany T, Pulvirenti M, Smith A, McMillan J. Examining the use of metaphors to understand the experience of community treatment orders for patients and mental health workers. BMC Psychiatry 2016; 16:82. [PMID: 27030136 PMCID: PMC4815077 DOI: 10.1186/s12888-016-0791-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community Treatment Orders (CTOs) are often complex because of the ethical tensions created by an intervention that aims at promoting the patient's good through an inherently coercive process. There is limited research that examines the complexity of CTOs and how patients on CTOs and workers administering CTOs make sense of their experiences. METHODS The study involved in-depth interviews with 8 patients on CTOs and 10 community mental health workers in South Australia, to explore how they constructed their experiences of CTOs. Critical discourse analysis (CDA) was used to analyse the data, supported by NVIVO software. RESULTS Analysis of the interviews revealed that patients and workers experienced the CTO process as multi-dimensional, including some positive as well as more negative constructions. The positive metaphor of CTOs as a safety net is described, followed by a more detailed description of the metaphors of power and control as the dominant themes, with five sub-themes of the CTO as control, wake-up, punishment, surveillance, and tranquiliser. DISCUSSION Metaphors are a way that mental health patients and mental health workers articulate the nature of CTOs. The language used to construct these metaphors was quite different, with patients overwhelmingly experiencing and perceiving CTOs as coercive (that is, punishing, controlling and scrutinizing), whereas workers tended to perceive them as necessary, beneficial and supportive, despite their coerciveness. CONCLUSIONS By acknowledging the role of metaphors in these patients' lives, workers could enhance opportunities to engage these patients in more meaningful dialogue about their personal experiences as an alternative to practice predominantly focused on risk. Such a dialogue could enhance workers' reflection on their work and promote recovery-based practice. More understanding of how to promote autonomy, capacity and supported decision-making, and how to address the impacts of coercion within care, is needed.
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Affiliation(s)
- Sharon Lawn
- Flinders Human Behaviour and Health Research Unit, Department of Psychiatry, Flinders University, Room 4 T306 Margaret Tobin Centre, PO Box 2100, Adelaide, South Australia, 5001, Australia.
| | - Toni Delany
- Southgate Institute for Health, Society and Equity, Flinders University, Adelaide, South Australia, Australia
| | | | - Ann Smith
- C/o Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, Australia
| | - John McMillan
- The Bioethics Centre, University of Otago, Dunedin, New Zealand
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Abstract
OBJECTIVES The aim of this study was to undertake a systematic review on violence risk assessment instruments used for psychiatric patients in China. METHODS A systematic search was conducted from 1980 until 2014 to identify studies that used psychometric tools or structured instruments to assess aggression and violence risk. Information from primary studies was extracted, including demographic characteristics of the samples used, study design characteristics, and reliability and validity estimates. RESULTS A total of 30 primary studies were identified that investigated aggression or violence; 6 reported on tools assessing aggression while an additional 24 studies reported on structured instruments designed to predict violence. Although measures of reliability were typically good, estimates of predictive validity were mostly in the range of poor to moderate, with only 1 study finding good validity. These estimates were typically lower than that found in previous work for Western samples. CONCLUSION There is currently little evidence to support the use of current violence risk assessment instruments in psychiatric patients in China. Developing more accurate and scalable approaches are research priorities.
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Affiliation(s)
- Jiansong Zhou
- Mental Health Institute of The Second Xiangya Hospital, Hunan Province Technology Institute of Psychiatry, Key Laboratory of Psychiatry and Mental Health of Hunan Province, Central South University, Changsha, China
| | - Katrina Witt
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Yutao Xiang
- Unit of Psychiatry, Faculty of Health Sciences, University of Macau, Macau, China
| | - Xiaomin Zhu
- Mental Health Institute of The Second Xiangya Hospital, Hunan Province Technology Institute of Psychiatry, Key Laboratory of Psychiatry and Mental Health of Hunan Province, Central South University, Changsha, China
| | - Xiaoping Wang
- Mental Health Institute of The Second Xiangya Hospital, Hunan Province Technology Institute of Psychiatry, Key Laboratory of Psychiatry and Mental Health of Hunan Province, Central South University, Changsha, China
| | - Seena Fazel
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
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Clancy L, Happell B, Moxham L. Perception of risk for older people living with a mental illness: Balancing uncertainty. Int J Ment Health Nurs 2015; 24:577-86. [PMID: 26514097 DOI: 10.1111/inm.12175] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 07/22/2015] [Accepted: 08/10/2015] [Indexed: 12/31/2022]
Abstract
Risk is commonly defined as a negative threat which needs to be controlled and mitigated; as a concept, it takes high priority in contemporary mental health services. Health-care organizations and clinicians are now required to use levels of risk as a benchmark for clinical decision-making. However, perceptions of risk change according to the lens through which it is viewed. A qualitative, exploratory research study was undertaken in an aged persons' mental health programme in Victoria, Australia, to explore the notion of risk from the multiple perspectives of service providers and consumers. Data were obtained through in-depth interviews, and analysis was based on the framework of Ritchie and Spencer. Balancing uncertainty emerged as a major theme, and comprised two subthemes: (i) complexity of risk from the perspective of providers of services; and (ii) complexity of safety from the perspectives of recipients of services. These differences emphasize a significant disjuncture between perceptions of risk and the potential for the individual needs and concerns of consumers to be subsumed under broader organizational issues. The uncertainty this tension highlights suggests the need to reconceptualize risk, incorporating the views and experiences of all stakeholders, particularly consumers and carers, to enhance recovery-oriented services and facilitate consumer participation within mental health services.
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Affiliation(s)
- Leonie Clancy
- Gold Coast Mental Health Services, Gold Coast, Queensland, Australia
| | - Brenda Happell
- Synergy, Nursing and Midwifery Research Centre, University of Canberra, and ACT Health, Canberra, ACT, Australia
| | - Lorna Moxham
- School of Nursing, Midwifery and Indigenous Health, University of Wollongong, Wollongong, NSW, Australia
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Lawn S, Delany T, Pulvirenti M, Smith A, McMillan J. A qualitative study examining the presence and consequences of moral framings in patients' and mental health workers' experiences of community treatment orders. BMC Psychiatry 2015; 15:274. [PMID: 26541546 PMCID: PMC4635603 DOI: 10.1186/s12888-015-0653-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 10/19/2015] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Mental health recovery involves acknowledging the importance of building the person's capacity for agency. This might be particularly important for patients on community treatment orders (CTOs - which involve enforced treatment for their mental illness), given limited international evidence for their effectiveness and underlying concerns about the use of coercion by workers and systems of care towards this population of people with mental illness. METHODS This study sought to understand how the meaning of CTOs is constructed and experienced, from the perspective of patients on CTOs and workers directly administering CTOs. Qualitative interviews were conducted with South Australian community mental health patients (n = 8) and mental health workers (n = 10) in 2013-14. During thematic analysis of data, assisted by NVIVO software, the researchers were struck by the language used by both groups of participants and so undertook an examination of the moral framings apparent within the data. RESULTS Moral framing was apparent in participants' constructions and evaluations of the CTO experience as positive, negative or justifiable. Most patient participants appeared to use moral framing to: try to understand why they were placed on a CTO; make sense of the experience of being on a CTO; and convey the lessons they have learnt. Worker participants appeared to use moral framing to justify the imposition of care. Empathy was part of this, as was patients' positive right to services and treatment, which they believed would only occur for these patients via a CTO. Workers positioned themselves as trying to put themselves in the patients' shoes as a way of acting virtuously towards them, softening the coercive stick approach. Four themes were identified: explicit moral framing; best interests of the patient; lessons learned by the patient; and, empathy. CONCLUSIONS Experiences of CTOs are multi-layered, and depend critically upon empathy and reflection on the relationship between what is done and how it is done. This includes explicit examination of the moral framing present in everyday interactions between mental health workers and their patients in order to overcome the paradox of the moral grey zone between caring and controlling. It suggests a need for workers to receive ongoing empathy training.
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Affiliation(s)
- Sharon Lawn
- Flinders Human Behaviour and Health Research Unit, Department of Psychiatry, Flinders University, Flinders Drive, Adelaide, 5042, Australia.
| | - Toni Delany
- Southgate Institute for Health, Society and Equity, Flinders University, Flinders Drive, Adelaide, 5042 Australia
| | - Mariastella Pulvirenti
- Discipline of Public Health, Flinders University, Flinders Drive, Adelaide, 5042 Australia
| | | | - John McMillan
- The Bioethics Centre, University of Otago, Frederick Street, Dunedin, 9016 New Zealand
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Ryan CJ, Callaghan S, Large M. The importance of least restrictive care: the clinical implications of a recent High Court decision on negligence. Australas Psychiatry 2015; 23:415-7. [PMID: 26104773 DOI: 10.1177/1039856215590025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This paper aims to explain the meaning and implications for practice of the High Court of Australia's finding in the negligence case, Hunter and New England Local Health District v McKenna [2014] HCA 44. METHOD The facts of the case and the law of negligence are reviewed before reporting the Court's decision. RESULTS The High Court found that the obligation upon doctors to provide the least restrictive option for care that was imposed by the, then applicable, Mental Health Act 1990 (NSW) was inconsistent with an obligation that might otherwise be imposed by a common law duty to have regard to the interests of those with whom a psychiatric patient may come into contact if not detained. CONCLUSIONS The Court's finding underlines the importance of clinicians documenting their clinical reasoning around why their negotiated management plan was the option least restrictive of the patient's freedom and most protective of his or her human rights.
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Affiliation(s)
- Christopher James Ryan
- Consultation-Liaison Psychiatrist and Clinical Senior Lecturer, Discipline of Psychiatry and the Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, NSW, Australia
| | - Sascha Callaghan
- Lecturer, Sydney Law School and the Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, NSW, Australia
| | - Matthew Large
- Conjoint Senior Lecturer, School of Psychiatry, University of NSW, Sydney, NSW, Australia
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40
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Decision-Making, Legal Capacity and Neuroscience: Implications for Mental Health Laws. LAWS 2015. [DOI: 10.3390/laws4020125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Tran T, Nguyen TD, Phung D, Venkatesh S. Learning vector representation of medical objects via EMR-driven nonnegative restricted Boltzmann machines (eNRBM). J Biomed Inform 2015; 54:96-105. [DOI: 10.1016/j.jbi.2015.01.012] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 01/19/2015] [Accepted: 01/26/2015] [Indexed: 11/24/2022]
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Wand T, Isobel S, Derrick K. Surveying clinician perceptions of risk assessment and management practices in mental health service provision. Australas Psychiatry 2015; 23:147-53. [PMID: 25688130 DOI: 10.1177/1039856214568227] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study aimed to survey multidisciplinary mental health staff on their perceptions of risk assessment and management practices in a local health district in Sydney. METHODS The research team developed the risk assessment and management survey (RAMS) which was distributed to staff across the district from November 2013 to January 2014. RESULTS A total of 340 RAMS were distributed and 164 were returned (48% response rate). There was considerable agreement that risk assessment and management is essential to maintaining safety and delivering good mental health care, and respondents reported high levels of confidence in their judgement when carrying out such practices. Respondents identified organisational pressure in relation to risk assessment and management but also felt supported. However, 65% of respondents considered that there 'is good evidence that risk assessment and management practices are effective in reducing risk in mental health care', when this is not the case. CONCLUSION The confidence that clinicians placed in risk assessment and management practices (despite an absence of evidence) is disconcerting. Given the dominance of risk assessment and management, health services mandating such practices have a duty to inform employees of the current evidence base for this approach in reducing risk.
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Affiliation(s)
- Timothy Wand
- Associate Professor, University of Sydney and Sydney Local Health District, Concord, NSW, and; Nurse Practitioner, Mental Health Liaison, Emergency Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Sophie Isobel
- Grad Cert, Child and Family Health, Clinical Nurse Consultant, Quality and Research, Sydney Local Health District, Concord, NSW, Australia
| | - Kate Derrick
- Grad Cert, Mental Health, Clinical Nurse Consultant, Mental Health Liaison, Emergency Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Wilson MP, Minassian A, Ronquillo L, Vilke G. Wilson reply to Ryan. J Emerg Med 2015; 48:336. [PMID: 25456779 DOI: 10.1016/j.jemermed.2014.09.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 09/30/2014] [Indexed: 06/04/2023]
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44
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Ryan CJ, Large MM. Preventing Suicide in the Emergency Department. J Emerg Med 2015; 48:335-6. [DOI: 10.1016/j.jemermed.2013.08.154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 08/24/2013] [Indexed: 10/24/2022]
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Large MM, Ryan CJ. 'Heed not the oracle': risk assessment has no role in preventing suicide in schizophrenia. Acta Psychiatr Scand 2014; 130:415-7. [PMID: 25230911 DOI: 10.1111/acps.12333] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M M Large
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.
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Silverman MM, Berman AL. Training for suicide risk assessment and suicide risk formulation. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2014; 38:526-37. [PMID: 25059537 DOI: 10.1007/s40596-014-0200-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 07/02/2014] [Indexed: 05/13/2023]
Abstract
Suicide and suicidal behaviors are highly associated with psychiatric disorders. Psychiatrists have significant opportunities to identify at-risk individuals and offer treatment to reduce that risk. Although a suicide risk assessment (SRA) is a core competency requirement, many lack the requisite training and skills to appropriately assess for suicide risk. Moreover, the standard of care requires psychiatrists to foresee the possibility that a patient might engage in suicidal behavior, hence to conduct a suicide risk formulation (SRF) sufficient to guide triage and treatment planning. An SRA gathers data about observable and reported symptoms, behaviors, and historical factors that are associated with suicide risk and protection, ascertained by way of psychiatric interview; collateral information from family, friends, and medical records; and psychometric scales and/or screening tools. Based on data collected via an SRA, an SRF is a process whereby the psychiatrist forms a judgment about a patient's foreseeable risk of suicidal behavior in order to inform triage decisions, safety and treatment plans, and interventions to reduce risk. This paper addresses the need for a revised training model in SRA and SRF, and proposes a model of training that incorporates the acquisition of skills, relying heavily on case application exercises.
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Disturbing findings about the risk of suicide and psychiatric hospitals. Soc Psychiatry Psychiatr Epidemiol 2014; 49:1353-5. [PMID: 25028199 DOI: 10.1007/s00127-014-0912-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Accepted: 05/26/2014] [Indexed: 10/25/2022]
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48
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Clarke LL, Clarke T. Realizing nursing: a multimodal biopsychopharmacosocial approach to psychiatric nursing. J Psychiatr Ment Health Nurs 2014; 21:564-71. [PMID: 24784837 DOI: 10.1111/jpm.12159] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2014] [Indexed: 11/28/2022]
Abstract
The biological and psychosocial components of health, illness and treatment are well recognized. In addition, pharmacological interventions interact with both these components regarding health and illness; all components are potentially modifiable. A better understanding of these interactions on the course of illness, especially at the interface between illness and treatment, is needed to guide effective clinical and psychiatric nursing interventions. To this end, a multimodal biopsychopharmacosocial approach to assessment, formulation, care planning and implementation by psychiatric nurses is proposed. It is argued that a biopsychopharmacosocial approach, including a multimodal functional element, provides a person-centred, responsive and responsible basis for a comprehensive approach to practice. The use of this approach will improve intervention outcomes and contribute to the ongoing development of psychiatric nursing practice. It is suggested that, in part, this will be achieved through innovative teaching methods delivered by 'expert nurses' and clinical academics.
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Affiliation(s)
- L L Clarke
- Mental Health/Intellectual Disability, King's College London, London, UK
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Large MM, Ryan CJ. Suicide risk categorisation of psychiatric inpatients: what it might mean and why it is of no use. Australas Psychiatry 2014; 22:390-392. [PMID: 24871970 DOI: 10.1177/1039856214537128] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Existing suicide risk assessment policies and guidelines do not specify whether the risk to be assessed is absolute, relative to other patients or relative to the same patient at an earlier time. METHODS We utilised the results of a recent study of inpatient suicide to explore the implications of each of the above types of risk. RESULTS No interpretation of the current requirements for suicide risk categorisation of psychiatric inpatients can lead to information that might usefully guide clinical decision-making. CONCLUSIONS Policies and guidelines requiring suicide risk categorisation of inpatients should be withdrawn. The College should delete the mandatory entrustable professional activity requiring risk assessment.
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Affiliation(s)
- Matthew M Large
- Department of Mental Health Services, Prince of Wales Hospital, and with the School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
| | - Christopher J Ryan
- Discipline of Psychiatry and the Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, NSW, Australia
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50
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Berman AL, Silverman MM. Suicide risk assessment and risk formulation part II: Suicide risk formulation and the determination of levels of risk. Suicide Life Threat Behav 2014; 44:432-43. [PMID: 24286521 DOI: 10.1111/sltb.12067] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/03/2013] [Indexed: 11/28/2022]
Abstract
The suicide risk formulation (SRF) is dependent on the data gathered in the suicide risk assessment. The SRF assigns a level of suicide risk that is intended to inform decisions about triage, treatment, management, and preventive interventions. However, there is little published about how to stratify and formulate suicide risk, what are the criteria for assigning levels of risk, and how triage and treatment decisions are correlated with levels of risk. The salient clinical issues that define an SRF are reviewed and modeling is suggested for an SRF that might guide clinical researchers toward the refinement of an SRF process.
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Affiliation(s)
- Alan L Berman
- American Association of Suicidology, Washington, DC, USA
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