CG

Comprehensive Study Notes: Risk Assessment in Mental Health

Objectives

  • Define risk and risk assessment in mental health
  • Identify what is considered in risk assessment
  • Review available tools and their purpose
  • Understand how risk assessment informs interventions and planning

What is Risk?

  • The possibility of an adverse outcome within a given time frame
    • Elements: Possibility, Adverse outcome, Time (imminency)
  • Risk domains in mental health include risks to self, others, and property:
    • To self: suicide, deliberate self-harm; falls; physical health; dignity
    • To others: aggression; property damage; intimidation
    • From others: exploitation; violence from others

Risks in Mental Health

  • Aggression: verbal, physical, towards property
  • Self-destructive behaviors: suicide, self-harm
  • Absconding (leaving a service without permission)
  • Falls
  • Risk to physical health
  • Dignity and Sexual Safety

Risk Assessment

  • Historically based on clinical judgement
  • Historically relied on clinical assessment tools
  • Now tends to use a combination of clinical judgement and tools

What is Risk Assessment?

  • Analyzing the potential outcome of a certain behaviour
  • We cannot make precise predictions
  • We cannot eliminate all risk
  • Distinctions:
    • Tolerability vs Acceptability
  • Risk management involves interventions to reduce risk

Dynamic vs Static Risks

  • Static risks: historical or slowly changing characteristics
    • Examples: Gender, Age, Family history, Past history/historical risk behaviours, History of substance abuse
  • Dynamic risks: risks that can change over time
    • Examples: Suicidal ideation, plan, intent; level of distress (emotional state); substance use/intoxication; illness symptoms; recent life events (e.g., job loss, role loss)

Risk Indicators

  • Recency
  • Immediacy / impulsivity
  • Severity
  • Patterns
  • Intent
  • Frequency
  • Warning signs
  • Plan

Suicide Risk (Mental State Examination) – Static vs Dynamic Factors

  • Static Factors:
    • Gender, Age, History, Protective factors
  • Dynamic Factors:
    • Suicidal ideation, Plan, Intent, Access to Means, Protective factors, Intoxication

Self-Harm Risk – Psychological and Physical Signs

  • Psychological signs:
    • Dramatic mood changes
    • Sleep and/or eating pattern changes
    • Social withdrawal
    • Loss of interest/pleasure in activities
    • Hiding or washing own clothes
    • Avoiding exposing arms or legs
    • Drop in work or school performance
    • Strange/unusual excuses for injuries
  • Physical signs:
    • Injuries: scratches, cigarette burns, bruises, cuts
    • Physical complaints: headaches, stomach pains
    • Wearing clothing inappropriate for weather (e.g., long sleeves)
    • Hiding objects: razor blades, lighters in unusual places

Risk of Violence

  • STATIC FACTORS:
    • Gender, Age, History, Criminal charges – violence, Diagnoses (e.g., antisocial personality disorder), History of family violence
  • DYNAMIC FACTORS:
    • Anger, Impulsivity, Intoxication, Pro-violence attitudes, Symptoms of illness, Carrying weapons
  • PROTECTIVE FACTORS:
    • Prosocial involvement, Strong social supports, Positive attitude toward intervention/authority, Resilient personality traits

Absconding Risk

  • Leaving a mental health service without permission
  • May indicate risk
  • Risk factors include: history, treatment refusal, environmental factors, illness symptoms, desire to leave
  • Approach: explore past reasons to address issues that may arise

Vulnerability

  • Self-neglect
  • Others taking advantage (economic, sexual)
  • Risk factors:
    • History of trauma/abuse, History of family violence
    • Cognitive impairment / disability
    • Gender, Age
    • Lack of social supports, Sexual disinhibition, Impaired interpersonal boundaries
    • Homelessness, Impaired decision making

Risk Assessment Tools

  • Clinical Risk Assessment and Management – CRAMM
    • General Vulnerability factors and dynamic risk domains
    • 3 points of ID checked
    • Y/NU/Unknown comments (static vs dynamic)
    • Specific domains included: Sexual vulnerability, Childhood abuse, Exploitation, Self-neglect, Medication issues, Physical illness impacting mental health, Infectious diseases, Homelessness, Driving risk, Transition of care, etc.
  • Dynamic Risk domains in CRAMM include:
    • Suicide (expressed ideas, plan, intent, distress, hopelessness, coping)
    • Self Harm (actual thoughts or actions)
    • Risk to Others (actual thoughts/acts, access to weapons, homicidal ideation, protection of children, etc.)
    • Falls Risk (screen and assess; refer for falls prevention)
    • Nutrition Risk (weight, BMI, diabetes, recent weight change, diet/food intake)
  • Static Risk in CRAMM includes:
    • Prior attempts, family history, major psychiatric diagnosis, psychosis, relationship status, job loss, etc.

Mental Health Community Falls Assessment (FRAME)

  • Use when falls risk identified or changes in risk
  • Components include:
    • Consumer risk factors (unsteady gait, impaired vision, medical conditions, dizziness, polypharmacy, movements, etc.)
    • Action Plan (injury concern, immediate medical review, GP referral, falls clinic referral, footwear, carer involvement)
    • Situational risk factors (environment, distractions, etc.)
    • Environmental risk factors (footwear, mobility equipment, need for assistance, etc.)
    • ID checks and clinical notes

Falls Risk Assessment Tool (FRAT)

  • FRAT purpose: Falls risk assessment in care settings
  • PART 1: FALLS RISK STATUS
    • RECENT FALLS: none in last 12 months; 1+ in last 3–12 months; 1+ in last 3 months
    • RISK FACTOR: scored based on falls history, recent falls, etc.
    • MEDICATIONS: sedatives, antidepressants, anti-Parkinson’s, diuretics, antihypertensives, hypnotics
    • PSYCHOLOGICAL: anxiety, depression, cooperation, insight, or judgment regarding mobility
    • COGNITIVE STATUS: AMTS score categories (9-10/10, 7-8, 5-6, 4 or less)
  • PART 2: RISK FACTOR CHECKLIST
    • Visual, Mobility, Transfers, Behaviours, ADLs, Environment, Nutrition, Continence, Other factors
  • PART 3: ACTION PLAN
    • List problem, interventions/referrals, plan review, risk status (LOW/MEDIUM/HIGH)
  • RISK SCORE interpretation:
    • Low Risk: 5–11
    • Medium Risk: 12–15
    • High Risk: 16–20
    • Note: Automatic High Risk status if ticked; commence fall alert when HIGH

Nutrition Risk Screen (CRAMM)

  • Inputs: weight, height, BMI
  • Assess: current GP management, newly diagnosed/unstable diabetes, limited nutrition or recent alcohol/drug history, weight loss in last 3 months, BMI < 20
  • Action: refer to GP/dietitian if high risk; community residential refers to GP

Static Suicide, Self-Harm, Risk History, and Risk to Others (CRAMM outline)

  • STATIC SUICIDE factors:
    • Previous attempts (number and lethality), family history, major psychiatric diagnosis (including first episode), psychosis, serious medical condition, relationship status changes, job loss/retirement/role loss
  • SELF HARM factors:
    • History of self-harm
  • RISK TO OTHERS factors:
    • Previous violence, weapon use, history of police charges or violent offences, predatory behaviour
    • Verbal aggression/intimidating behaviour, substance use, intervention orders
    • Sexual offences, etc.

Mental Health Sexual Safety Assessment

  • Purpose: identify consumer risk related to sexual safety on inpatient units
  • References: guidelines stress duty of care to protect patients and discourage inappropriate sexual activity in treatment settings
  • Risk profile includes historical factors, current concerns, and potential for unsafe sexual behaviour
  • Flags for high risk include:
    • History of sexual offending, sexual disinhibition, intoxication, trafficking, exploitation, exposure to trauma
    • Current intent to have sexual relations, minimal insight, non-consent to treatment in presence of risk factors
  • If YES to high-risk indicators: consumer must be assessed as overall HIGH level of sexual risk and placed in ICA (intensive care area)
  • Sexual safety orientation checklist covers: informing patients about restrictions, privacy, reporting procedures, and how to report concerns
  • Action plan to minimize risk includes individualized interventions (e.g., same-gender contact, psychology referral, sexual health follow-up, CASA referrals)
  • Documentation and designation (bed location, ICA status) are part of the risk management records

Management Plans and Safety Planning

  • Safety Planning components:
    • Early warning signs
    • Coping strategies
    • Contacts to call (family, friends, supports) with numbers
    • Professionals to call (include numbers)
    • Goals / reasons to live / protective factors
    • Environment safety checks
    • Clear steps on where to go if not safe

Conclusions

  • Follow organisational policies and procedures
  • Risk documentation is a legal document and should be accurate and complete
  • Risk assessment is part of a broader assessment framework
  • Risk is dynamic and requires regular review
  • Combine clinical skill/judgement with risk assessment tools for best practice

References (illustrative, not exhaustive)

  • Australian Nursing and Midwifery Foundation. (2018). Education. Mental Health Triage and Assessing Risk. Australian Nursing and Midwifery Journal, May 2018, Vol. 25, No. 10
  • Blumenthal, S., Wood, H., & Williams, A. (2018). Assessing risk: a relational approach. Routledge: Abingdon
  • Briner, M., & Manser, T. (2013). Clinical risk management in mental health: a qualitative study of main risks and related organizational management practices. BMC Health Services Research 2013, 13:44
  • Elder, R., Evans, K., & Nizette, D. (2017). Psychiatric and Mental Health Nursing (4th ed.). Elsevier: Australia
  • Jansson, L., & Hällgren Graneheim, U. (2018). Nurses' Experiences of Assessing Suicide Risk in Specialised Mental Health Outpatient Care in Rural Areas. Issues in Mental Health Nursing, 39:7, 554-560
  • Haines et al. (2018). Assessing Protective Factors for Violence Risk in U.K. General Mental Health Services. International Journal of Offender Therapy and Comparative Criminology, 62(12), 3965–3983
  • Higgins et al. (2015). There is more to risk and safety planning than dramatic risks: Mental health nurses’ risk assessment and safety-management practice. International Journal of Mental Health Nursing, 25(2), 159–176
  • Racine et al. (2023). Utilization of the Fordham Risk Screening Tool for Violence Risk Assessment in an Emergency Department. Acad Emerg Med, 30, 927–934
  • FRAT resources: Mental Health falls risk assessment tools (FRAME) and FRAT guidelines/pack
  • CRAMM – Clinical Risk Assessment and Management documentation and practice guidelines