Chapter 35Risk Assessment: Self, Others, Children, and Property

• We are not in the practice of predicting individual risk of violence or suicide – use a risk stratification approach. Risk is not predicting who is going to do what, but looking at likelihood of harm – where danger is an unacceptable risk of harm.
• Accuracy vs. Specificity of Predictions: If definition of what you are predicting expands, you are more likely to be correct.
• Infrequent events (e.g. murder) intrinsically difficult to predict, vs. higher baseline rates (e.g. intimate partner violence).
• Time Frame of Risk: Are you considering risk in the next week, next year? Shorter time frame of concern ↓ risk assessed.

• Risk Assessment: Assert an individual has specific characteristics associated with a probability of danger (to self or others) based on risk stratification, which may be high enough to warrant intervening to ↓ risk. Risk assessment tools help clinicians to perform this work in a systematic way to inform management decisions.
• Certification Process: A legal judgment based on social policy, based on our responsibility as clinicians to protect the public. This brings into tension:
  • Medicine’s Erring on the Side of Caution: When in doubt, admit – better to be safe than sorry.
  • Law’s Erring on the Side of Caution: When in doubt, acquit – better to go free than to falsely imprison.
• Performing Risk Assessments: Difficult to do, but clinicians are expected to establish some idea of patient’s risk to:
  • Self – including self-harm, self-neglect or suicide.
  • Others – including violent assault, sexual assault, stalking, and harassment.
  • Children – including physical abuse, sexual abuse, emotional abuse, neglect, and deprivation.
  • Property – including arson and physical property destruction.

• Failing to incorporate environmental info: If patient 1 has a supportive community and is working at a job of their own volition, and patient 2 does not have this supportive environment, all things being equal, patient 1 should have a lower risk.
• Selective Risk Aversion: We over-predict risk by 40-95%, but we also tend to underestimate violence e.g. against women.
• We ask about SI but not HI: We tend to consistently ask about suicidal ideation, but a history of violence is also important to assess.

• Medportal eLearning Course Modules (requires Medportal Login): Assessment of Suicide Risk.
• Archived Lecture: Suicide Risk Assessment (requires Medportal Login)
• Archived Lecture: Violence Risk Assessment (requires Medportal Login)
• Archived Lecture: How to determine if your patient is decision-capable, and Mental Health Act: what a physician needs to know (requires Medportal Login)
• Book Chapter: Carlat DJ, “Assessing Suicidal and Homicidal Ideation”. The Psychiatric Interview, 4th edition, 2017.

• When to Screen: Every time; it should be part of each MSE as an important part of any psychiatric assessment. You do NOT ↑ risk of harm to self by bringing up the topic. Suicidal intent is a medical emergency – don’t let discomfort with the area interfere with your clinical duties to care for your patients.
• How does Screening for Suicidal Ideation Help? While psychiatric disorders are common, and many can be deadly, they are also treatable. You can make an enormous difference in morbidity and mortality through proper suicidality assessment.

• Sometimes when people get depressed, they think that they are better off dead. Has that thought crossed your mind?
• Considering all that you have told me, has it ever gotten so bad that you have thought of taking your own life?
• It sounds like you have been under a terrible amount of stress, have you had any thoughts that life is not worth living?

• Normalization: Many people who have suffered from losses like yours feel life just isn’t worth living. Do you feel this way?
• Denial of the specific: Have you been thinking about shooting yourself? Have you been thinking of hanging yourself? Etc.
• Symptom Amplification: How many hours have you spent thinking of suicide this week? 20 or 30?
• Behavioural Incident: How many times have you gone to garage? How many minutes did you look down from top floor?
• Gentle Assumption: You likely have thought about your children. How do you think your death will affect them?
• Shame Attenuation: How does your husband make life difficult for you?

• Is there intent to die? Why do they want to die, why now? What is intensity of SI thoughts (1-10)?
• Are the suicidal thoughts active or passive?
• Does the patient have a plan? – ask for specific details surrounding it
• Has the person started to act on it?
• Note - Methods of suicide with success rate > 50%: Hanging and Firearms

• Contribution to Risk Picture: Previous suicide attempts is one of most powerful predictors of suicide for all age groups → Risk increases with each attempt (38x the expected risk vs. general population)
• Repeat Attempts: Multiple attempters considered at least moderate risk and chronically at risk.
• Lethality of Attempt: When index attempt high lethality, 21% committed suicide over 5-year period
• Time Sensitive: Higher risk during 1st month post-indexed attempt (accounts for 21% of all suicides)

• Current Psychiatric Disorder:
  • Bipolar Risk: 36.3% Bipolar I, 32.4% Bipolar II attempt; Bipolar II tend to use more lethal methods
  • Depression risk: 15% die by suicide
  • Schizophrenia risk: 20% attempt suicide, 5-6% die by suicide
• Hopelessness: “Do you feel hopeless?” → Hopelessness explains > 90% association between depression & SI
• Mood Disorder + Substance Abuse: 20X expected risk to commit suicide vs. general population
• Post-Partum Depression: LOW risk for suicide
• Demographics: Groups most likely to commit suicide are adolescents/young adults (15-24yo) and elderly males (>65yo). Women 4X more likely to attempt; men 3X more likely to complete (re. lethality – males more likely to use firearms, hanging, or jumping; females more likely to overdose or self-harm)

Other Risk Factors to Consider:

• HPI: Stressful Life Event (SLE) – e.g. loss of significant relationship, death of loved one
• Past Psychiatric Hx: Recent antidepressant start (re. psychomotor retardation tends to improve before mood)
• PMHx: Chronic disease (COPD, cancer, DM, chronic pain, terminal illness, CAD)
• FMHx: Suicide
• Social-Developmental Hx: Childhood abuse or neglect; Living alone; Access to Firearms

• Social-Developmental Hx:
  • Marital Status: Risk if Married with children > Married without children > Divorced > Separated > Widowed > Never married
  • Parenthood: Children < 18 years old & Pregnancy
  • Social Network: Strong social networks
  • Patient Relationship with their Clinician: Strong therapeutic alliance
  • Religion: Religious beliefs
  • Cognition: Problem solving skills and cognitive flexibility
  • Self-Esteem
• Other Protective Factors:
  • Hx: No previous suicidal attempts; No psych Hx; No Hx of impulsive behaviour; No recent losses
  • Ambivalence: wanting to live and wanting to die
  • MSE: Reality testing intact

• Δ Suicidal Intent over course of Interview: Did they report ↓ suicidal intent? Is it credible?
• Patient on MSE: Spontaneously generating plans, problem solving, talk convincingly about the future?
• Can patient achieve initial symptomatic relief? Is there an accompanying change of affect?
• Dynamic vs. Static Risk Factors: Of risk factors identified, are these subject to change by intervention?

• Risk Categories: Very High, High, Moderate and Low
• How do people communicate suicidal intent?
  • Informing Others of Intentions: 66% tell someone
  • Visiting Family Doctor Prior to Completing Suicide: 50% visit family doctor (hence importance for all clinicians to feel confident and comfortable broaching the subject)
  • Screening: 70% of patients deny any suicidal thinking or plans during interview before completing suicide.
  • Suicide and Monitoring Utility: 40% of patients commit suicide while on 15-minute checks.
• Reporting your Risk Assessment: When reporting, document your opinion is based on a single assessment.

• Consider the assessment room and your position within it: Ideally, exit should be equidistant from you and the patient. Ensure you are positioned close to the door with easy access to the exit. Do not have patient positioned between you and exit. More modern assessment rooms will have 2 exits, such that this becomes less of an issue.
• How to assess the patient:
  • Do not assess an agitated patient alone; consider asking for security to be present.
  • Position yourself at angle from patient as less confrontational vs. sitting directly across from them.
  • If you feel anxiety or uneasy during an assessment, immediately excuse self and leave assessment.
  • If the patient begins to escalate or become agitated, remain calm and non-confrontational in your interaction; keep your hands open and visible, and leave the assessment room if needed.
  • Empathize with the patient and redirect anger (without corroborating).

• History of Violence: One of strongest predictors of risk for future violence.
  • Legal issues or previous incarcerations – both being charged (arrests), and criminal record.
  • “Have you ever been in a physical fight?” → physical assaults, threats, or property damage.

• Seriousness & Frequency.

• Risk Factors: Father committed acts of abuse; Father used drugs; Father had a criminal record.
• Protective: Father was present in the home at least until age 15.

• Age: Peak is in young adulthood.
• Sex: Men are more violent, but we also tend to underestimate violence risk in women.
• Intelligence: Low IQ; SES: Low SES & Social Isolation; Employment Status: Unemployed.

• More psychiatric diagnoses → more violence: Women with Major Mental Disorder 28X conviction rate.
• Psychosis & Schizophrenia:
  • Schizophrenia: Untreated/Active → ↑ violence risk; treated Schizophrenia → ↓ violence
  • Paranoid schizophrenia: ↑ risk of violence if patient believes someone is trying to hurt them
  • Command Hallucinations: Important risk factor for violence
• Depression: In cases of hopelessness and losing connection to the world → loss of inhibition
  • Murder-suicides (suicide follows <1 week): Victims tend to be female sexual partners (possessiveness, control), or children of women with depression with psychosis (e.g. post-partum)
• Mania: ↑ violence, typically less serious/criminality vs. Schizophrenia, e.g. in response to limit setting.
• Stalkers: Rejected lover seeing self as victim (defense against narcissistic hurt, rage at abandonment)
• Personality Disorders: Anti-Social Personality Disorder (ASPD)
• Psychopaths: Robust Construct, not in DSM-5, but with PCL-R (Hare Psychopathy Checklist) – see below

• Substance abuse: Once substance abuse added to risk, this overshadows other independent risk factors
• Anger control; Violent fantasies; LOC; Involuntary status

• Facet 1 – Interpersonal: Glibness/superficial charm; Grandiose sense of self-worth; Pathological lying; Cunning/manipulative
• Facet 2 – Affective: Lack of remorse or guilt; Emotionally shallow; Callous/lack of empathy; Failure to accept responsibility for own actions

Correlation: Narcissistic Personality Disorder

• Facet 3 – Lifestyle: Need for stimulation/proneness to boredom; Parasitic Lifestyle; Irresponsibility; Lack of realistic, long-term goals; Impulsivity
• Facet 4 – Antisocial: Poor Behavioural Controls; Early Behavioural Problems; Criminal versatility; Juvenile Delinquency; Revocation of conditional release

Correlation: Antisocial Personality Disorder; Borderline Personality Disorder; Reactive Anger; Criminality; Impulsive Violence

Many short-term marital relationships; Promiscuous Sexual Behaviour

• 20 items: 0 points if not applicable; 1 point if partial match/mixed info; 2 points if reasonably good match
• Scoring: In Canada, >30 = Psychopath; 17-30 = Mixed; <17 = Non-Psychopath
• High Scores: positive correlation with impulsivity, aggression, Machiavellianism, persistent criminal behaviour; negative correlation with empathy and affiliation

Correctional Services Canada (CSC) – Assessing Risk of Recidivism (i.e. Relapse into Criminal Behaviour – Study of 81 male federal offenders, average follow-up 29.7 months, max 67 months; mean PCL-R score 22.1, Standard Deviation 6.7)¹

Completed By: Physician (examined patient with reasonable degree of interaction in prior 7 days)

Given To: Hospital Records

Purpose & Description:

• Effect: ≤72 hours detained at Schedule One Psychiatric Facility – application for psych assessment - clock starts once decision made to detain with patient arrived at the Schedule One facility.
• Process after completing form: Person can be taken into custody within 7 days. The original, signed copy must accompany pt (do NOT send pt with photocopy).
• What if patient arrives with Form 1 to you? No exam is required at the door, so long as the Form 1 is valid. If invalid, either the physician who signed the Form 1 completes a new one, you examine them and fill out a new Form 1, patient is released, or patient is admitted as a voluntary patient
• What form do you need to complete along with a completed Form 1? Form 42
• Is it Reviewable? No right of appeal for a Form 1 in Ontario

Completed By: Any Person (e.g. family)

Given To: Justice of Peace

Purpose & Description:

• Effect: Authorize patient apprehension and transportation by Justice of Peace to hospital for assessment – not an authorization for involuntary detention.

Completed By: Attending Psychiatrist

Given To: Hospital Records

Purpose & Description:

• Effect: Up to 2 weeks’ involuntary admission to psychiatric facility.
• Associated with a certificate of involuntary admission.
• To complete with Form 3: Form 30 (notice to patient), Form 50 (Confirmation of Rights Advice); Form 16 is related app to CCB (Consent and Capacity Board)
• Is it Reviewable? Patient has right to apply to CCB to review

Completed By: Attending Psychiatrist

Given To: Hospital Records

Purpose & Description:

• Effect: Renewal of involuntary admission to psychiatric facility – 1 month on 1st Form 4, 2 months on 2nd Form 4, 3 months on 3rd form 4.
• Associated with a certificate of involuntary admission.
• What forms do you need to complete along with a completed Form 4? Form 30 (notice to patient), Form 50 (Confirmation of Rights Advice); Form 16 is related application the CCB.
• What happens on 4th Form 4? Triggers a Mandatory Board Review of Patient’s involuntary status – Fill out a Form 17.
• Is it Reviewable? Right to apply to CCB (Consent & Capacity Board) to review

Completed By: Attending Psychiatrist

Given To: Hospital Records

Purpose & Description:

• Effect: Change from involuntary status to informal or voluntary status

Completed By: Judge

Given To: Hospital Records

Purpose & Description: Effect: Order for Attendance for Exam – judge who has reason to believe pt suffers from mental disorder, may order them to attend a psych facility for exam.

Completed By: Judge

Given To: Hospital Records

Purpose & Description: Effect: Order for Involuntary Admission to Psychiatric Facility (up to 2 months) – Judge who has reason to believe the person suffers from mental disorder.

Completed By: Minister

Given To: Hospital Records

Purpose & Description: Effect: Order for person coming into Ontario to be taken into custody and admitted into a psychiatric facility

Completed By: Attending Psychiatrist

Given To: CCB

Purpose & Description: Effect: Application to CCB to review a patient’s involuntary status

Completed By: Attending Psychiatrist

Given To: CCB

Purpose & Description: Effect: Notice to CCB -need to schedule mandatory review of involuntary status

Completed By: Attending Psychiatrist

Given To: Patient

Purpose & Description: Effect: Written notice of Form 3 or Form 4 given to Patient when a certificate of involuntary admission is completed.

Completed By: Physician

Given To: Patient

Purpose & Description: Effect: Written notice of incapacity with respect to treatment, manage property, or collection/use/disclosure of personal health information to patients

Completed By: Physician

Given To: Patient

Purpose & Description: Effect: Written notice of Form 1 or Form 13 given to Patient

Completed By: Physician

Given To: Patient & Hospital Records

Purpose & Description: Effect: Community Treatment Order (CTO) – structured treatment of persons with mental illness in the community.

Completed By: Physician

Given To: Hospital Records

Purpose & Description: Effect: Confirms patient was given rights advice