Intended for healthcare professionals

Head To Head Maudsley Debate

Does the emphasis on risk in psychiatry serve the interests of patients or the public? No

BMJ 2013; 346 doi: (Published 12 February 2013) Cite this as: BMJ 2013;346:f857
  1. Matthew Large, medical superintendent
  1. 1Mental Health Services, The Prince of Wales Hospital, Randwick, Sydney, NSW 2031, Australia
  1. mmbl{at}

Identifying patients who are likely to harm themselves or others has become central to psychiatry. John Morgan (doi:10.1136/bmj.f902) argues that though the methods are flawed, identifying risk is essential, but Matthew Large thinks we should focus on the wider harms that patients may experience

The emphasis on risk in mental health has been growing over the past 30 years. Thousands of papers about risk assessment have been published, and each year brings a crop of new methods with their associated acronyms. Risk assessment is now central to decisions about the admission and discharge of people to and from psychiatric hospitals and involuntary community care. However, I believe that efforts to anticipate future harms such as suicide and violence are flawed and should be replaced by a greater consideration of people’s wishes, capacities, and best interests.

No evidence of effectiveness

Risk assessment was not introduced into mental healthcare because of scientific progress but because of complex social and political factors, including media pressure after a small number of catastrophic events. Subsequently, no scientific evidence has emerged to show that risk assessment reduces the harms associated with mental illness.

Risk assessment does not work because it lacks the statistical power to discriminate between those who will and those who will not commit particular harms, such as suicide and severe violence, …

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