Does the emphasis on risk in psychiatry serve the interests of patients or the public? No
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f857 (Published 12 February 2013) Cite this as: BMJ 2013;346:f857
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In the debate on risk in psychiatry both John Morgan and Matthew Large agree on the main point. Risk assessment doesn’t work. Morgan seeks to improve clinical input to risk assessment and Large wants us to abandon risk assessment and develop our recovery approach instead. Both raise concerns about the risk concept in psychiatry.
Risk assessment is used defensively to protect reputations as much as to protect patients or the public. If risk assessment doesn’t work, but public and professionals think it does, we need a believable alternative before we can move away from what has become the appearance of good practice. The direction we should take is that of increasing safety.
Health care organisations are more prepared to assess the risks posed by individual patients than by health care systems, and cannot see the wood for the trees. Home Treatment in England appears to be much less safe than hospital treatment in terms of suicides (1). The rate of suicide is double that for in-patient care and the rate has been increasing over the last 10 years. Making a risky system safer is more likely to reduce risk than repeatedly assessing the patients within it. For example, removal of ligature points in hospital wards has been associated with a halving of in-patient suicide by hanging.
Health care organisations take responsibility for another person’s behaviour too readily and delegate this “risk-holding” to inexperienced clinical staff. This is unacceptable corporate behaviour. We must not assume incapacity in service users. Where we see clear and present danger we should bring in our experienced staff to apply their clinical expertise, and containment when appropriate, but we should not be screening every person for every risk with random checklists. Instead we could train our staff to coach interested service users in safer behaviours as part of a broader recovery plan.
Although we collect considerable risk and safety information over time, we generally fail to present it in forms that are meaningful or readily assimilated. Risk records are buried in pages of computer or paper text instead of being visible as trends on charts. Sometimes a chart can reveal a pattern of harmful behaviour that is otherwise unobtainable until the critical incident review. We need to present the information we collect safely.
Reference
(1) The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Annual Report: England, Wales, Scotland, and Northern Ireland. July 2012. http://www.medicine.manchester.ac.uk/cmhr/centreforsuicideprevention/nci...
Competing interests: I carry out and supervise risk assessments. I work with service users to increase safety.
Taking risks is part of being alive. Our society is becoming increasingly intolerant to risk-taking and nowhere is this more apparent with with state-sanctioned organizations such as mental health services. There seems to be an underlying assumption that when things go wrong it is because there was a deficit of knowledge or reasoning, and that something, or someone, has made a mistake. This is largely guided by the Newtonian cause and effect model of thinking that neglects the dual reality of a chaotic and quantum universe, where uncertainty is intrinsic to any complex system.
This model makes the assumption that to prevent risk we must know more and put more effort in each decision so that risk can be reduced and aims for risk to be prevented entirely. Whilst this is true to an extent with more experienced clinicians making better decisions, there is an important balance to be sought, as incorporating too much information into the decision making process can lead to wrong decisions being made through focusing on the wrong piece of information or due to the volume of data making it impossible to make a decision at all (the so called 'analysis paralysis'). If this is coupled to a natural inherent recall bias for sensationalized media headlines, it sets up the 'perfect storm' to make defensive, overly cautious decisions that are likely to felt as authoritative and punitive to our patients.
It is a reality that to learn how to walk we must risk falling over. Recovery from mental illness is similar, we need to take some positive risks exposing patients to normal life stressors to rehabilitate them back to the community. In doing so we run the risk of relapse and increase in risk-taking behaviour. The general public has taken on board the reality that mental illness is akin to physical illness and that sometimes this necessitates hospital treatment, however, this has come at the price of the belief that mental illness needs to be ‘cured’ or ‘excised’ like a tumour with hospitalization and medication. This leads to the assumption that if there is a negative outcome after discharge from hospital it is because the patient wasn’t treated properly.
The reality of course, is that discharge from hospital is only the first step on the journey to recovery that may take many years. A better metaphor maybe to think of a patient who has become a recent leg amputee. When on orthopaedic or rehabilitation ward in hospital, many of your practical difficulties are met through special adjustments. It is only when you are back home, struggling to work out a way navigate environments that are not tailored to your individual needs that it becomes stressful. More often than not this is 'healthy stress' (presenting new challenges that lead to new neuronal connections which physically rewire the brain). If something goes wrong and you fall over or develop a superficial infection rarely is this attributed to improper treatment at the hospital.
Are we doing society any favours by maintaining this cultural fiction of certainty and are we relieving society of its wider responsibility towards people living with mental health difficulties. Are we deskilling our patients at an institutional level? These questions need to enter a national debate and a consensus decision needs to be made on how society wants psychiatry as a whole to proceed. At present we are rapidly returning to a paternalistic model of care, undoing many decades of progress for patient's rights. I have recently heard forensic psychiatrists extolling the virtues of the forensic model of patient treatment and how this needs to be rolled out to other areas of psychiatry. Tongue in cheek, one argued that ignoring patient demands when they are unwell and only listening to them when they are heavily medicated has improved his practice. Is this what we want we want for the future of psychiatry with its heavy focus on risk avoidance?
Andy Pain
CT2 Psychiatry, Wessex Deanery
Competing interests: No competing interests
As a practising psychiatrist of over 10 years' experience, I have observed a definite shift towards the management of patients with an ever-increasing emphasis being placed on risk management. There is no doubt that risk assessment and management is a critical component of psychiatric practice, it often feels as if we lose sight of treating the patient's underlying mental illness, and now have a tendency to focus almost exclusively on their risks.
As a consequence, I have observed that it is often the 'riskiest' patients who receive the most attention, and take up the most resources. This is often to the detriment of other patients, who may in fact be more unwell, but do not present with significant risks. Such patients are being neglected in essence. I have seen many patients who as a direct consequence of their illness, have an awful quality of life and functional impairment, but simply because they are not having thoughts of killing themselves or anyone else, we choose to neglect their needs. These attitudes have negatively affected our concept of patient need to the extent distorting our views on the need for detention under the Mental Health Act. Legally, patients should be detained to hospital if they are suffering from a mental illness which may represent 1) a risk to self, 2) a risk to others or 3) a deterioration of their illness if left untreated. When deciding on which course of action to take, I have been amazed at the number of times that i am met with the question of "why on earth do you want to admit them, they're not suicidal or homicidal." It is almost as if we have forgotten about the third criterion completely-we have a duty to provide timely and effective intervention to prevent further deterioration in a patient's underlying mental illness, IRRESPECTIVE of the presence or absence of risk!!
In conclusion, psychiatry's obsession with risk management has come at the expense of patient care based on needs. It has given us an increasingly narrow-minded and myopic view in the way in which we treat our patients, and prevents us from taking a broader perspective of their needs.
Competing interests: No competing interests
Large [1] wrote in his article about the emphasis on risk in psychiatry that there is as a shift because professionals and governments have placed too much confidence in risk assessment. I think that there are strong efforts in suicide prevention. Hegerl et al.[2] observed in a community-based intervention program in Nuremberg/Germany a reduction of suicides with respect to suicide attempts of about 22% compared with a control city. There is an implementation of similar studies in many communities in Europe. Van der Feltz-Cornelis and his collegues[3] recommended similar preventive activities with multilevel intervention strategies.
There is a strong influence of mass media in public opinion related to suicides and violence. In response to the shooting at US schools there is an intensive debate in USA in causes and prevention of gun violence. But it is importan to lay emphasis on violence associated with schizophrenia, too. Volavka and Citrome [4] described the aetiological heterogeneity of violent behavior of patients with schizophrenia and the fact that most patients are not violent. Today there a different anti-stigma programmes designed for psychiatric disorders. The effectiveness is still unclear.
Durand-Zaleski et al.[5] concluded that in their first population-based study with pyschiatric disorders they were linked with a high discrimination against patients with schizophrenia, with poor information about different disorders in general population and a high importance of the media. Innovative anti-stigma campaigns could be developed--for instance, objective informations in local newspapers[6], information campaigns at schools [7] and combined mass interventions that smooth the progress of disclosure and make progress by personal social contacts[8]. Personalized medicine in Psychiatry (genetics, epigenetics) has made improvements and will make important progress in the future. Drug surveillance projects observe and describe adverse drug reactions (ADR) associated with psychopharmacological substances and can help to identify ADR risk groups.
References:
1) Large M. Does the emphasis on risk in psychiatry serve the interests of patients or the public? BMJ 2013; 346:f857
2) Hegerl U et al. Sustainable effects on suicidality were found for the Nuremberg alliance against depression. Eur Arch Psychiatry Clin Neurosci. 2010;260(5):401-6
3) van der Feltz-Cornelis CM et al. Best practice elements of multilevel suicide prevention strategies: a review of systematic reviews. Crisis. 2011;32(6):319-33
4) Volavka J, Citrome L. Heterogeneity of violence in schizophrenia and implications for long-term treatment. Int J Clin Pract. 2008;62(8):1237-45
5) Durand-Zaleski I et al. A first national survey of knowledge, attitudes and behaviours towards schizophrenia, bipolar disorders and autism in France. BMC Psychiatry. 2012 Aug 28;12:128. doi: 10.1186/1471-244X-12-128.
6) Nowack N et al. Psychiatry in local newspapers.Psychiatr Prax. 2011 Apr;38(3):129-34
7) Bock T, Naber D. "Anti-stigma campaign from below" at schools--experience of the initiative "Irre menschlich Hamburg e.V.". Psychiatr Prax. 2003;30(7):402-8
8) Evans-Lacko S et al. Association between public views of mental illness and self-stigma among individuals with mental illness in 14 European countries.
Psychol Med. 2012; 42(8):1741-52
Competing interests: No competing interests
Psychiatry has the same problem as aviation or the nuclear power industry - it strives to prevent rare but unpredictable catastrophes (suicide or homicide). However the responses to date have been mostly repetitive and unhelpful with much work going into producing risk assessment scales or forms which aim to manage organisational reputation rather than stop disasters. We need to learn from other industries and develop new risk management systems rather than new forms.
Incidentally cardiologists are better at predicting who will have another heart attack than psychiatrists are at predicting suicide. Why isn't cardiology obsessed with risk management and why aren't cardiologists frequent attenders at coroners courts?
Competing interests: No competing interests
Re: Does the emphasis on risk in psychiatry serve the interests of patients or the public? No
This is a late response, as I am slow to read through journal piles. Reading both sides of this debate was instructive. In substance misuse work, our team is often faced with the issue of whether a patient on our opiate substitution program is currently "at risk" or not. The risk would normally be of a severely adverse health event in relation to substance misuse. Many such patients, however, will have significant concurrent mental health problems ("dual diagnosis").
We don't use a checklist, for which I imagine there would be even less of an evidence base than for the psychiatric tools the authors refer to. Our criteria include a number of factors and observations, such as apparent deterioration in the level of engagement with the service, appearance of intoxication when the person does turn up for dosing, avoidance of team efforts to increase support, history of overdose or other emergency drug-related hospital admission (medical, psychiatric or both), concern expressed by family/friends/partners/carers, and so on.
The clinical impression and gut feel built up over many contacts with many members of our team is, I suppose, the key.
How does "at risk" help us? In my view it is by keeping the person high on everyone's awareness, reducing the threshold for seeking welfare checks form other agencies if contact ceases, maximising flexibility to create opportunities for re-engagement, etc.
Competing interests: No competing interests