Intended for healthcare professionals

Rapid response to:

Head To Head Maudsley Debate

Does the emphasis on risk in psychiatry serve the interests of patients or the public? Yes

BMJ 2013; 346 doi: (Published 12 February 2013) Cite this as: BMJ 2013;346:f902

Rapid Response:

Re: Does the emphasis on risk in psychiatry serve the interests of patients or the public? Yes

Risk assessment has its place in every branch of medicine. Comprehensive screening is valuable if only to remind physicians of the diversity of presentations, and the broad range of factors that must be taken into consideration, as Dr Morgan suggests. However, I have a further issue with intervention based on universal risk assessment.

Specifically, involuntary detention and perceived loss of civil liberty may precipitate violent or self-harming behaviour in individuals that would not otherwise have gone on to exhibit it. In other words, some of the ‘true positives’ identified via risk assessment screening - individuals with high risk attributes associated with undesirable behaviour, who then go on to commit it - would have been ‘false positives’ (high risk attributes but never escalate to such undesirable behaviour) had they not been subject to unwanted and occasionally highly invasive attention.

As discussed, the predictive value of psychiatric risk assessment for these behaviours (particularly suicide and homicide) is already low - false positives far outweigh true ones (1). Any effect that served to overestimate true positives, even slightly, would surely lead us to seriously question their validity. I do not believe that the evidence base on possible negative consequences of psychiatric intervention is robust enough to rule out such an effect as described above (2).

Is it not possible that risk assessment could be a self-fulfilling prophecy - by labeling an individual as high risk and treating them as such due to their score on a questionnaire, we may increase the likelihood of violent or self-harming action? In order to ensure that this is not the case, psychiatrists must be guided and not directed by risk stratification. They must take into account the level of isolation and victimisation their patients are suffering, their willingness to engage with treatment and the outcomes they hope to achieve - variables that questionnaires cannot measure.

As no current screening tool can predict the few cases that will escalate, we must resist the urge to intervene based purely on risk assessment - treating many to save few. In this case, the treatment itself could be far from benign and will only compound the problem.


Morgan JF. Giving up the culture of blame: risk assessment and risk management in psychiatric practice. Royal College of Psychiatrists, 2008.


Saliz HJ, Dressing H. Coercion, involuntary treatment and quality of mental health care: is there any link? Current Opinion in Psychiatry. 2005;18(5): 576-584

Competing interests: No competing interests

20 February 2013
Ryan G Williams
Medical Student
Imperial College London
East Dulwich