A mental health risk assessment form for the Metropolitan referral unit
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The assessment and management of the risk of a person with a mental illness causing harm to another is an extremely important part of psychiatric practice.
It is integral to providing safe and effective care and making decisions on transition between services.
This guide to good practice is produced for psychiatrists, but might also be useful to other healthcare professionals, patients and carers, as all have a part to play in risk management.
A printable version of the Risk Assessment Guide is available here:
This risk assessment guide is from the Mental Health in South Australia Emergency Management Policy and Procedure Series (2002) that is used by staff in mental health services. It forms part of the risk assessment, referral and follow up form developed for private practitioners.
| Risk of harm to: Self Others Both | ||||
| None | Low | Moderate | Significant | Extreme |
| No thoughts or action of harm | Fleeting thoughts of harming themselves or harming others but no plans, current low alcohol or drug use. | Current thoughts/distress, past actions without intent or plans, moderate alcohol or drug use. | Current thoughts/past impulsive actions/recent impulsivity/some plans, but not well developed. Increased alcohol or drug use. | Current thoughts with expressed intentions/past history/plans. Unstable mental illness. High alcohol or drug use, intoxicated, violent to self/others, means at hand for harm to self/others |
| Level of problem with functioning | ||||
| None/mild | Moderate | Significant impairment in one area | Serious impairment in several areas | Extreme impairment |
| No more than everyday problems/slight impairment when distressed. | Moderate difficulty in social, occupational or school functioning. Reduced ability to cope unassisted. | Significant impairment in either social, occupational or school functioning. | Serious impairment in several areas such as social, occupational or school functioning. | Inability to function in almost all areas. |
| Level of support available | ||||
| No problems/highly supportive | Moderately supportive | Limited support | Minimal | No support in all areas |
| Most aspects are highly supportive. Effective involvement of self, family or professional. | Variety of support available and able to help in times of need. | Few sources of help, support system has incomplete ability to participate in treatment. | Few sources of support and not motivated. | No support available. |
| History of response to treatment | ||||
| No problem/minimal difficulties | Moderate response | Poor response | Minimal response | No response |
| Most forms of treatment have been successful or new client. | Some responses in the medium term to highly structured interventions. | Minimal response even in highly structured interventions. | Minimal response even in highly structured interventions. | No response to any treatment in the past. |
| Attitude and engagement to treatment | ||||
| No problem/very constructive | Moderate response | Poor engagament | Minimal response | No response |
| Accepts illness and agrees with treatment, or new client. | Variable/ambivalent response to treatment. | Rarely accepts diagnosis. | Client never cooperates willingly. | Client has only been able to be treated in an involuntary capacity. |
Is the person’s risk level changeable?
Highly changeable Yes No
Are there factors that indicate a level of uncertainty in this risk assessment? (Eg. Poor engagement, gaps or conflicting information?)
Low Assessment Confidence Yes No
Note: Risk assessment is not a precise ‘science’. Your professional judgement and experience are also crucial. Remember too, that a person’s risk of suicide may be highly changeable, fluctuating at different times and in response to certain events.
Abstract
Although risk assessment in mental health practice can influence and measure treatment outcomes and level of care provision, risk assessment practices are not standardised and different screening tools are used. The aim of this integrative review was to review the literature on risk assessment in mental health practice to promote evidence-based care. Electronic databases were searched for articles available in English and published from 2013 to 2019. The findings from 12 articles evaluated the evidence for risk assessment tools utilised and discussed the justification, barriers and enabling factors for risk assessment. Lastly, recommendations were made to improve risk assessment.
While there is no single prescribed standard of care or clinical approach for situations involving suicide and self-harm, Working with the suicidal person recommends a series of general practices and principles to guide the assessment and management of people at risk.
The ultimate judgement must be made by the attending clinician, based on their experience, the clinical presentation and the assessment and management options available at their health service.
Risk factors for suicide
Although risk factors cannot identify suicidal individuals with any certainty, they can alert a clinician to take particular care in assessing an individual.
There is a wide range of factors that can influence suicide risk, from mental illness or physical ill-health to abusive relationships, stressful life events such as unemployment or bereavement, or a history of suicidal thoughts.
- Men are three times more likely to die by suicide than women (although women make more suicide attempts).
- There are some groups of people that experience higher rates of suicide due to sustained trauma or discrimination, such as Aboriginal and Torres Strait Islander people and gay, lesbian, bisexual, transgender and intersex people.
- People recently discharged from acute psychiatric services are particularly vulnerable, exhibiting a suicide risk 100 to 200 times greater than normal in the month after discharge.
- Adolescents and young people can also face risk factors that may elevate their suicide risk, from mood and anxiety disorders to substance use, bullying, feelings of isolation, or the influence of close friends who have taken their own lives.
- The elderly face unique risks stemming from their declining health, social isolation, recent bereavements and concerns about being a burden to others.
Guiding principles in assessing suicide risk
There are several general principles for mental health staff to consider in the assessment and management of people at risk of suicide.
Positive engagement
Good communication and listening are vital to establish rapport with a person, to validate their feelings and to discuss difficult issues with them in an empathetic way. Clinicians are encouraged to ask a person directly: Are you thinking about suicide?’
Talking about suicide will not encourage a person to take action – it will actually decrease their risk because it lets them know they are able to talk about it with you.
Ascertaining a person’s level of distress and feelings about their life provides a crucial foundation to identify and reinforce any positive thoughts and reasons for living.
Clinicians should find out if they have made any preparations for death, such as giving possessions away or saying goodbye to loved ones. If a suicide attempt has been made, ask about any precipitating events, whether it was impulsive or premeditated, and whether they sought help beforehand.
It is very important to gain information, not only from presenting individuals but from their friends, family, caregivers or medical records, which can help gauge their level of risk and determine appropriate clinical options.
Clinicians should take particular care to ensure that pertinent information is accurately documented and passed on to other staff to ensure a consistent approach and prevent adverse outcomes.
Thorough assessment
Keeping a person safe and comfortable while they are waiting for an assessment is paramount, and any restrictions of their liberty must be kept to an absolute minimum.
For acutely suicidal people, assessment should be made immediately. Intoxication should not delay an assessment, as it can increase impulsiveness and the risk of self-injury in the short term.
The practical quick guide, Working with the suicidal person, Rapid suicide-risk assessment at emergency department triage, provides a useful list of pointers and questions to assist clinicians during the key stages of a risk assessment.
Follow-up assessment
An initial suicide risk assessment should always be followed up with a comprehensive mental health status examination and psychiatric assessment. This applies in particular to people who present after a suicide attempt or an episode of self-harm, with probable mental illness or dual diagnosis, or after a recent discharge from a psychiatric inpatient unit,