The Risk In Risk

There is a risk in being overly reliant on a risk assessment approach. A number of studies in psychiatry point to the fact that risk assessment may be helpful in developing plans but is unlikely to really improve outcomes in the long term.

In one particular study. A Suicide in the 18 Years After Deliberate Self-harm A Prospective Study. The British Journal of Psychiatry. 1996);169:489-49. de Moore and Robertson followed up patients from 1975 for 18 years. Patients enrolled in the study had made an attempt at deliberate self-harm and many were likely to have been diagnosed as having a personality disorder (versus major depression).

4% had completed suicide at 4 years,

4.5% at ten years

and 6-7% by 18 years

These figures are largely the same as for major mental conditions, such as depression.

Patients who engage in deliberate self-harm are often either not admitted to hospital or given brief admissions on the basis that the immediate risk has now abated and that hospital has little to offer them and impinges on their autonomy. Many such patients would be classified as low to medium risk on assessment.

On the flip side. This study also demonstrates the problem with applying risk to such significant decisions such as involuntary admission. Should every patient in this study been admitted to hospital in order to reduce their longitudinal risk of suicide over 90% of such patients would have been unfairly incarcerated.

Take Home Message

We are not suggesting that you totally abandon any process of assessing risk. There are many reasons to consider risks in patients. Identifying one risk factor often leads to the identification of another and can help in pulling together the overall picture or the formulation of the patient. Just be mindful that a risk assessment on its own is not particularly useful unless put together with an expert review of the patient's situation. Your risk assessment should always lead to a risk management plan where possible.