Risk Assessment
Core concepts
Risk assessment is structured, dynamic, and documented. Assess suicide risk (ideation, intent, plan, means, previous attempts, hopelessness, substance use, access to means, protective factors), self-harm, risk to others (violence, stalking), and vulnerability (self-neglect, exploitation, safeguarding). Use structured tools (e.g., C-SSRS, HCR-20) alongside clinical judgement.
Management
- Remove means; involve family/carers with consent where possible.
- Safety planning and crisis contacts.
- Consider admission for high risk, psychosis, or inability to contract for safety.
- Document reasoning, not just the score.
Traps
- Relying on a single score without narrative.
- Missing protective factors and collateral information.
- Failing to reassess risk over time - risk is dynamic.
- Ignoring risk to others and safeguarding responsibilities.
Worked example
A patient with active suicidal ideation, a plan, access to means, and recent attempt requires urgent assessment, means restriction, and likely admission - regardless of a "low" score on a screening tool.
Emergency Psychiatry and Ethics/Professionalism
Core concepts
Emergencies include acute agitation, violence, self-harm, suicide attempts, psychosis, delirium, serotonin syndrome, NMS, and alcohol withdrawal. Management: verbal de-escalation first, environmental safety, then pharmacological (benzodiazepines or antipsychotics) and physical restraint only when necessary, with monitoring.
Ethics and law
Know capacity (four-stage test), consent, confidentiality and its limits, duty to warn/protect where applicable, involuntary admission criteria (mental disorder, risk to self/others, treatment available), and safeguarding. Respect autonomy, least restrictive option, and document decisions.
Traps
- Restraining without monitoring or documentation.
- Confusing capacity with compliance or with a specific diagnosis.
- Breaching confidentiality without legal justification.
- Failing to consider least restrictive alternatives before involuntary admission.
Rule of thumb
In any emergency: safety first, de-escalate, assess capacity, document, and use the least restrictive option.