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Uh good evening everyone, um or good morning or good afternoon if you're joining us from outside of the UK, er, we're really excited to have uh another great session on middle primary care uh this evening um on mental health risk assessments. Um we're really proud to have, er, Doctor Mavi Capanna, er, joining us um er, Doctor CPAA is a Darty fellow in, er, the West London NHS Trust and she specializes in adult Psychiatry. Um She holds a medical degree with honors and has completed extensive training in mental health and psychiatry. Her focus includes innovative treatment methods and patient centered care with a commitment to staying abreast of the latest developments in psychiatric research and we're really grateful to her to, to, to speak this evening on mental health risk assessment. Um This is aimed um predominantly at um general practitioners um and GP trainees in the UK. Um really as a refresher as, as an opportunity, I need to ask some questions as an opportunity to um to dive into mental health risk assessment in more detail. Um Please use this opportunity to ask some questions to um get clarity on things that you want clarity on and we'll have some time for questions at the end, just pop them in the chat and, uh, and we'll get them at the end. We're going to have some pools during the session as well. Um Please contribute your thoughts and ideas to the polls and, um, and, uh, and, and we'll, we'll take a look at those as we go through. It gives me a great pleasure to hand over to doctor Kana right now. And um and we're really looking forward to a great session. Thank you. Ok, thanks, Phil. Um Hi, everyone. Welcome. Thanks for joining. Um So as Phil eloquently said, this is kind of a recap and guide to mental health risk assessments. Um And to start off, um I thought I'd summarize the learning objectives for this session. So the aim is to try and get a working understanding of what a dynamic risk assessment and mental health triage involves um as well as understanding the difference in risk to self others and from others and how we can expand on this by asking in depth specific questioning to our patients as well as understanding the triggers and thresholds to escalation and referral for crisis support from mental health services. So I thought I'd start off with a poll um to get an idea of who's in the room um in terms of which mental health conditions you most commonly treat. So I've given some options, but you can also press other if that's not involved in the common ones. So I think, yeah, depression leading as always is a common. Yes. So I think this is gonna be really relevant to a lot of people that have said depression and psychosis as one of the kind of common um mental health conditions. We see a lot of nuances within the risk assessment and a lot of stigma especially associated with psychosis. So, um we'll touch on this later on and for my second poll, um how confident have you felt completing a risk assessment? Um And you can add in the chat function um if you want and we can touch on it later in terms of if not, why, like what do you find most difficult about it? Interesting. Interesting to see. I'm glad the people that have said that they're not confident are here so that we can hopefully by the end of the session, have a bit more confidence in that. So in order to start off, I just wanted to clarify some basic points about risk assessment. So what is a risk assessment? Why do we do it? And when should it be done? So, in terms of what it is, we're trying to assess the level of risk that a person might pose to themselves, others or from others and the specific behaviors that this might lead to or that predispose to this. We're looking at why they're presenting and what they're telling us. And what they're not telling us and how that can predict future and past risk. Um We're also, so why do we do risk assessment? Um We're assessing the likelihood that the behavior is going to happen. Now, if it's going to happen in the immediate future, or if a past behavior that's been risky is going to be repeated again to prevent future risk and mitigate those circumstances. So we're trying to understand the impact of the illness, not just on the patient, but also on those around them. And at a time, especially if they don't have insight. Um and we should do this at every interaction or when concerns arise. Um But really, it should be at any point of contact with the patient with any professional, there should be some element of risk assessment. Um What I'm going to be touching on especially is this idea of a dynamic risk assessment which we use in psychiatry and is used quite commonly in forensic psychiatry as well. And this is the concept that risk isn't static, it's fluid and it takes into account multiple factors including contextual factors, social factors, societal factors. So we saw this a lot with the COVID pandemic where there was a lot of changes in risk very rapidly in our psychiatric patients, but also patients that had never had psychiatric symptoms or even people that had were not known to mental health services. So for example, school age, Children or teenagers or families that were undergoing a lot of financial stress with the pandemic. So these are the important things to remember is that when you're doing it at every contact you have to bear in mind that it might change and it might change from before they came into your clinic room, even within the same clinical setting or after they leave your clinic room, and it might be triggered by a variety of things that we'll touch on later in the talk. Um My main point with the risk assessment that I think I'll repeat a few times throughout is that there's a stigma around people that come and tell you that they're risky. So this is a lot of the personality disorder patients that will come to your clinic and they say, you know, I'm feeling really, really suicidal, I'm feeling like I'm going to self harm, they're presenting you their risk and they're telling you and a lot of the time these get dismissed because of the stigma associated with diagnosis or the fact that it's chronic. So to the first key point is just because it's chronic doesn't mean it can't be acute and just because it's chronic doesn't mean there's no risk. The, the flip side of that is when you have a patient that isn't telling you anything that's also a very risky patient. So someone with schizophrenia, for example, that's not offering you any risk is also as worrisome as the patient presenting you their risk on a silver platter in your consultation room. So those two extremes I would say, in my opinion, are the ones that we should be concerned about, even though they're opposites to each other. So alongside the risk assessment, just a quick um kind of recap. Um just to not forget the rest of the the assessment. So we would always do a risk assessment in line with our mental state examination for a psychiatric patient or someone presenting with a mental health, um, presentation. And we're looking at every aspect of the person and that all feeds into the risk assessment. So how are they behaving? Do they look like they're on edge? Do they look like they have something on their mind? They're not talking to you about how are they appearing? Have they looked, do they look like they haven't looked after themselves? Do they look like they've lost a lot of weight recently? And as well in their speech, are they coming across very guarded? Are they giving you free information? Do they look like they're struggling to find the words because they're distracted by some other thoughts and their mood and affect, um, which people get confused about quite commonly. So in terms of the mood, you know, do they look visibly depressed? Do they look like they visibly look guarded and they're preoccupied with something else? Um, and the affect is, is that it's the, how they are looking right now in that instant to you. How does it feel? And the mood is the relative undercurrent of that person. So if you can people describe it like the mood is the climate of somewhere and the affect is the weather on that day is a good analogy to remember it by um perception is in terms of kind of um hallucinations, whether it be in any modality. Um And so that might be coming to the risk assessment in terms of command hallucinations where people are hearing voices that are telling them to harm themselves or others or do specific actions, um or whether they feel that their body is under the control of another entity. And so they're doing behaviors, they don't want to do, but they feel they have no control over that, which is the passivity phenomenon that comes under perception. And in terms of thoughts, that's where in the mental state we explicitly ask about risk. Um And that includes risk too from um self and others as well as um people being vulnerable. And then obviously the last two insight, do they know that they're at risk? Do they know that their mental state has changed? Um And cognition is in terms of memory, awareness of time place and person. So, moving on to the two aspects of a risk history, whether it be to themselves, others or from others is the split between the current and the historical risk. Um And that is really important, especially in risk to others because in violence risk, past risk determines future risks. So, if someone has been violent before, when they've been unwell, there's a higher risk of them being violent again if they relapse in their mental state. So it's important to assess each individual in relation, not only to their present risk, but their past risk as well. And a really good way to do that is by using this tool called the Structural Clinical Assessment. Um And I've included a link in the resources that you've been sent out. Um And I'll go through kind of each stage what you would do and what you'd cover. Uh But you can also find this online in, in the link that I've attached. So in terms of this is what you do at, you meet a patient. Um you've gone through and you've decided, ok, you need to get a better understanding of their risk. So you're looking in the stage one where you gather information, you want to get information from multiple sources done by someone that they call in this structured assessment, a competent assessor. So that could be a nurse, a doctor, an ot that knows the patient, a key worker. And you're looking to understand the different links between what happened in the past, what has been the, the risk that's happened, what, what is it across different sources and that feeds into your collateral information as well to understand that person's life culture and risk. In stage two, you identify present and relevant risk and protective factors, which we'll touch on a bit later in terms of what those are. But you're looking for things like triggers, you're understanding previous risk through the historical risk factors. You're looking for protective factors to help build that resilience and enhance rehabilitation of that person through identifying things that have helped them in the past. In stage three, you look for offense analysis and risk formulation. So you look at again, previous risk and it's really important, it keeps coming up again and again, this idea that previous risk determines future risk. And you need to understand the past patterns to determine your best guess at making, you know, some level of risk assessment for the future, which is very hard to do. But this is the best way to kind of make an educated guess at that. Um And so in this stage, you look for patterns relationships between circumstances and risk. So for example, if you have someone that right before every admission relapses in their substance misuse and then stops taking their medication and then that leads to their psychosis kicking back in and then their aggression and then they get, get arrested or they end up in a mental health unit. That's a pattern that if you see over and over again can help you build some rehabilitation potential for that person by catching them at the first step next time. So next time when you relapse in your drug use, we're going to make sure that someone is there checking you taking medication to avoid a mental health relapse. So this helps us learn, not just about what has happened, but how does this person cope with stress? And it aids the formulation of their risk, looking at predisposing, motivating, precipitating, perpetuating and protective factors and really exploring them and getting to the root of why they happen. And if there's any patterns in stage four, you look at scenario planning. So that's understanding those previous situations and understanding the risk behaviors that come from them and then discussing this with the patient and, and asking them, do we need to explore this more? What is this risk behavior about? Did we miss anything? Um In risk five, we prepare for the risk management plan and relapse plan. Um So you identify and address points of escalation and risk. Um And you try and target them to manage risk in the least restrictive way to try and keep the patient out of hospital if that's their wish or out of the criminal justice system and set some good rehabilitation targets that have clear goals um and is drawn up in conjunction with the patient. So this could include stuff like monitoring, frequency of clinic visits, supervision, um treatment and interventions and safety plans. Um And the patient a lot of the time will say, you know, if I stop coming to these clinics or if I stop getting repeat prescriptions from my GP, this is what helps me break out of that cycle. This is what helps me reengage and this is a really fine balance between giving an intervention but also respecting the patient's autonomy and making sure that they have some control out of their care plan. So stage five, I think I slightly disagree with um the fact that they put this as a separate stage because as I've said, I think we should be doing the presentation of findings and feedback to the patient along the way. Um And at least in, in the way that we practice in my trust, we try and feed that in throughout rather than keeping it as an endpoint separate phase. Um And in stage seven, updating the risk assessment. So like we said before, this idea of a dynamic risk assessment, so requires regular review update. You can't just write it down and wait for the next admission or wait for the next next risk incident to update it again. It needs to be at every point of contact with an every clinician, it needs to be updated. So here I've expanded a bit on the factors that we spoke about in the previous um slide. So looking at the predisposing the modifiable future um factors as well as the strength and protective factors. So obviously, the strength and protective ones are the ones we've said. Um So things like that the, the, the clinical tool we just used is a really strong protective factor for some patients. A lot of the patients might not have social support or families. And so they really need that containment from the healthcare professional of someone being there that if they start showing relapse signs, somebody will catch them and avoid a full blown relapse. And that's kind of also the interesting part um where social inequalities come into it. Because if you have a patient that's really well supported with a really supportive, supportive family that knows this, they tend to do better in outcomes because someone is picking up on their triggers and their risk from the past. Whereas if you have someone that's quite socially isolated and doesn't have that support, it can get quite tricky and they end up with more admissions um and more sectioning and more detentions. So it's actually really important to do this work with the patient and see, well, what is the things they're hopeful for? Do they have insight into what they would like out of their mental health treatment? How are they engaging with services? And if they're not engaging, it's not that they're choosing not to engage as we're probably not providing the correct service. So how can we adjust our service in order to support that patient and give them that support? And obviously in, in, in the UK and where I work, we link them up with social support as well so that they can go to groups and we have walking groups and cinema groups to build some of that network that we know keeps people better in their mental health. Um So that kind of is the, the, the bottom bit of that pie and it's, I think it's a really crucial one in terms of the, the, the factors that we have. So predisposing factors, that's the history, that's the, the previous risk and this person's history. So, have they self harmed before? Have they had mental health issues in the family before? Do they have a family history of suicide? Do they have trauma abuse things that are predisposing them to develop risky behavior or in Children especially? Have they seen risky behavior and then normalized it? And so are more likely to act on that risk in terms of the modifiable risk factors. So things that there's some control over and it's changeable. So is there been a recent relationship breakdown? As have they just been given a physical health diagnosis? You know COVID I mentioned before, a change in social circumstances with isolation in the pandemic was a big modifiable risk factor for a lot of our mental health patients and people who develop mental health issues within the pandemic. Um in terms of substance use, which we said before, big trigger and big cause of relapses, but also a very common coping mechanism. Um So, you know, it's, it's hard to differentiate, did the depression come first and then the substance use or is the patient self medicating with substances? And so we really need to get to the root of what is the problem and how can we help them manage it, whether it's medication or psychological therapy? Um And in terms to future factors. So these are the ones that we're anticipating and that we should be getting on top of this is the key bit of the pie where we have some control as clinicians. So, you know, if the risk factors aren't stable, if they've changed recently, has somebody picked that up is anything likely to occur that might change the risk that we can get on top of. You know, if someone every year around the anniversary of someone's death gets very depressed and has a suicide attempt, what can we do to put in place something to get ahead of that risk happening? Um And that's that, that's on building that network relationship with your patient knowing what matters to them. And it does take a bit of time to do. I mean, and we're all short of time in any health service, but actually in the long term, it will save a lot of time because if you get ahead of those problems, it saves problems in the future and it builds that security for that patient to come to you or come and be understood before the risk escalates. Um So I think you know, looking for evidence of recent stressors, losses or threats of loss, um as well as a lot of the time, understanding personality factors that our patients have is really, really pivotal to getting ahead of that risk. So in the next bit, uh we're gonna look in detail over the assessments um of risk to self others and from others along kind of this, this subtle art in psychiatry of not colluding with your patient's psychosis, but trying to entice the truth out with a level of curiosity that lets you do a proper risk assessment in those psychotic patients. Um I don't know if there's any questions, but if there are, we'll cover them at the end. Um Unless there's any pressing ones filled that you think we should cover. Now, we've got a, we've got a couple here mavi, but we're going to save them up for you. Um So, uh if there's any, if there's any that, that need us to jump in straight away, we will. Um But we'll see, we'll see if the ones we've got until the end. Cool. Thank you. Um Right. So, moving on then. Um, so first before we go into um each individual risk part of the risk assessment, um, just wanted to add a slide about kind of this um myth busting about self harm because I know it's very common. Um And we've touched before on the fact that there's a lot of stigma associated with it. Um And there's a lot of risk being underplayed with people with self harm. And a lot of this comes from a lot of personality disorders having presenting with self harm quite frequently. Um So this is a really useful way to think about self harm that we got taught at um within our own teaching in psychiatry. And it's the stages of a suicidal process um from a, from a man named Hale. Um And I think it's, it, it made me really view self harm completely differently after this lecture. So I think it's really important to, to cover. Um So in terms of psychodynamic thinking, I mean, every human and you probably know within yourselves, people want to survive and that's the kind of human nature of why people struggle to drown themselves and, or, or harm themselves significantly because there is an innate animal drive to survive like most animals. Um And so the initial part of self harm is this betrayal between the part of yourself that wants to stay alive and the part of yourself that split from this identity and actually doesn't want to be alive anymore. And that betrayal within the self creates the split that creates the suicidal state where there's a lot of confusion. Um And you, you're kind of wanting to survive but also contemplating not wanting to survive. And what does that mean? Um And that puts people in this presuicidal state of uncertainty and this can either regress and this might happen in grief, for example. And then it goes back to normal and you, and you go back to being in your normal state or this persists. And if this persists and then there's a trigger, so let's say someone leaves you or there's a relationship breakdown or you lose your job, then this puts you into a confusion even more severe where you're really starting to not want to be within your body. And you see yourself and your body is two separate entities and you don't, you no longer want them to stay together. And this progresses to a body barrier being broken, which is the act of self harm. So the the most risky part ahead of a suicidal patient is that initial breach. It's I am now going from thinking about it to actually doing something to my body. And so if you think of it that way self harm as a precondition to suicidality, it really shows the severity that it can have and the risk that it carries. And like I said before, just because something is chronic and there is chronic self harm, it doesn't mean that the risk is an acute and especially when the self harm changes, this is when the risk goes up. So if you have someone that, you know, continuously self harms and they have emotionally unstable personality disorder and you're, and they're telling you, you know, I don't want to harm myself I don't want to kill myself. I'm doing it because it leaves pressure and it helps me cope with stress. That's very different to someone who's depressed that comes in doesn't say much but has self harmed quite significantly. Or even a person, the same personality disorder patient. That isn't saying that it's because of pressure, but they just were scared to end their life, but they want, they needed to self harm and those are really risky patients. Um, and so that's kind of my way of understanding it that has helped me deal with all of our biases which come into play when you have a chronically self harming patient, which is that people just jump to conclude that they're never going to kill themselves because all they do is self harm and they've done it for 20 years. Well, that's just fundamentally not true. And a lot of the personality disorders actually carry a high, high risk of suicide. Um, some of it through misadventure, but a lot of them through working back and forth between the last two stages of, of this diagram. Um, and the other bit, um, that I think really helps me think about overdose specifically is if you, when we were, um, being taught, um, in, in the same class, someone said, you know, have you ever tried to sit down and take, you know, 50 T tacks with a cup of water? Um, and this was someone in A&E who was trying to explain that. Actually, the number of tablets that the patient has taken, tells you a lot about their risk of suicide. Because if you try it and you know, me and my colleagues have tried it with, with um with tick tack, it takes a lot of effort and a lot of time to take each individual one out of the packet and swallow it and take a gulp of water. So the persistence needed to when someone comes in with an overdose, about 100 tablets is actually telling you a lot about their commitment to how suicidal they were. Because at some point, if you're having second thoughts, at some point in that taking 50 or 100 or 80 it, it, you, you would stop, you would have the time to reflect. So the the impulsivity will wear out. So the quantity of overdose is actually quite important to look at even if the patient is saying, you know, I didn't mean it ii just, you know, I was downplaying it and minimizing it. The to, to remember in your mind, this patient sat, you know, for maybe an hour um doing that. So that, that speaks a lot to the risk. So yeah, moving to the wrist itself um from that. So like I said, uh we've covered self harm, we've covered suicidality, but uh risk to self is not just about um suicide or suicidal thoughts. Um It's about drugs and alcohol. Um people escalate in their drug and alcohol use because they no longer feel hope for the future or they feel depressed and they're self medicating or, you know, they feel less concerned about if they overdose or about their physical health and the vulnerability when it comes to gang involvement, especially in young kids or teenagers um that have first episode psychosis and they're quite vulnerable um neglect. So that's really important looking at the person seeing how they're presenting, which also includes neglect of their physical health conditions. So, um, some of the time patient presents with seizures because they've not taken their physical medications or diabetes. Their A1C is off the chart because they've stopped complying because they don't feel motivated to do that anymore. So those are all little hints that you can pick up quite early on, um, about someone's mental state and risk, um, isolation we've talked about before. Um, noncompliance relapse. I've just mentioned, um, and as well as kind of seeing if people's guilt and hopelessness and the way out through that is through self harm, it happens a lot in complicated bereavement cases where people feel guilty. Um, and then they take that onto themselves and the way out they see is through suicide or self harm. So it's, it's, it's really important and it's important here as well to remember those people that don't have those supportive relationships that don't have that care at home. Um And who, but on the flip side, the people who do and they stop being concordant with treatment or they disengage what's happening there as well. So it's, it's both sides of the coin um and looking and, and looking and inquiring and having that curiosity to ask a bit further. Um So the, the, the tip I have here is, is, is applicable to all my slides in terms of the, the risk assessment and it's the command hallucination and passivity phenomenon are under every category. So it, it's really important to explore. So, you know, the way we usually ask it is, do you feel like you're in control of your thoughts and actions or do you feel like somebody else has control over that? And if they say yes, it's good to ask, you know, do you feel like you can resist it or do you feel like sometimes it's beyond your control and what helps and what doesn't help? And that helps you understand the level of, of risk that that carries um and as well that the impulsivity that that person has and the fact that if they're also using drugs and alcohol, that impulsivity is gonna go up and, and their ability to control those commanding hallucinations or passivity is gonna go down. So, in terms of risk to others, um we're, we're thinking about patients that are violent to others, whether it be professionals or family and friends or random members of the public. Um So when you go in, obviously, you should always be aware that you're safe. Um And the first question I usually think about as well is after the patient and myself, you know, are there any Children? And that always should be, you know, is there any safeguarding needed? Is there any Children involved at home? If there are, where are they now, who are they with? They need to be alerted in terms of social care. Um, And, and maybe temporary emergency accommodation for those Children. Um, in terms of aggression, there's a big range. So I, I've, I've worked in forensics a lot and that's kind of one side of the spectrum. Um But there's also other types of aggression. Um, you know, people can be quite verbally aggressive, um They can be racist, they can physically assault staff and others. Um but they can also, you know, prevent elderly parents from going to their appointments, they can prevent them from leaving the house, they can just be quite intimidating if unwell. Um And a lot of the time that the families don't report this because they're worried about getting their child in trouble, um or having them go into hospital again. Um in terms of threat perception, it's a very common thing to look at in terms of forensics. So this is when you have a psychotic patient. Um and they're feeling like they're under threat. So a lot of the big kind of crimes that happen within mental illness um is when someone feels at risk. So if you have a voice, for example, I saw a case of a man who um thought that he could hear the devil and the devil told him that both his parents were possessed. And the only way to get rid of the possession was to slit their throats. And this went on for a long time and then he eventually completed the act of killing both his parents. But the problem there wasn't that he wanted to kill his parents. He didn't even realize he was committing murder. He was thinking my family is at risk. I'm at risk. I need to do something and that's the threat perception. So the good question to ask for patients that you feel are a risk to others. And that's obviously an extreme example. It is to ask people, you know, do you feel at risk from anyone? Do you feel like you need to protect yourself or your family from anything? And if so, who, who is it from? Is it a specific person? Is there a specific action you have to take? And I've been surprised so many times by asking that question and so much more information comes out because remember people don't want to tell you this information, if they're psychotic a lot of the time or they know that it's gonna cause issues for them or maybe the voice is telling them not to tell you. So it, you need to find a way like we said before of this really fine art of not colluding with the patient but trying to be curious that they want to tell you the information. So telling someone, do you hear voices to harm yourself or others is not going to get you that information? But if you say, you know, I see that you, you, you've been looking to the corner sometime. That's really interesting that you also mentioned that you felt someone was monitoring, you tell me more about that. How, how does that impact you? That must be really stressful. How, how do you, how do you deal with it? What, what makes you kind of want to escalate? Do you wanna go find these people that gets them to feel understood and that someone's just inquiring and then the information will come out and could prevent some serious risk to other people. Um Yeah, in terms of um we touched on the predisposing ones as well, but exposure to violence being part of a violent subculture obviously increases risk to others as well. Um And I think it's important to say here that, you know, if there is a named risk to a to a specific person, then that is enough to call the police and to breach confidentiality and say to a lot of the times, say to that person, listen, you're at risk. This person has told me that they feel that you're monitoring them and if, if this keeps going, they're going to come to your house and confront you. Um, that, that's enough of a risk. So if somebody tells you that they're going to go and hurt someone that, that's enough to, to breach confidentiality with that patient. Um, but you need to make sure that you're also safe in doing that and not getting the patient angry when you're in a room alone with them. Um, so, um I've put another pole here, um which is pole number three. So it's, do you, do you feel like you need a parent or a guardian's consent for, for to complete a children's safeguarding? Yeah. So, correct. It's a bit slow on my side. Sorry. Yeah. So you, you, you don't need a parent or guardian's consent um To, so I think the majority of people got that right. Uh You don't, you don't need parents or guardians consent. If you have a Children safeguarding risk, you can just complete that. Um And then question number four, I've put another poll is um what, what do you think is the commonest disorder associated with criminality and risk to others? Sorry, I'm not getting them on my side yet, but um hopefully they should be coming in soon. Ok. Interesting. So the majority of people have said schizophrenia, which shows a lot about our stigma to psychotic patients. Um which, you know, I, I've been, if I hadn't had to study this, I'd, I'd be the same as well. Um So in the lead there, schizophrenia, but the correct answer is actually personality disorder. Um, so, you know, um, a lot of patients in prison, um, have personality disorder, especially antisocial personality disorder is very commonly associated with risk and violent risk to others. Um, in terms of schizophrenia, a lot of these patients are portrayed, especially in the media as being quite aggressive sometimes and being a risk to others. But a lot of our schizophrenic patients don't pose a risk to others and it's only the extremes that typically do and there's usually a lot of other factors. So stuff like drug and alcohol use or comorbid personality disorder. Um, so schizophrenic patients are more likely to be aggressive to their families as well. Um And they're, um, they're not commonly, if they just have schizophrenia, they're very uncommonly um violent to others. So it's, it's mostly um things that are with personality disorders as well or drug and alcohol use. I thought that was just interesting to have because um, we, we, we, we get that a lot and it's very misrepresented in the media as well. Um, so risk from others, um which is the, the final one in the risk assessment. Um So we're looking at people, um and the risks that they can have from other people when they have mental health disorders. So we've just touched on some of that, don't forget about the stigma. Um And always think, you know, these, these people and patients are usually very vulnerable, especially the socially isolated ones. Um people that use drugs and alcohol can also be very vulnerable to exploitation. And you should always be asking yourself is safeguarding needed, not just for any Children, but also for the patient themselves. Um So we're looking at, you know, vulnerability, are they being odd? And so they're at risk of retaliation. So a lot of the patients, um, you know, that talk to themselves, sometimes they get bullied or they get attacked on the street. Um, some patients that are manic can dress quite exuberantly and then get targeted. Um, and sometimes patients that are, um, paranoid can approach people and then people get quite irate about it and can also kind of attack them or be violent towards them. Um, exploitation we've touched on and we can't make the mistake that it's, you know, just strangers, it can be staff, it can be partners, it can be their family members. A lot of this happens with, um, government benefits in this country where people take people's money saying, you know, they're mentally ill, we need to look after their money, but then they're actually reducing, um, their autonomy and freedom. Um, patients who are sexually disinhibited. So that's bipolar and mania patients. Um, again, you know, they can put themselves at risk, they can get into, um, very risky cir circles as well as being at risk of sexually transmitted um uh diseases and poor standards of care. Um So this is relevant especially to black and ethnic minority groups where there is evidence in the literature that people, especially young black men are treated with lower standards of care than other people with mental health issues. Going into seclusion more often and being sectioned more often than their white male counterparts. Um So that's something we need to bear in mind all the time, especially in terms of our psychotic patients in that um in that category or people with a criminal justice system, um they will get, they, they does have carry stigma with the criminal justice system and they do tend their mental health issues do get thought of as a secondary um aspect. So, and that falls in all under the umbrella of discrimination. Um And especially when people are isolated and don't have people advocating for them, it's really important to pick up on that stuff. And I think a lot of the time if you're looking for it and you're inquiring about it and it's on your mind, it's, it's not that hard to pick up. I think it's when we're in a rush. Um and we're not looking um that these things get missed and I think we, we, we spoke about it as well before about, you know, poor concordance with treatment. It might be that people aren't giving them medication. Um So I had a case recently of a woman who was unwell, um, with bipolar and every time she didn't take her medication, she would relapse. But her mom also had bipolar and she didn't even medication. So every time her daughter came home, she would throw away all her medication and that would lead to a relapse and it would go round and round and round and this, this woman kept going into hospital and her disorder kept getting worse and worse. Um, so it's thinking about those things as well, which, you know, a lot of the time, maybe they're not done in malice, but they're still causing harm. So then the final bits is to remember, um, in the risk assessment after we've done all that is absconce. So if they're in hospital, are they at risk of leaving without leave, uh, risk to property? Have they damaged property before? Um, have they, you know, uh, broken other people's property before? Um, and that, you know, common, um, when you're hearing voices from the TV, people tend to smash T VS or personality disorders and when they're acting out and smashing property and fire setting, um, as well, that's a big risk and even, especially if they're living in shared accommodation or, um, apartment flats. Ok. So the risk formulation at the end of that, so you've done your risk, um, you've asked all the questions, you've understood the patient, you've looked at their history, you looked at the present risk, you're all good to go and you're trying to make your risk formulation. So what, what is the actual risk right now? So how serious is it, how immediate is the risk? So it, how it, is it a specific risks? What we said before? Is it to a named person? Is it a, a named time place person or is it a general risk that they're carrying? How volatile is it? Is it that they said that if the, if the, you know, the people keep talking about them one more time, they're going to go and set something on fire or is it more of a stable risk that they've had these voices for a long time? Um And things are just bubbling along but we need to treat them to get the voices better. Um What are the signs of increasing risk? So what are those triggers really important? Are any triggers coming up? And are there signs of them getting worse? And which specific treatment and which management plan can we use to best reduce this risk? So this um ties in with kind of escalations. So if they, you know, um I think, I assume the majority of people um are aware of how the NHS and the UK mental health system works. But we have um like three tiers. So you can be, well, four tiers, you can be under your GP you can be under community mental health services um or you can have a crisis team come into your house and support you, monitor your risk, get uh give you your medication or monitor medication taking and then you have informal or detained admission to hospital. So if you have someone that has an acute rising risk needs a medication change, maybe some of the triggers or the stressors are coming into play, then they would go to those crisis teams. If there's an imminent risk, you should be thinking around admission or if they've had a with the crisis team and things are still not getting better, then you have to think admission and whether the patient is gonna consent to that and come in as an informal patient so they can come and go as they wish. Or if they have to be detained under the Mental Health Act and kept in hospital against their will, once you've decided that it's also good to remember. Physical health has anything been neglected or needs checking beforehand and the security level if an admission is needed. So do, do they need to be in a psychiatric ward? Like a standard General Adult ward? Do they need to go to um a secure uh we call it psychiatric intensive care unit. Um or do they need to go to a forensic setting where they have higher levels of security? Usually that's from um risk to others. There's also um more structured assessments if you're interested that you can get training on. Um And these are the names of them um that you can look up if, if you like um just coming to an hour has gone incredibly quickly, me talking with nobody else talking. Um But we'll come to the summary. Um So research time, I hope it's like transpired that the time taken to research on historical risk and understand the patient and get that collateral is essential to a good risk assessment because it helps you predict future risk by understanding the past risk. And just because it's chronic, doesn't mean it can't be acute. Um assessing and comparing the historical risk with the past and present triggers and triggers that might be coming up and making sure those relapse markers are discussed with the patient to make a safety plan that can come into place quickly to avoid long relapses or try and avoid a relapse altogether and making that management plan, safety plan care plan. But knowing that you can also discuss it with the mental health team, the crisis team, the safety netting of that. Um And if needed mental Health Act assessments with detentions, um we have added in the last slide um which um can also send round um is is kind of a, a summary diagram which I thought would be helpful if you wanted to just kind of have a quick recap if a patient came up and it summarizes what we've, what we've touched on today. Um And it has all the key points in terms of um taking a history and looking for the background and, and, and then the way through it and the reevaluation of the risk um and communication with the patient. So it kind of a quick summary, but it's in one of the links um from the Royal College that we have made available to you. And yes, with 10 minutes for questions. That's, that's me. Uh Thank you so much doctor. We've got some uh questions. Um, uh, but, uh, first up amazing session, uh, really helpful, we've got so many comments in the chat saying that it was a really informative session, really helpful, extremely well presented. So we're all really grateful. So, er, so thank you, uh, for, uh, for such a great session. Um, if you do have questions, er, please pop them into the chat, we'll try to get through as many as we can in 10 minutes, but we do have, er, quite a few already. Um, and if it's ok, I'll, I'll, I'll just work through these, um, er, Doctor Cabana. So, um, er, we've got one from, er, Katrina, er, Cooper, which is, um, er, er, the main concerns, her main concerns with risk assessment are those who act impulsively, for instance, no act of suicidal planning and, er, you know, that they've act impulsively et cetera, what they're going to jump over bridges. How do you, how do you, how do you assess that type of patient? Yeah. So I think a lot of, um, yeah, II, they're really difficult patients, uh, start with that. Um, so I think a lot of the time there's some misconception around impulsivity and a lot of the time things aren't as impulsive as they seem. Um, I think a lot of the patients that, especially in, from a primary care setting that have been depressed then start medication, their energy goes up but their mood stays low and those are the patients that can become quite impulsive in their suicidality. Um So there's, there's certain things like that, that is good to bear in mind and just have in the back of your head that you need to have a closer follow up. So, in a young patient, yeah, for example, you know, young patient around, you know, mid twenties, depressed, given antipsychotics, they really need follow up almost on a weekly basis thereafter because their energy levels and impulsivity is gonna go up. Um same with AD HD patients that develop mood elements to their AD HD. So I think, yeah, my, my main answer to that is if you actually look at a lot of the cases, there's not that much impulsivity. Um And a lot of it can be predicted. And the, the second bit of my answer would be that um what is the patient trying to communicate? Because a lot of the time what they're doing with that is that they're communicating that some, some need isn't met. And that's the personality disorder patient with the impulsivity is, you know, they're frustrated, they haven't presented as depressed. They need, they need help. They don't know how to ask for help. They feel this sense of like loss and abandonment. And so they act impulsively. But actually, if they have a safety plan written up saying, well, when you feel impulsive because we can't be there all the time and that's impossible for any clinician to do when you feel this way. Let's write down what you can do. What, what's the number you can call? What's your safety mechanism? What's actually gonna help you when you feel like that? And when I've done that with a lot of the patients, you'd be surprised at how many things they list off that are really simple. Like, you know, when I get frustrated, I lose sight of things and I don't know how and I, and I don't know how to cope. But if I can just, you know, go and read my book, then I, I'll feel better. If I do a crossword puzzle, I feel better. And it seems really silly because you're not actually doing an intervention but having written it down with them and a lot of them laminate the piece of paper. They just look at it when they feel stressed and they're like, ok, well, what helps me? And they look at it and then they do the action and the impulsivity just goes down. Uh, next question is how can we best manage in primary care? A patient who stops their medication and has capacity. But you family and other professionals can see that they are deteriorating. Um Balj is saying that they've had a paranoid schizophrenic patient who stopped medication, she had capacity. Um And over the course of a year, she became more paranoid, losing weight and eventually was sectioned. Um But up until sectioning, she had capacity and insight to stop her medication. So it was a very difficult case to kind of manage. And he's asking if you have any, any tips. Yeah. So um that's basically our job every day. Um So I ii feel your pain. Um Yeah, unfortunately, if the patient has capacity and they don't wanna take the medication and then they're in the community, there's little you can do. Um I think so I if there's significant enough risk, you can use that in a mental health Act assessment setting. So I've done it before where the patient says um they don't want their medication and I can see that they're relapsing, they're not meeting threshold for detention just on that. But because their risk has been so severe, went unwell, you can actually um use that bring them into hospital. Um because you know, you're saying if we let this go any further, actually, there's a very severe risk. Um So we need to get on top of it and um I think the crisis teams are quite good with that. They'll, they'll go in every day. So for us that's really helpful. Um And patients need to have capacity to work with the crisis team. So that that's one option, you could just get them to be visited um by the crisis team and my trust, they do up to two times a day visits. Um I think the best thing which it does take practice, the best thing is trying to convince the patient. Um And what that, this is why writing up that care plan together is really useful. So I've had patients this has happened with and I've gone back and said, you know, I remember two months ago when you told me how horrible it was to be in hospital and you felt really terrible. Well, we wrote all this down and now you're doing something that's against it and this might happen to you again. Do we not just want to try a different medication that they usually, you know, they, they want to stay well, as much as we want them to stay well? Um And the other thing is, is there something that isn't working in that medication? So if they have capacity and they don't want to take medication, you know, is it because the medication you have them on gives them sexual side effects? Like, maybe it's just a question about that. Like, you know, is it that this medication is just intolerable to you can we try something else? Uh, we've got a really excellent question from, er, surge, which is, how do we assess the risk in a 10 minute GP consultation? Um, for instance of a 35 year old patient without any previous history of self harm is on antidepressants but stating that he has plans to take his own life. Uh, I think it's doable. Um, and, and we do it as psychiatrists. Um, I think it takes practice. I think um the, the, the question II hope that this session has kind of given you some kind of key focus points, but it's not the amount of questions you ask. It's the time to develop that relationship with the patient. So I usually spend most of the time doing that and I think you can do that within 10 minutes because you can figure out someone's risk within a few minutes. So I think the spending the first few minutes just allowing the patient to feel comfortable and being able to open up to you then makes your job a lot easier when you need to ask the more delicate questions. Because the worst thing you can do, especially in your example, with a suicidal patient is if they feel you're doing a tick box exercise and they actually just really want to kill themselves, they will just give you the answers that you wanna hear. And that, that, that's what you're gonna get. But actually, if you take those first few moments to understand the patient to show them that you, you, you are not gonna judge them, you're gonna try and support them and even just saying things like I say this to my patients a lot. I just say to them, you know what you're saying isn't matching up with what I'm feeling coming from you or how you're presenting to me like you look really not very well and I'm really worried you're gonna hurt yourself or do something? Like, can we have a frank discussion about this? And it's, it doesn't increase risk to tell someone that you think they're gonna kill themselves. It doesn't increase risk to talk about suicide. So I think don't be scared to just put it in the room and let them talk about it. Um, and, and, and say that, you know, a lot of the time you can feel if someone's feeling really sad and it's OK to just name it. Um Yeah, so, II think it is possible and, you know, in your case, if you think there's an immediate risk, I would just call the, the crisis team as well as a follow up unless you can make a safety plan with that patient. Uh, brilliant. Um, Doctor Kana, we've got, we've got a few more questions, but I think we're, we're at time. So what, what we're gonna do is, um, we'll, we'll post those questions into uh a thread on metal. Um If er, if folks want to, to kind of continue the conversation, uh, you can, um, and, um, and, er, and you'll be able to, to kind of do, do that, um, do that straight away on, on metal. Um, we're gonna post a feedback form into the chat. Um, and, er, when you complete that feedback form, so there's a link in the chat at the moment. Er, there's also a link to the Q and A thread, um, on meal in the chat. If you want to kind of continue this conversation, you're really, you're really welcome to, er, when you complete the feedback form, you'll get an automated, er, certificate. Um, so, er, so that will be uh sent to you automatically. And, um, and, er, and we'd love to see you at, at our next event. I know doctor C is doing another one for us uh, really soon um, on AD HD. Uh, so you're all really welcome to that and, uh, we're, we're really grateful to you doctor for, uh, for giving you, giving your time and, and, and, and doing so. So, Gene, um, I hope you find this, er, session useful. I think it's been um, uh, a really great session and really comprehensive, um, so massive. Thank you to doctor and I hope everyone else has, has really enjoyed, er, the session. Uh, thank you so much for joining us and we hope to see you next time. Thank you. Thanks everyone.