This document discusses mental health risk assessment and management. It notes that clinicians have poor ability to predict suicide or homicide. It identifies static risk factors like previous self-harm and dynamic factors like suicidal ideation. Guidelines are provided for asking patients about suicidal thoughts and developing safety plans. Involuntary referral criteria and processes are outlined when significant short-term risk is present.

1. Mental Health Risk Assessment
Dr Ewen McPhee

2. How do you feel
 Reported feelings of
 Fear
 Helplessness
 Anxiety
 Anger
 Counter transference
 The ability of clinicians to predict suicide of homicide
is poor

3. Suicide
 1.6% of deaths in Australia
 20% of deaths Male 20 – 39
 Men X 4 more likely than Women
 8.9 per 100,000
 Prevalence of 2.3% Suicidal ideation
 45% presented to a GP in the month Prior
 50% Self harm prior

4. Risk Factors
Static Dynamic
Previous self harm Active Suicidal ideation
Diagnosis of a Mental Disorder e.g Guilt
depression
Substance abuse (especially alcohol) Hopelessness
Family History of Suicide Current Substance Use
Recent Stressors or loss Psychosocial Stressors
Age, gender, Marital status Problem solving deficits
(Older age, male, divorced)

5. How to ask about suicide
 Do you ever feel like giving up?
 How does the future seem to you?
 Does your life ever seem so bad that you wish to die
 How severe are the thoughts? How frequent
 Have you made any plans
 How close have you come to doing something
 Access to methods of suicide e.g. Firearms, stockpile of
medications, chemicals
 What stops you doing something?
 Protective factors e.g. Religeon, love for children/family
members

6. Ideation
Suicidal ideation that includes a plan for suicide or
evidence that the individual has been engaging in
preparations for a suicide attempt are signs of
significant short term risk

7. Management
 Rapport and therapeutic alliance
 Active empathetic listening
 Involve family, support networks, other care givers
 Consider substance use disorders, psychiatric
illness, personality disorders
 Address Dynamic factors e.g. access to firearms
etc...
 Voluntary participation is ideal

8. Contracts
 The use of ‘no self harm’ contracts should be
avoided as they are generally held to be ineffective
and not supported by evidence.
 Instead, a safety plan for the patient can be drawn
up and this can include information such as help
lines (particularly in an emergency out of hours),
follow up appointments and online resources

9. Involuntary referral
 Referral may need to be undertaken without the consent
of the patient using the relevant Mental Health Act
legislation.
 This would be considered as a last resort and only in
exceptional circumstances. Although state based Mental
Health Act legislation may vary, most allow for a referral
for psychiatric assessment without the consent of the
patient where:
 the patient appears to be mentally unwell
 there is a risk to life or substantial risk to health of self or
others,
 And it is reasonable to believe that treatment will reduce those
risks and that this cannot be provided in a less restrictive
manner.

10. How is the involuntary assessment
process started?
 Two assessment documents, the request for assessment
and the recommendation for assessment, must be made
before a person can be assessed without their consent.
 A request for assessment can be made by any adult who,
having seen the person within the last three days,
believes the person has a mental illness of a nature, or to
an extent, that requires involuntary assessment.
 A recommendation for assessment can be made by any
doctor or an authorised mental health practitioner who
has examined the person in the last three days.
 The doctor or health practitioner must be satisfied that all
of the assessment criteria (set out in section 13 of the
Act) apply to the person.
 The recommendation is effective for seven days.

11. What safeguards are there in this
process?
 The request and the recommendation for
assessment must be made by different people.
 In addition, the person making the request cannot be
a relative or employee of the person making the
recommendation.
 The Act also applies penalties for providing false or
misleading information.

12. What if the assessment documents
cannot be made?
 Two options are available to enable a person to be examined to determine if
the assessment documents should be made.
 A justices examination order may be made by a justice of the peace
(qualified) or magistrate. The justices examination order is valid for up to
seven days. The justices examination order authorises a doctor or
authorised mental health practitioner to go to the location of the person and
conduct an examination to decide if a recommendation for assessment
should be made.
 The person can only be taken to an authorised mental health service if the
assessment documents are made. An emergency examination order can be
made by a police officer, ambulance officer or a psychiatrist.
 Strict criteria apply to the making of an order.
 An emergency examination order authorises a person to be taken to an
authorised mental health service and detained for up to six hours. The
person must be examined by a doctor or authorised mental health
practitioner to determine if a recommendation for assessment should be
made.
 If a recommendation for assessment is not made, arrangements must be
made for the person to be returned to the place from where they were taken
or to another place the person reasonably asks to be taken.

13. What happens once the request and
recommendation have been made?
 The person can be taken to an authorised mental
health service by a health practitioner or an
ambulance officer for assessment.
 Police are not automatically involved in this process,
but must provide assistance if requested.
 http://access.health.qld.gov.au/hid/MentalHealth/Car
erInformation/involuntaryAssessment_is.asp

14. Section 13
 What are the assessment criteria
 (1) The assessment criteria for a person, are all of the
following, based on available information
 (a) the person appears to have a mental illness;
 (b) the person requires immediate assessment;
 (c) the assessment can properly be made at an authorised mental
health service;
 (d) there is a risk that the person may—
 (i) cause harm to himself or herself or someone else;
 or
 (ii) suffer serious mental or physical deterioration;
 (e) there is no less restrictive way of ensuring the person is
assessed.
 (2) Also, for chapter 2, the assessment criteria for a person
include
 (a) lacking the capacity to consent to be assessed; or
 (b) having unreasonably refused to be assessed.[s 14]