Clinical Methods in Psychiatry

Resident’s Handbook

Editors:
Rakesh K Chadda Pratap Sharan
MD, FAMS, FRCPsych, DFAPA MD, PhD
Professor and Head, Department of Psychiatry, Professor, Department of Psychiatry,
All India Institute of Medical Sciences, New Delhi All India Institute of Medical Sciences, New Delhi

Mamta Sood Raman Deep

MD, DPM MD
Professor, Department of Psychiatry, Professor, Department of Psychiatry,
All India Institute of Medical Sciences, New Delhi All India Institute of Medical Sciences, New Delhi

Associate Editors:
Nishtha Chawla Preethy Kathiresan
MD, DNB MD, DM, DNB
Assistant Professor, Assistant Professor,
Department of Psychiatry and JPNATC Department of Psychiatry,
All India Institute of Medical Sciences, New Delhi All India Institute of Medical Sciences, New Delhi

Foreword
S K Khandelwal
MD, MAMS
Former Professor and Head & Chief, NDDTC,
Department of Psychiatry,
All India Institute of Medical Sciences, New Delhi

Published by
Department of Psychiatry,
All India Institute of Medical Sciences, New Delhi
 Chapter 15
Risk Assessment
Raman Deep, Swarndeep Singh

Learning Objectives
After reading the chapter, the student should be able to:
• Describe the need to assess risk
• Outline the approach and enumerate the principles in risk assess-
ment
• Outline the approach to assess suicidal risk and risk of harm to
others
• Enumerate the risk and protective factors
• Understand the need to communicate and document risk

Introduction
Risk assessment is one of the core competencies to be acquired during
residency training. It is often the first step in risk mitigation strategies and
helps in for mulating management plan, including the need for
hospitalization or appropriate urgent interventions. A formal risk assessment
also helps in proper communication of the risk to caregivers or other health
professionals. Carefully documented risk assessment also assists the court
in evaluating clinicians’ decision-making process.
The chapter shall discuss various issues and considerations in risk
assessment conducted by a mental health professional. It shall provide an
overview of comprehensive risk assessment in clinical settings, including
key themes of clinical enquiry, a thorough assessment of risk and protective
factors as well as approach to risk determination. Certain guidance questions
which can be used during the interview have been tabulated. The chapter
does not cover the risk management or risk mitigation strategies.
252 Clinical Methods in Psychiatry

Approach to risk assessment

Suicide or violence risk assessment is frequently warranted in
emergency, out-patient or in-patient psychiatry settings. An unstructured
clinical assessment might vary across interviewers and might be prone to
various cognitive and personal biases. A clinician is also likely to miss out
on some relevant information. The actuarial risk assessment involves the
use of clinical scales or instruments to identify variables which are known
to influence risk. This approach, however, does not consider the relative
importance of individual’s risk or protective factors. A structured clinical
assessment is the most widely recommended approach for risk assessment.
The clinician assesses the risk factors based on actuarial research, but also
incorporates the information about the relative importance of those risk
factors based on the patient’s history and clinical examination conducted
in a systematic manner. It also emphasizes upon identification of relevant
risk and protective factors for a given individual, and to utilize this
information for reducing the risk in future.

General Principles
• Physical comfort and safety of the patient, as well as safety of
professionals involved in the care should be ensured prior to start-
ing the assessment.
• The privacy and wishes of the patients should be respected to the
extent possible during the interview. The patient-clinician com-
munication cannot, however, be treated as privileged or confiden-
tial in instances with risk of harm to self and/or others.
• Clinician should be mindful about the possibility of negative emo-
tional reactions, especially while dealing with aggressive or vio-
lent patients.
• Provided there is no imminent risk, it is a good practice to involve
patient in the risk assessment process and explore his/her subjec-
tive perspectives.
• Risk factors for self-harm or violence needs to be contextualized
for a particular person to make better sense of the individualized
risk. For example, loss of employment could act as a significant
stressor for a person who is sole earning member in the family.
• Interview style must be calm, objective, non-judgemental, and
empathic. Effort must be made to establish rapport.
 Risk Assessment 253

• Clinicians should not shy away from direct questioning about sui-
cidal ideas and plans. On the contrary, evidence suggests that it
might be a relief for the patient to be able to express their lack of
desire to live with someone without stigma or admonition. Fur-
ther, it can help to prevent and mitigate future risk.
• Some patients may under-report or deny the risk on direct ques-
tioning. Appropriate attention must be paid to non-verbal commu-
nication such as poor eye contact, evasiveness from questions
around a particular theme, inconsistencies across interview, clini-
cal history and alternate sources of information.
• Relevant information must be gathered from collateral sources like
family, friends, previous treating physicians, police, or past medi-
cal records after taking appropriate consent.
• It is a good idea to take second opinion from a colleague or an
experienced mental health professional, in case of doubt regard-
ing risk assessment of a given patient.
• The risk can be dynamic and could escalate over a relatively short
period of time. Risk assessment should be understood as an ongo-
ing process.

Suicidal risk assessment

Suicidal ideation and behaviors is perhaps the most commonly
encountered and important risk in psychiatry. The purpose of suicide risk
assessment is to identify modifiable or treatable acute, high-risk suicide
factors, as well as protective factors that can inform patient treatment and
safety management. Various areas pertaining to risk assessment have been
discussed below.

Exploration for parasuicide vs suicide

Both parasuicidal and suicidal attempts involve intentional self harm,
but the key difference is person’s intent or motive behind the act. A suicidal
attempt is characterised by an intention to end the life or kill oneself. A
parasuicidal attempt, on the other hand, is characterized by an absence of
intent to end life, but self-harm is a cry for help, a means to seek attention
from others, and/or to inflict physical pain with an aim to reduce emotional
distress.
A gentle exploration may be done regarding patient’s intent at the time
254 Clinical Methods in Psychiatry

of harming self during the course of interview, in addition to taking into

account other relevant information in psychiatric history and mental state
examination. However, the differences between suicidal and parasuicidal
attempt must be viewed with due attention to these points:
• Accidental serious harm or deaths may occur in parasuicidal at-
tempts due to errors in perceived lethality of a method or delayed
rescue measures.
• It may not be always possible to clearly delineate a parasuicidal
from a suicidal attempt, especially after a single interview or in
limited time.
• Further, some amount of dimensionality exists between these con-
cepts making it difficult to discern a clean-cut differentiation in
each and every case.
Risk assessment must, therefore, be made in all cases with potential
for self harm.

Structured Clinical Assessment in Patients with Suicidality

Risk assessment is preceded by a psychiatric evaluation aimed at
making diagnosis and establishing psychopathology. Primary focus of risk
assessment interview is kept at ascertaining and documenting risk, to inform
management. The recommendations by American Psychiatric Association
(APA, 2010) capture the major themes for risk assessment.
Suicidal risk assessment must explore and account for the following
aspects:
• Current suicidal ideas, plans, and intent, including active or pas-
sive thoughts of suicide or death
• Prior suicidal ideas, plans, and attempts, including aborted or in-
terrupted ones
• Prior self harm behaviors, if any, without suicidal intent
• Presence of current and lifetime psychiatric diagnoses, along with
need for psychiatric hospitalizations, if any
• Clinical presentations with severe hopelessness, pathological guilt,
prominent anxiety symptoms, etc.
• Problematic substance use disorder or recent change in pattern of
substance use
 Risk Assessment 255

• Trait Impulsivity
• History of suicidal behaviors in first or second degree biological
relatives
• Presence of stressors (e.g., financial, interpersonal, lack of social
support etc.) or history of trauma
• Terminal or incurable medical illness
For those who report current suicidal ideation must be additionally
assessed as below:
• Frequency, intensity, duration and perceived controllability of sui-
cidal ideation
• Any specific triggers, real or imagined losses or specific psycho-
pathological symptoms (such as hopelessness, delusions etc.) as-
sociated with suicidal ideation
• Any suicidal plans or preparatory behaviors (e.g., writing a sui-
cide note or making legal will etc.), and details thereof
• Access to suicide methods, including firearms (e.g., in case of police
personnel)
• Any attempted suicide in the past, including aborted or interrupted
attempts
• Patient’s possible motivations for suicide (e.g., shame, humilia-
tion, command hallucinations, reunion with dead ones, rebirth or
re-incarnation etc.)
• Reasons for living (e.g., sense of responsibility to significant oth-
ers, strong religious beliefs deterring death by suicide, etc.)
• Any intended course of action by patient if and when suicidal ide-
ations worsened (e.g. disclosing to others around, seeking treat-
ment, etc.)
• Perspective about future, including hope and plans for future
Those with suicidal attempt’s must be additionally assessed as below:
• Context and circumstances surrounding the attempt–(Site of at-
tempting, e.g., home, public place, deserted place; time of attempt,
e.g.,during busy day-time or at night when others might be asleep/
unaware; presence of other individuals around, e.g., family/ rela-
tives/ friends/ colleagues/ passerby; indicating warning/ threat of
harming self; immediate triggering event)
256 Clinical Methods in Psychiatry

• Intent at the time of attempt (may or may not be verbally described

discretely)
• Potential lethality of attempt (choice and type of method, perceived
lethality)
• Actual damage incurred during the attempt
• Degree of planning involved
• Availability of rescue measures
• Patient’s response after the act or after being rescued (remorse/
indifference over the attempt, relief/ anger on being rescued)
Box 1 provides guidance questions for important themes that must be
enquired in a person with suicidal thoughts or behaviors. The questions
displayed in the box are representative or indicative of a particular theme,
and may be modified in accordance to the patient’s clinical history and
socio-cultural context.

Box 1: Guidance questions for clinical enquiry into suicidal risk

Screening for suicidal ideation
• Do you ever feel like giving up or think that life is not worth living?
• Do you ever feel that things won’t get better in future?
• Do you ever wish to just go to sleep and never wakeup?
• Does your life ever seem so bad that you wish to be dead?
• Have things ever been so bad that you seriously considered about harming
yourself?
• Have you thought or made plans about death or dying recently?
Exploration in patients with suicidal ideations
• When did you first have such thoughts?
• How often do you have such thoughts? For how long? How intense? Degree
of control exercised?
• Are there any particular events, circumstances or situations associated with
these?
• How close did you actually come to acting on them?
• Did you or do you have a specific plan to harm yourself?
• Did you make any particular preparation? (e.g. writing a suicide note, a will
for legal heirs, arranging your finances, etc.)
• Did you tell anyone about your plans to harm (or kill) yourself?
 Risk Assessment 257

• Did you ever start to harm (or kill) yourself but aborted it before doing some-
thing?
• What stopped you from going ahead with the suicidal behavior?
• What do you envision to happen after suicide?
• Do you have access to firearms, or other lethal means of harming yourself?
• What did you do when thoughts of harming or killing yourself became in-
tense?
• How do you view future? Do you think things can get better in future?
Additional exploration in patients with suicidal attempt
• What was your intent at the time of harming self?
• Can you describe the circumstances surrounding an attempt?
• Did you plan ahead for the suicidal attempt? What kind of plans? For how
long?
• Why did you choose this particular method?
• How did you feel when you found that you have been saved?

Following points must be noted with respect to clinical risk assessment:

• The exploration for risk assessment must be done systematically
as part of a clinical interview and not in a checklist manner.
• Risk assessment is best started from open-ended questions, and
gradually moving towards closed-ended, leading (yes/no) ques-
tions.
• Lethality must be determined as per objective assessment of the
actual danger to life posed by a particular method or act. The
person’s expectation of what he/she considers to be medically dan-
gerous must be taken into consideration. For example, a layperson
may have limited knowledge on maximal lethal dose for benzodi-
azepines
• Clinician must also explore for time during which intensity of sui-
cidal ideation and behaviors was considered to be at its worst over
their lifetime, and ascertain their course.
• An exploration can also be made for evidence suggestive of an
escalation of potential lethality of suicidal behaviors (e.g. from
cutting wrist to hanging or shooting with gun).
• Clinician must ask open-ended questions about reasons to live and
reasons to die, and observe for the spontaneous responses pro-
vided by the person.
258 Clinical Methods in Psychiatry

• Patients with very high suicidal intent may not express and/or can
conceal warning signs of imminent suicide. Clinician should also
gather information from collateral sources instead of sole reliance
on self report.

Exploration for Static vs Modifiable Risk factors

Box 2 lists some of the common risk factors which are taken in
consideration during assessment of suicidality. As oppose to static risk
factors, the dynamic risk factors are potentially modifiable, can change
spontaneously with time or are amenable to change by interventions.

Box 2: Some risk factors for suicidality

Static factors (non-modifiable) Dynamic factors (potentially modifiable)

• Recent stressful life event or loss • Current psychopathology : hopelessness,

• Lifetime psychiatric diagnosis delusional guilt, etc.
• Past history of self-harm attempt/s • Ongoing alcohol or substance abuse
• Family history of completed suicide • Morbid mood states, severe anxiety
• Presence of a severe intractable or agitation, associated sleep disturbances
medical morbidity or terminal illness • Poor coping or problem-solving skills
• Demographic risk factors • Psychosocial stressors (e.g. conflicts)
• Poor compliance to treatment
• Lack of purpose in life

Exploration for Protective factors

The assessment should also explore and document protective factors
which may act as buffer between suicidal ideas and actual behavior.
Interventions with chronically suicidal patients often focus on enhancing
the support and protective factors for an individual.
Potential protective factors could be
• Social support systems
• Strongly held, religious beliefs prohibiting death by suicide
• Sense of purpose in life
• Sense of responsibility towards others
• Problem-focused coping skills, etc.
Two important points need to be noted in this context, as follows
• The protective factors should be ascertained in the context of that
 Risk Assessment 259

individual and not presumed. For example, family can act as a

source of stress rather than support for individuals with inter-per-
sonal conflicts, property disputes or other issues acting as a stres-
sor.
• Mere presence of protective factors should not be considered to
protect an individual from suicide especially when potential warn-
ing signs or high degree of suicidal risk is noted in clinical inter-
view.

Use of Suicidal Risk Assessment Instruments

The Columbia Suicide Severity Rating Scale (C-SSRS) is currently
considered as the gold standard instrument for assessment and monitoring
of suicidal behaviors among at-risk individuals. It is free for use in clinical
settings. Three different versions are available which can be used as per
requirement:
a) Lifetime/Recent version: for baseline assessment
b) Since Last Visit version: for evaluation of change in suicide risk
during follow-up
c) Screener version (brief set of questions for triaging by non-spe-
cialists).
Apart from this, the C-SSRS also has a risk assessment page which
enlists risk and protective factors of suicidality. However, there is a need
to contextualize the risk factors in light of current life situation and beliefs
of a particular individual.
Some of the other commonly used instruments in clinical or research
settings include Beck Scale for Suicide Ideation (B-SSI), Suicide Intent
Scale (SIS) etc., which are used to assess for suicidal risk, in addition to
scales for rating psychopathology (e.g. Hamilton Depression Rating Scale).
Risk-Rescue Rating determines the balance of risk and rescue factors in
association with a particular suicidal attempt by patient. Besides these,
patients can also be assessed for protective factors using instruments such
as Reasons for Living Inventory.
As previously discussed, we wish to re-emphasize that rating scales or
clinical instruments must not be used as stand-alone measures, but should
form a part of the comprehensive suicidal risk assessment.
260 Clinical Methods in Psychiatry

Determination and documentation of overall risk level

The risk level of an individual should be determined after a careful
assessment and weighing of above factors, and a clear reasoning for the
determination should be documented. It might be useful to indicate a level
of concern (viz. high, moderate, or low) for the overall assessment, but it is
even more helpful if the identified situations and triggers are qualitatively
described, which can help to plan for potential mitigation strategies.
The risk must be communicated in clear, unambiguous and accurate
terms to legal guardians. Risk must also be discussed with patients, along
with management plan. A clear documentation must also be made in the
written records.

Box 3: Case vignettes with risk assessment

Case 1: A 27-year old married female, educated upto 5th standard, homemaker,
presented with history of suicide attempt by cutting her neck. The woman had
been suffering from depression for last three months and wasn’t able to carry
out her household responsibilities for the last month. She had started thinking
of killing herself for last 2-3 weeks. On the day of attempting suicide, she
bought a new shaving blade from the market, and kept it in the cupboard. After
cleaning the house, and sending the husband to work, patient wrote a suicide
note. She stuck the suicide note on the almirah and planned to kill herself in the
afternoon since no vendors would visit during those hours. She locked the house
from inside and cut her neck with the blade and became unconscious. She was
discovered by her husband, who incidentally came back. Patient was taken to
the hospital and was stabilized with neck reparative surgery and admission in
ICU. On further evaluation, it was discovered that patient’s sister had also died
by suicide, and the patient had a previous attempt during past depressive episode.
Patient was initially not cooperative for interview and kept expressing her
failures, including a failed suicide attempt. She expressed to the psychiatrist
that if she had gone out of home to a secluded place, she wouldn’t have survived
to suffer more. She was kept in-patient with high-risk precautions and later
shifted to psychiatry in-patient settings for management.

Case 2: A 27-year old married, male, educated upto [Link] Nursing, working in
ICU in a tertiary hospital presented with history of cutting wrist with the intent
to die. On detailed assessment, it was discovered that the patient had history of
opioid dependence for the last 10 years and was currently using tramadol
injections, often stealing them from the ICU. He had frequent interpersonal
conflicts with his wife over this and was also facing issues at workplace due to
absenteeism and negligence. He would have occasional low mood with bouts
of irritability whenever he would be restricted from using the psychoactive
substance. He would tell his wife that if she continues to keep him under
surveillance, he would either kill her or himself. When allowed to administer
 Risk Assessment 261

injection, he would remain calm and euthymic. One day after having an
altercation with wife, he threatened her to kill himself and went outside the
home. He then started making a video call to his wife, cut his wrist superficially.
As soon as passersby noted the same, an ambulance was called. Patient was
awake throughout and guided the ambulance to take him to his place of
employment. On exploration, he further told the consulting psychiatrist that he
was aware that cut would not injure him deeply. He expressed remorse on
making the attempt and was ready to seek treatment. There was no other past or
family history of any psychiatric illness. Patient was admitted in psychiatry
ward for a week before being stabilized and discharged.

Risk Assessment for Harm to Others (Violence Risk Assessment)

Several different scenarios may warrant risk assessment. The broad
principles and themes in violence risk assessment remain the same as
discussed in the above section. Approach may have to be somewhat
customized across different types of settings and patient populations.
• Individuals may be referred by judiciary or brought by other au-
thorities after a violent incident/threat has taken place. In such
scenarios, the clinician may explain about the purpose, processes
as well as potential benefits of cooperation in order to reduce any
hostility directed towards the clinician.
• Violence risk assessment can also be conducted in emergency or
ward settings for patients who have demonstrated an agitated/vio-
lent or threatening behavior. Clinician may have to ensure safety
of patient, self and other staff first, prior to making assessment
based on all available sources of information, including observa-
tion.
• Occasionally, risk assessment might also be required for a particu-
lar out-patient who may talk about ideas to harm a particular per-
son or group of persons. Such patients may be interviewed in de-
tail for a formal risk assessment, in order to ascertain their intent,
plans etc. and decide the next course of action accordingly.
In this section, we discuss the risk assessment with respect to clinical
settings rather than forensic settings, though basic principles remain the
same.
Safety considerations
The examiner needs to ensure own safety first, and should make a
mental note of all the exit points from the place where assessment is to be
262 Clinical Methods in Psychiatry

carried out. A safe distance (of about 3-4 feet) should be maintained during
the assessment of potentially violent patients. Clinician must demonstrate
a calm tone and non-threatening posture, especially with a suspicious or
hostile patient. Further, any object which can be used to harm can be
cautiously removed the environment prior to start of an interview (e.g., a
jug of water, tea kettle, etc.). Clinician can also ask security staff to stay at
some distance so as to intervene in case of need, especially for patients
who have displayed violence in the past.
Clinician should be watchful for premonitory warning signs and
symptoms of impending physical violence, which can be as below:
• Rigid muscle tone or aggressive posture
• Brisk walking or pacing
• Banging of fist or feet on nearby objects like table/wall/floor
• Clenching of fists or teeth
• Throwing off objects
• Overt or covert threats, shouting in anger
• Invading personal space
• Pressured and/or loud speech
• Disinhibited or authoritative behavior
• Emotionally aroused state (e.g. agitated, extreme fearfulness)
• Non-cooperation (e.g. refusal to undergo testing)
Their presence indicates the need to immediately stop the interview
and ensure one’s safety first. At the same time, other relevant risks such as
patient self-harm (murder-suicide), absconding, etc., may also be anticipated
and appropriately managed.

Clinical enquiry into risk

Prior to start of an interview, the clinician must ask permission and
observe for willingness to start the interview. A formal risk assessment can
proceed ahead only if patient consents to be interviewed. As discussed in
the section above, one must begin with open-ended questions and slowly
proceed to narrow ended or specific questions as per earlier responses. In
order to explore for the risk of violence, clinician can ask open-ended
questions such as:
 Risk Assessment 263

• “Are you angry at someone?”

• “Do you sometimes wish to punish or take revenge for the wrong
doings?”
• “Have you thought of any ways to do that?”
• “Have you made any preparation towards that?”
The duration, frequency, severity, and recency of such violent thoughts
or behavior should be assessed in a non-confrontational manner. It is also
important to explore if patient has made any specific plans or engaged in
any preparatory behavior. For example, “I will go to my office tomorrow
and confront all those who conspired to expel me. I will also take my knife
along, just in case”. Further, if there is history of violent behaviors, the
interviewer should try and look for any repeating patterns or situations
that lead to these escalations.

Exploration for Risk factors

Box 4 lists some of the risk factors of relevance to violence risk
assessment. Factors related to the patient’s environment, life situation, or
relationships which are potentially modifiable must be carefully noted as
they can help in subsequent management.

Box 4: Risk factors for violence/risk of harm to others

Static factors (non-modifiable) Dynamic factors (potentially
modifiable)

• History of violence • Easy access to lethal means

• Antisocial or narcissistic personality • Negative affect states (e.g. irritability,
disorder anger, suspiciousness)
• Trait impulsivity • Psychosocial stressors (e.g. conflict
• Lifetime substance use disorders with one or more person)
• Younger adults (especially • Current alcohol or other substance use
15-24 years) • Positive psychotic symptoms
• Male gender (e.g. delusion of persecution, command
hallucinations)
• Non-compliance to treatment

Exploration for Protective factors

The protective factors must also be assessed as part of the violence
risk assessment. Instruments such as Structured Assessment of Protective
Factors for violence risk have been used to identify some common
protective factors based on literature, which then allows clinicians to use
264 Clinical Methods in Psychiatry

their professional judgement about the relative protective effect offered by

each of them in a particular individual’s context. It divides protective factors
into three broad groups: internal factors (e.g. secure attachment in
childhood, empathy, coping skills, intelligence); motivational factors (e.g.
work, leisure activities, financial management, motivation for treatment);
and external factors (e.g. social network, intimate relationship).
Apart from this, the individual should also be asked about the reasons
or factors which have stopped or are stopping him from committing
violence. Factors which could be further strengthened by means of
intervention should be carefully noted.

Use of Clinical Instruments

As previously discussed, it may not be prudent to rely solely or
excessively on rating scales or clinical instruments in clinical risk
assessment, but these can form a part of the comprehensive violence risk
assessment.
The Historical Clinical Risk (HCR-20)Violence Risk Assessment
Scheme is a 20-item assessment tool, which is one of most researched and
empirically guided risk assessment tool. It provides a higher emphasis on
risk management and risk reduction compared to other actuarial approaches.
It is often used in clinical or forensic settings in order to assess the future
risk of violence. Briefly, HCR-20 risk factors are dispersed across three
scales, as below :
• Historical scale (10 risk factors), which focuses on past events,
experiences, and psychiatric conditions (e.g., past violence, young
age at first violence, major mental illness, psychopathy, personal-
ity disorder, childhood maladjustment)
• Clinical scale (5 risk factors), which focuses on recent function-
ing (e.g., negative attitudes, psychiatric symptoms, non-compli-
ance, impulsivity)
• Risk Management scale (5 risk factors), which deals with factors
such as feasibility of plans, stress, and support.
HCR-20 carries a total of 10 static risk factors (historical scale) and 10
dynamic or potentially changeable risk factors (Clinical and Risk
Management scale), with a recommendation that dynamic risk factors
should be re-evaluated periodically. Each item can be scored as absent
(score of 0), possibly/partially present (score of 1), or definitely present
 Risk Assessment 265

(score of 2). The clinician then makes a final summary risk rating (viz.
low, moderate, or high) for violence risk, depending on the number of risk
factors present, their relevance and the degree of intervention or risk
management that is estimated to be necessary to mitigate risk.
Such an approach can be used in conjunction with other instruments,
as relevant, in clinical or research settings including scales for assessing or
rating psychopathology (psychosis, mania, psychopathy etc.).

Determination of risk level

The overall risk level should be determined after a careful assessment
of all factors, and a clear reasoning for the determination should be
documented. The severity of risk assessment is not related to the number
of items ticked on a scale or checklist, and should involve professional
judgement based on clinical interview by a trained professional.
Additionally, if the risk of violence is identified to be directed at
particular individual/s, then the clinician has a duty to take appropriate
steps to protect them, including informing authorities, while fulfilling their
duty to care for the patient. The communication can no longer be considered
privileged in cases with risk for violence; however clinicians must
thoroughly appraise or update themselves of the relevant legal aspects
surrounding such scenarios.

Summing up
Risk assessment serves a two-fold purpose i.e. predicts the possibility
of an adverse outcome and identifies the potential factors contextualized
to that individual which can help to mitigate risk. A thorough risk assessment
forms the cornerstone of effective risk management in clinical settings.
The process takes place in an open and collaborative manner with
involvement of patient and family members. Clinician usually assesses the
risk and protective factors, and also incorporates the information about the
relative importance of these factors based on the examination of patient’s
life situation or context in a systematic manner. The instruments are often
incorporated as an aid and not meant to substitute clinical judgement and
decision-making. Further, the individual’s own perspective, current life
situation, personality aspects, social support are also taken into conside-
ration, in addition to lifetime and current psychiatric diagnosis. In situations
where the patient is an imminent threat to self or others, the psychiatrist
would need to proceed with hospitalization in accordance to existing legal
266 Clinical Methods in Psychiatry

provisions. Risk assessment must be clearly conveyed to family or legal

guardians, and same must be documented in written records. Risk
assessment should not be restricted only to a one-time evaluation after
crisis, but may be conducted on a periodic basis during the follow-up visits
for those with chronic suicidality or lifetime risk.

Suggested reading
• The Tavistock and Portman NHS. Clinical Risk Assessment Procedure
V2.5; 2019. NHS Foundation Trust. [Link]
[Link]/documents/5/Clinical-riskassessment_Procedure_v_2.5_
June_19.pdf (Last accessed on 4 January, 2024).
• Brendel RW, Wei MH, Edersheim JG. An approach to the patient in
crisis: assessments of the risk of suicide and violence. Med Clin North
Am 2010; 94(6) : 1089-102.
• Jacobs DG, Brewer ML. Application of The APA Practice Guidelines
on Suicide to Clinical Practice. CNS Spectr 2006; 11(6) : 447-54.
• Practice guideline for the assessment and treatment of patients with
suicidal behaviors. Am J Psychiatry. 2003; 160(11 Suppl) : 1-60.
• The Columbia-Suicide Severity Rating Scale. Available from: http://
[Link]/ (Last accessed on 4 January, 2024).
• Pinals DA. Violence Risk Assessment in Clinical Settings: Enduring
Challenges and Evolving Lessons. Harv Rev Psychiatry 2021; 29(1) :
90-3.
• Ramesh T, Igoumenou A, Vazquez Montes M, Fazel S. Use of risk
assessment instruments to predict violence in forensic psychiatric
hospitals: a systematic review and meta-analysis. Eur Psychiatry 2018;
52 : 47-53.
• Historical Risk Assessment. Available from: [Link]
accessed on 4 January, 2024).