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The need for Structured risk assessment in Psychiatry in Developing Countries
- Prof K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), Dr.A.Hapangama MD , Lecturer in Psychiatry, Faculty of Medicine, University of Kelaniya,Ragama,Sri Lanka (8 September 2008)
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Prof K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), Professor of Psychiatry Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka, Dr.A.Hapangama MD , Lecturer in Psychiatry, Faculty of Medicine, University of Kelaniya,Ragama,Sri Lanka
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lalithkuruppu{at}lycos.com Prof K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), et al.
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Structured risk assessment and violence in acute psychiatric wards: randomized controlled trial by Abderhalden et al (2008) was read with interest. Violent behavior by psychiatric patients poses a considerable challenge to psychiatric staff because of the risks to the individuals and the implications of those risks. Therefore predicting violence is critical for establishing a management plan for patients and also is important in ensuring the safety of staff and other patients. The objective of the risk assessment should not be just to label an individual as low or high risk but to identify factors, which would assist in the plan of management of the particular patient. Research conducted in the 1970s and 1980s had called into question the ability of clinicians to make accurate risk assessments of violence (Monahan et al 2000). But, recent research has been slightly more optimistic. A suggested way to improve the accuracy of risk assessments of violence is to use structured risk assessment instruments (Swanson 2008). Risk assessment in psychiatric patients (both in and out patients) is an important issue globally; particularly in countries like Sri Lanka where community services are poorly developed and where the clinicians depend entirely on the families for various aspects of their patient’s management. Past violence, frequent medication change, high use of sedative drugs, ICD 10 diagnosis of dissocial personality disorder or emotionally unstable personality disorder, compulsory (involuntary) admission, comorbid diagnoses, past self-harm, and non-alcohol drug abuse have been shown to be predictors of violent behavior in in-patient settings (Soliman 2001). Overcrowding has also shown to increase the violence in psychiatry units (Ng B et al 2001). These risk factors are abundantly found in our psychiatry set ups, where patients of all ages with a variety of diagnoses are managed in the same units and where the wards are overcrowded with poorly trained and inadequate staff. A study done in a general hospital psychiatry unit in Sri Lanka found that violence was a common incident and overcrowding, lack of planned activities and having patients with alcohol withdrawal syndrome were risk factors for such episodes(Abeysinghe R et al 2003). We believe that in addition to educating the staff and improving the physical resources, introduction of protocols and structured risk assessment procedures can be used in order to reduce the risk of violence and coercion in acute psychiatry wards. We could also introduce similar scales to non- psychiatry settings, which could help to pick up people with self-harm ideas as many of the patients with deliberate self-harm, are managed in non psychiatric setting in countries like Sri Lanka. Like in the present paper nurses can be trained to do the risk assessment so that they will not only play a more active role in patient management but also there would be early identification of potentially dangerous and risky patients. Abderhalden C, Needham I, Dassen T et al. Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial. The British Journal of Psychiatry.2008 193: 44-50 Monahan J, Steadman HJ, Robbins PS et al. Developing a clinically useful actuarial tool for assessing violence risk. The British Journal of Psychiatry.2000; 176: 312-319 Swanson JW. Preventing the Unpredicted: Managing Violence Risk in Mental Health Care. Psychiatric Services. 2008; 59:191-193 Soliman A E, Reza H. Risk Factors and Correlates of Violence Among Acutely Ill Adult Psychiatric Inpatients. Psychiatric Services.2001; 52:75 -80 Ng B, Kumar S, Ranclaud M, Robinson E. Ward Crowding and Incidents of Violence on an Acute Psychiatric Inpatient Unit. Psychiatric Services. 2001. 52(4):521-5. Abeyasinghe R, Jayasekera R. Violence in a general hospital psychiatry unit for men. Ceylon Medical Journal. 2003. 48(2):45-7. |
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