Risk Assessment

As with all medical emergencies, psychiatric emergencies are among the most clinically challenging situations.

In addition to their use in the management of epilepsy, anticonvulsants are indicated for management of bipolar disorder, mania, neuralgia, migraine, and neuropathic pain.

My reality is constantly blurred by the mists of words.

Hy Bloom provided an expert psychiatric report in a multiple murder case in which the accused, who had schizophrenia and depression, had killed his wife and 2 children. Before the murders, the accused had been seeing a psychiatrist and family physician for treatment of the mental disorders.

The United States Census Bureau projects that by 2010 nearly 13% of the US population will be over the age of 65. The elderly are one of the most rapidly growing segments of the US population and are expected to account for more than 20% of the total population by 2050.1 In 2001, the prevalence of dementia in North America was 6.4%. A 49% increase in the number of people with dementia is expected by 2020, and a 172% increase by 2040.2 Patients with dementia may lack the capacity to consent to treatment. The need to evaluate capacity to consent to treatment will therefore increase as the aging population grows.

In the 33 years since I began medical school, psychiatric knowledge has greatly increased in depth and breadth, rendering much of what I originally was taught about diagnosis and treatment in need of revision. Critical concepts in malpractice have also been codified and studied since that time. We can now educate ourselves on the constituents of malpractice, as opposed to the vague admonitions I received in medical school to “watch out for the lawyers.”

Many forensic psychiatrists are known for never shrinking from a controversial subject. So it is with leading forensic psychiatrists Drs Donna M. Norris and Marilyn Price. In the November issue, they took on a sensitive subject that desperately needs more attention: firearms and mental illness.

Practical approaches to integrating these 3 aspects of a suicide assessment have been well delineated for adults and adolescents.1-8 Innovative systematic approaches, such as the Collaborative Assessment and Management of Suicidality (CAMS) approach created by David Jobes,9 have also been developed for integrating all 3 tasks while providing collaborative intervention, which may help lay the foundation for a more evidence-based protocol for suicide assessment. Recently, Joiner and colleagues10 have delineated a promising approach based on the interpersonal theory of suicide, which gracefully integrates all 3 components necessary for a suicide assessment.

Low levels of 3-methoxy-4-hydroxyphenylglycol (MHPG) in patients with major depressive disorder (MDD) or bipolar depression were shown to be associated with increased risk of suicide attempts. Hanga Galfalvy, PhD, assistant professor of clinical neurobiology at Columbia University and the New York State Psychiatric Institute, New York, and her colleagues found that patients with the lowest levels of MHPG at baseline were more likely to commit highly lethal suicidal acts.

A few simple steps can enhance your assessment of a patient’s suicide risk—and thereby reduce your own risk for liability if the patient does commit suicide. Phillip J. Resnick, MD, professor of psychiatry and director of forensic psychiatry at Case Western Reserve University in Cleveland, described those measures in a lecture today at the US Psychiatric Congress in Las Vegas.

The right of American citizens to own, register, and carry firearms has a significant history of federal and/or local regulation dating to the early 18th century.1 With the passage of the federal Gun Control Act of 1968, persons who have been treated for mental illness and/or substance abuse are among a defined group restricted from owning and carrying firearms.2-4 While violence is often portrayed in the media as related to persons with mental illnesses, there are limited research data to support this idea.5

Since the time of Homer, warriors have returned from battle with wounds both physical and psychological, and healers from priests to physicians have tried to relieve the pain of injured bodies and tormented minds.1 The soldier’s heartache of the American Civil War and the shell shock of World War I both describe the human toll of combat that since Vietnam has been clinically recognized as posttraumatic stress disorder (PTSD).2 The veterans of Operation Iraqi Freedom (OIF) and of Operation Enduring Freedom (OEF) share with their brothers and sisters in arms the high cost of war. As of August 2009, there have been 4333 confirmed deaths of US service men and women and 31,156 wounded in Iraq. As of this writing, 796 US soldiers have died in the fighting in Afghanistan.3

Many refugees have been victims of severe violence that has profoundly affected their physical, psychological, and spiritual lives

The epidemiology and management of psychiatric disability have gained increased attention for a variety of reasons in the past 3 decades. There are issues of empowerment, advocacy, and reduction of stigma. There are also concerns about cost containment as well as reliability, validity, and efficacy of the determination process.

Suicide risk assessment is a core competency that all psychiatrists must have.¹ A competent suicide assessment identifies modifiable and treatable protective factors that inform patient treatment and safety management.² Psychiatrists, unlike other medical specialists, do not often experience patient deaths, except by suicide. Patient suicide is an occupational hazard. A clinical axiom holds that there are 2 kinds of psychiatrists: those who have had patients commit suicide—and those who will.

In this podcast, Dr Thomas Gutheil talks about a key challenge facing psychiatrists. . . valid medical record keeping. Here: important tips from an expert based on an article he coathored with Dr. Robert Simon.

In the second in his series of podcasts, Dr Phillip Resnick answers questions psychiatrists often ask about assessing the risk of violence.