Psychiatric Risk Assessment – OSCE Guide

Conducting a risk assessment is integral to any psychiatric history and often appears in OSCE stations. Any mental health condition can increase a patient’s risk, for example:

• Depression can lead to suicide ideation and deliberate self-harm
• Mania may cause reduced risk awareness, leading to dangerous driving
• Psychosis may come with command hallucinations to hurt others
• Post-traumatic stress disorder (PTSD) can lead to alcohol use as a way of managing unbearable memories

There are three broad areas to consider:

• Risk to self
• Risk from others
• Risk to others

When assessing risk, you should be empathetic, curious, and ask for specifics. It is important to ask patients whether they have any thoughts or plans to harm themselves or others. 

This guide provides a general framework for performing a psychiatric risk assessment in an OSCE setting.

Assessing risk to self

Risk to self can be subdivided into the following sections:

• Personal safety
• Personal health

Personal safety

Ask the patient if they are experiencing any thoughts of harming themselves and whether they plan to act on these thoughts.

It is also important to ask about deliberate self-harm, which some patients may undertake not with suicidal intent but as a way of managing overwhelming and difficult emotions or feelings of dissociation. Normalising statements can help reduce shame and stigma, helping the patient talk more about this challenging topic.

Ways of approaching this might include:

• “Sometimes, when people are going through difficult things, they might have thoughts of wanting to harm themselves – is this something you’ve experienced?”
• “Do you have any plans to act on those thoughts?”
• “People can sometimes hurt themselves as a way of managing overwhelming emotions or feelings of numbness– is this something you’ve ever done? If so, what things do you do to cope with these feelings?”

If the patient has attempted to harm themselves

If the patient has attempted to harm themselves, it is important to take a detailed history of events before, during and after the episode of self-harm. For more information, see our guide to performing a suicide risk assessment. 

What was going through their mind when they harmed themselves?

• Check for any delusions of control or command hallucinations

Clarify details about the method of the attempt at self-harm/suicide (e.g. what tablets did they take and when?)

• Be aware of methods with high lethality, such as hanging

Were any preparations made? Did they make attempts not to be found? Did they make a will or leave a note?

• “Some people might make preparations such as getting their affairs in order or writing a note to loved ones – was this something you did?”
• “Did you let anyone know what you planned to do?”
• “Did you think you’d be found?”

Was the attempt planned or an impulsive action?

• “Was this something you’d been planning for a while?”
• “Did you make any preparations?”

What was their assessment of lethality?

• “What did you think would happen?”
• “What outcome were you hoping for?”
• “Did you expect to die?”

Did alcohol play a role at all?

• Were they drunk/under the influence of drugs when they attempted to harm themselves?
• Did they drink alcohol to help ensure the attempt was successful?

How do they feel about the attempt now?

• Are they regretful of their actions?
• Are they upset the attempt was unsuccessful?

Do they have any further plans to harm themselves?

• “Do you think you would try to harm yourself again? “
• “Do you think you would be able to keep yourself safe?”
• Be aware of ongoing access to means (e.g. stockpiles of medication at home, knives etc.)

Can they identify any protective factors?

• Family, friends and pets are commonly cited protective factors
• “What would stop you from harming yourself again?”
• “Is there anything that has been helpful in keeping yourself safe in the past?”
• “Would you be able to reach out for support if you felt like harming yourself again? Who would you contact?”

Are there any risk factors in the history?

• Any family history of suicide?
• Any precipitating triggers?
• Ask about psychosocial stressors such as financial worries or housing insecurity
• Any recent losses?
• Are they socially isolated?

Personal health

Mental health conditions can impair a person’s ability to look after their health in many ways. For example:

• Depression can lead to self-neglect due to feelings of worthlessness and a lack of motivation
• Psychosis can lead to reduced oral intake if people are experiencing command hallucinations not to eat or drink
• Mania can impair people’s judgment and lead to risky behaviour, such as driving too fast or engaging in unsafe sexual practices
• PTSD or past trauma may lead to patients self-medicating with alcohol or drugs as a way of coping

Substance abuse

Does the patient use alcohol or drugs as a way of managing difficult feelings or memories?

• “When things are difficult, people can turn to drugs or alcohol as a way of coping – it this something you’ve done?”

Neglect

Consider personal hygiene, nutrition and safety:

• “Are you managing to look after yourself at the moment?”
• “When did you last have something to eat?”
• “When people are struggling with their mental health, it can be difficult to take care of ourselves – is this something you’re struggling with?”
• “Is anyone telling you not to take care of yourself?”
• “Are you taking more risks than you normally would?”

Concordance

Psychiatric diagnoses can increase the risk of non-concordance with medication, whether through impairing judgement (e.g. in mania or psychosis) or by interfering with patients’ ability to perform activities of daily living (e.g. in depression).

• “Have you been taking your prescribed medication?”
• “Are you able to attend your appointments?”
• “How often do you remember to take your tablets?”
• “Is anyone telling you not to take your tablets?”

Physical health

Chronic illnesses and pain can increase the risk of harm to self, especially in older adults:

• “Do you suffer from any physical health conditions that are affecting your mental health?”

Assessing risk from others

It is important to clarify if the patient is at risk from others. Consider whether there are any safeguarding concerns, and state that you would discuss these with a senior clinician at the earliest appropriate opportunity. Remember that patients who rely on others for their care may be at risk of neglect and/or financial abuse.

Patients may be unable to speak openly in front of others and ensure that you can speak to the patient alone if you have concerns. Remember that it is not best practice to use family or friends as interpreters. 

Patients who are experiencing abuse from others can feel ashamed. Being empathetic and non-judgmental can help encourage patients to talk about these difficult topics. Examples of questions you can ask include:

• “Do you feel safe at home?”
• “I can see how hard things are for you at the moment. Is there anyone in particular making you feel scared or unsafe?”
• “Is there anyone controlling you or stopping you living your life how you want to?”

Domestic violence and abuse

It is important to remember to ask about domestic violence and abuse, as mental health conditions are possible indicators of domestic violence or abuse.

Domestic abuse is defined as “any incident or pattern of incidents of controlling behaviour, coercive behaviour or threatening behaviour, violence or abuse between those aged 16 or over who are family members or who are, or have been, intimate partners. This includes psychological, physical, sexual, financial and emotional abuse. It also includes ‘honour’-based violence and forced marriage.”¹

All genders can experience domestic abuse, and it is estimated that 2.4 million adults experienced domestic abuse between October 2021 and March 2022, equating to 5% of the adult population

It can be helpful to frame questions using statements such as “It is not uncommon for people who experience mental health difficulties to be dealing with abusive relationships. Sometimes, it can be difficult to talk about these things, so I always ask about it routinely.”

Questions to ask include:

• “How are things at home?”
• “Has anyone at home hurt you or threatened to hurt you?”
• ” Does anyone at home control or isolate you?”
• “How does your partner treat you?”
• “Are you having any problems with your partner?”
• “Does your partner ever hurt or threaten you? Do they ever force you to do things you don’t want to do?”
• “Are you able to say no to your partner?”
• “How do your family treat you?”
• “Does anyone in your family police your behaviour?”

If you have any concerns that a patient may be at risk from others, it is important to always discuss with a senior clinician and consider whether a safeguarding referral may be warranted. 

Assessing risk to others

Ask the patient if they are having any thoughts or have made any plans to harm others. Again, normalising statements can help elicit this.

• “Sometimes, when people are going through difficult things, they might have thoughts to harm someone else. Is this something you’ve experienced?”
• “Do you have any plans to act on those thoughts?”

Clarify if they are experiencing any command hallucinations or delusions of control:

• “Is anyone telling you to harm other people?”
• “Do you feel in control of your thoughts and actions?”

References

1. NICE. Domestic violence and abuse. Published in 2016. Available from: [LINK]
2. Office for National Statistics. Domestic abuse prevalence and trends, England and Wales: year ending March 2022. Available from: [LINK]