So, I guess I’ve committed myself now I have to do something medical at least most Wednesdays.
Maybe I should start with something about why I should be writing posts about medicine on my blog anyway. I am a doctor: a psychiatrist working in the public service in a busy health service in one of the largest and busiest Local Government Areas in Australia – and one with some of the worst deprivation, and heaps of drug use to complicate things. I work in the acute part of ourservice, in the hospital Emergency Department and also on an outpatient basis: at our clinic, and (probably more often) at people’s homes.
So what can I offer in a blog? There are a lot of misunderstandings out there about psychiatry: what it is, what are psychiatrists, why do we do it, what is mental illness …. I might be able to shed a bit of light and humanity on some of these. Also, I hope there might be some interest in some broad reviews of some interesting areas of psychiatry.
So where to start tonight?
The Folly of Risk Assessment
There. I said it. The one thing we are asked more than anything else – and the request that bugs me more than just about any other – is to “do a risk assessment”. In fact NSW Health has enshrined the notion of “a risk assessment” in policy and mandatory documentation. I can understand: when people are psychiatrically ill, and talk about suicide, or harming others, other people want to know how likely it is that person will carry out what they’re speaking of. Sorry. Can’t be done, and I hope to illustrate why.
First, the fact that it can’t be done. There has been a lot of study over many years, about predicting suicide/homicide etc. Basically, we’re no better than chance (I’ll come back to this). Consequently, various actuarial methods of risk assessment have been devised: counting up various identifiable risk factors and coming out with a result purporting to tell you how much risk there is. Sounds a good idea, no? Problem is, they’re no better than chance either. That doesn’t stop forensic services and Governments enshrining them in policy – but that doesn’t make them work any better. Why don’t they work? Again, I’ll get to that. After a little detour through a pet peeve of mine.
Take cardiology for a minute. The median 30-day mortality after an acute myocardial infarction is 1 in 6 and for heart failure just over 1 in 10. It is accepted that these are potentially fatal diseases, despite our best efforts to prevent that outcome. Perhaps because the (most visible) method of lethality of psychiatric illness is by the patient’s own hand, the same acceptance does not exist that these are potentially fatal illnesses (in fact, most of the excess mortality in people with psychiatric illness is not due to suicide, but that’s possibly a topic for another post …). Sad to say however, they are – again, despite our best efforts. I don’t mean to sound defeatist – and I certainly don’t feel it – but it is a fact that we cannot prevent every suicide.
Back to “Risk assessment”:
So how can we prevent at least a significant chunk of sucides? We need to identify those at risk, and identify of those, who are at risk because of mental illness. Despite what “common sense” might tell you, not everyone who talks of harming or killing themselves is psychiatrically ill. – And if they’re not, there’s actually nothing that we can do, other than locking them up forever and a day (which is perhaps a subject for a future philosophy/ethics post …). So clearly we need to perform a comprehensive psychiatric assessment, to ascertain the presence (or absence) of psychiatric illness, and formulate a plan to treat appropriately whatever we might find. So far, so fine. But what about the RISK?
Earlier I mentioned various identified risk factors; what are they? There are things we know to be associated with a higher risk of suicide: age is one (young adults generally, though elderly have high rates), male gender, previous attempts, presence of psychiatric illness, alcohol or other drug use, lacking social support networks …. All make sense, right? So why can’t we put those together – like those actuarial tools try to do – and know?
An analogy I came up with today was with road traffic fatalities (which by the way are about as common as suicides). We can be very clear about a bunch of very important risk factors for dying on the roads: driving excessively fast/recklessly, driving while intoxicated, previous crashes (I would imagine), young age/provisional license, male … and so on. However, most people with those risk factors don’t die on the roads. Most young men who drive fast don’t die on the roads – even the intoxicated ones, though they’re much more likely to do so. The thing is, we absolutely can identify an elevated risk, but we absolutely cannot identify who of a group of people is going to be the one or ones to die on the road. Think about Isaac Asimov’s “Foundation” series: the “psychohistorian” Hari Seldon made some major predictions about what would happen to the Foundation(s) he set up – and these were very accurate … except as applied to individuals. Groups can be studied, modelled and predicted about; individuals not so much. Same with road fatalities, and same with suicide: we know the factors that are associated with increased risk. We know that more of them being present suggests a higher risk, but we just cannot say with any useful degree of surety that Joe Bloggs will suicide and John Smith won’t.
So what can/should we do? I would suggest we should recognise and accept that not all suicide and self-harming behaviour is the business of psychiatry, and not all of it (even that that is our business) is always preventable. Our business is certainly to make sure we identify those that are our business (i.e. those with psychiatric illness – about whom we can actually do something), and then to do what we can to treat that illness, thereby decreasing the risk they will carry out their ideas of suicide. Basically I’m advocating a shift towards risk management, rather than a reified Risk Assessment. However, politicians are anxious; they like order, and forms, and numbers. It makes them look like they are doing something. – And that’s all well and good and lovely … except that it’s not a particularly helpful way to address the problem.
As I said in a meeting today, while we can’t do less than the Government mandates (we can’t simply refuse to fill out their forms, and train our staff in their model of “Risk Assessment”) we can do more, and educate our staff in comprehensive assessment, and risk formulation and management. We’re still expected to prevent the sometimes unpreventable, but I don’t see a clear or easy way out of that.
Finally – please, please remember, next time you see some melodramatic newspaper or television headline screaming that the “mental health system failed” some poor person who suicided (or killed someone else: a much rare event, and one even more emotionally charged for everyone – but one to which everything I’ve written above applies in the same way): that all the facts are not given to you; that it is very hard to predict the actions of an individual (despite identifying all the correct risk factors); that it might not have been a psychiatric problem at base anyway; and assuming it was, the men and women involved in the person’s treatment would have done their level best to help the person, and manage the risk.