Chris J. Hawley

Structure and content of risk assessment proformas in mental healthcare

Background: The NSF specifies that mental health service providers should have a locally agreed proforma for assessing risk. Risk assessment proformas (RAPs) currently in use vary considerably in both structure and content. This study describes some similarities and differences. Method: We requested a copy of each provider trusts RAP. These were assessed across a range of structural characteristics, including layout, design, data coding, and were also studied for their content. Results: Some consistency was seen in the themes addressed: suicide/self harm, risk to others (notably violence) and vulnerability were well represented. Several additional themes were notable by their absence. There was general conformity in the way in which data was coded, with most using tick box categories. However, there were striking differences in layout quality and usability and many common problems were identified. Conclusions: RAPs as currently used in NHS mental-health practice vary in structure, content, length and quality. We question (i) the most common approaches in recording risk data in RAPs, and (ii) whether the focus on three domains of risk acts to neglect other, less dramatic, areas. Risk assessment procedures need to be critically evaluated and the introduction of standardized tools would be advantageous in this respect. Declaration of interest: This work was supported by NHS R&D Support funding awarded to Hertfordshire Partnership NHS Trust.

Risk assessment in mental health : staff attitudes and an estimate of time cost

Background: Risk assessment is a routine part of mental health services, with professionals being required to complete a risk assessment proforma (RAP) for every patient under their care. Aims: This study was designed to investigate staff attitudes to, and beliefs about, the completion of risk assessment paperwork. Method: We surveyed 300 professionals across one county to examine: (i) the amount of time taken to complete RAPs; (ii) attitudes towards completing such paperwork; and (iii) beliefs about the quality and usefulness of the information recorded. Results: We found considerable variation in the amount of time taken to complete RAPs. The median time was 18 minutes with doctors spending significantly less time than nurses. More favourable attitudes towards RAPs were seen in nurses than in doctors, in spite of the increased time spent completing them. Moreover, nurses also held more positive views about the value and benefit of the information recorded in RAPs. Conclusions: The findings suggest that RAP completion may account for a significant proportion of staff time. Inter-professional differences in belief and attitude were prominent and this should be an important consideration in the evolution of risk assessment procedures.

Depression rating scales can be related to each other by simple equations

We present evidence that scores on the Montgomery, Hamilton and Beck depression scales are strongly intercorrelated and can be equated to each other. These scales were administered on 107 occasions to patients with major depression. The correlations between scores on each scale were much higher than has been previously reported and, furthermore, the relationships were always well described by a linear function. The close correlations could not be explained by rater biases. We were able to provide validation data for two of the rating scales, demonstrating that our simple models generalize well to a novel dataset. The knowledge that there is a robust relationship between the three scales has practical value for both clinicians and researchers.

Switching stable patients with schizophrenia from depot and oral antipsychotics to long-acting injectable risperidone: reasons for switching and safety

An international, non‐randomised study evaluated efficacy and safety of risperidone long‐acting injectable (RLAI) compared to previous treatment. To investigate generisability of the European data set to the UK subset safety and switching data are reported here.

Do mental health professionals really understand probability? Implications for risk assessment and evidence-based practice

Background: Many studies have highlighted poor understanding of risk and probability in NHS service users. By contrast, few studies have explored whether health professionals share similar conceptual difficulties. The current study is an attempt to address this issue within the field of mental health. Aims: The principal aim of the study is to test knowledge of basic probability across a range of Mental Health Professionals (MHPs) and to identify those aspects which they found difficult Method: MHPs sample were compared to age-, gender-, and education-matched control group to establish whether MHPs were more skilled in dealing with probabilistic concepts. The assessment addressed several key aspects of probability that are important in risk assessment and evidence-based evaluations. Results: Contrary to our predictions, the MHP group was no more accurate than the control group and many conceptual problems were highlighted, ranging from basic arithmetic difficulties to problems in evaluating relevant information. Systematic error was common in all areas tested. More generally, age, educational level, gender and professional group all strongly predicted response accuracy. Conclusions: Our findings are discussed principally in relation to risk assessment practice. Our data suggest that all MHPs would benefit from receiving greater training in probability theory, since risk is central to so many concerns in mental health services. Declaration of interest: None.

Excessive daytime sleepiness in psychiatric disorders: Prevalence, correlates and clinical significance

This study examined the prevalence of excessive daytime sleepiness, as measured by the Epworth Sleepiness Scale (ESS), in a cohort of adult psychiatric patients. A total of 300 psychiatric outpatients and an additional 300 healthy controls completed the ESS. Excessive sleepiness was defined by a score of > or =10. The prevalence of excessive daytime sleepiness was higher in the psychiatric group (34%) than the control group (27%), and the mean ESS score was also significantly higher in the psychiatric group. The prevalence of excessive sleepiness was higher for female psychiatric patients, but this pattern was not found in the control group. Surprisingly, there was no difference in ESS score between patients taking antipsychotic medication and those not taking antipsychotic medication. The data suggest that excessive daytime sleepiness is a significant issue in general adult psychiatry, but this must be interpreted against a relatively high prevalence in the normal population.

Equations for converting scores between depression scales (MÅDRS, SRS, PHQ‐9 and BDI‐II): good statistical, but weak idiographic, validity

A variety of depression rating scales are currently used in clinical and research practice. As these scales are generally thought to correlate well, there may be some benefit in deriving equations to translate the score on one scale to that on another.

To admit or not to admit? The effect of framing on risk assessment decision making in psychiatrists

Abstract Background: The way that information is presented is well known to induce a range of biases in human decision tasks. Little research exists on framing effects in psychiatric decision making, but it is reasonable to assume that psychiatrists are not immune and, if so, there may be implications for the welfare of patients, staff and the general public. Aims: To investigate whether presentation of risk information in different formats (frequency, percentage and semantic) influences inpatient admission decisions by psychiatrists. Methods: Six-hundred seventy-eight general adult psychiatrists read a short clinical vignette presenting a case scenario of a patient presenting for inpatient admission. One of four condition questions followed the vignette, incorporating either numerical or percentage probabilities and the semantic labels “high” and “low” risk. In each condition, the actual risk was identical, but the way it was presented varied. The decision to admit the patient or not was recorded and compared across conditions. Results: More individuals chose to admit the patient when risk information was presented in numerical form (X2 = 7.43, p = 0.006) and with the semantic label “high” (X2 = 7.27, p = 0.007). Conclusions: Presentation of risk information may influence decision making in psychiatrists. This has important implications for mental health clinical practice where clinicians are required to interpret probabilistic information within their daily work.

Are placebo-controlled trials still important for obsessive compulsive disorder?

The use of placebos as reference agents in randomised controlled trials for psychiatric disorders has come under question for ethical reasons. Alternative methods for validating the efficacy of new treatments exist, but may not be as reliable as placebo. In this paper we examine arguments for and against the ongoing use of placebo agents in the development of new treatments for obsessive compulsive disorder in the context of evidence from randomised controlled trials.

Excessive daytime sleepiness in psychiatry: a relevant focus for clinical attention and treatment?

Excessive daytime sleepiness is a feature of many general medical disorders and is associated with significant impairment in function and well-being. It has, however, received little attention in psychiatry although it may be a common and clinically important problem. The opinions of two expert groups, and a survey of the literature, were used to form views about the prevalence and clinical significance of excessive sleepiness in psychiatric populations. Issues relating to pharmacological treatment were also considered. Despite a scant evidence base, the conclusions are that excessive sleepiness may be a common and significant problem, and potentially amenable to treatment. However, clinician awareness is probably limited and there are opportunities for further research.