Skip to main content

Advertisement

SpringerLink
Log in

Psychiatric Risk Assessment from the Clinician’s Perspective: Lessons for the Future

  • Original Paper
  • Published:
Community Mental Health Journal Aims and scope Submit manuscript

Abstract

Accurate prediction of risk-states in Serious Mental Illnesses (SMIs) is critical for reducing their massive societal burden. Risk-state assessments are notably inaccurate. Recent innovations, including widely available and inexpensive mobile technologies for ambulatory “biobehavioral” data, can reshape risk assessment. To help understand and accelerate clinician involvement, we surveyed 90 multi-disciplinary clinicians serving SMI populations in various settings to evaluate how risk assessment is conducted and can improve. Clinicians reported considerable variability in conducting risk assessment, and few clinicians explicated their procedures beyond tying it to broader mental status examinations or interviews. Very few clinicians endorsed using currently-available standardized risk measures, and most reported low confidence in their utility. Clinicians also reported spending approximately half the time conducting individual risk assessments than optimally needed. When asked about improvement, virtually no clinicians acknowledged biobehavioral, objective technologies, or ambulatory recording. Overall, clinicians seemed unaware of meaningful ways to improve risk assessment.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  • Beal, A. C. (2012). The Patient-Centered Outcomes Research Institute (PCORI) national priorities for research and initial research agenda. JAMA, 307(15), 1583. https://doi.org/10.1001/jama.2012.500.

    Article  PubMed  Google Scholar 

  • Ben-Zeev, D., Davis, K. E., Kaiser, S., Krzsos, I., & Drake, R. E. (2013). Mobile technologies among people with serious mental illness: Opportunities for future services. Administration and Policy in Mental Health and Mental Health Services Research, 40(4), 340–343. https://doi.org/10.1007/s10488-012-0424-x.

    Article  PubMed  Google Scholar 

  • Ben-Zeev, D., Drake, R. E., Corrigan, P. W., Rotondi, A. J., Nilsen, W., & Depp, C. (2012). Using contemporary technologies in the assessment and treatment of serious mental illness. American Journal of Psychiatric Rehabilitation, 15(4), 357–376. https://doi.org/10.1080/15487768.2012.733295.

    Article  Google Scholar 

  • Bernert, R. A., Hom, M. A., & Roberts, L. W. (2014). A review of multidisciplinary clinical practice guidelines in suicide prevention: Toward an emerging standard in suicide risk assessment and management, training and practice. Academic Psychiatry, 38(5), 585–592. https://doi.org/10.1007/s40596-014-0180-1.

    Article  PubMed  PubMed Central  Google Scholar 

  • Boudreaux, E. D., & Horowitz, L. M. (2014). Suicide risk screening and assessment: Designing instruments with dissemination in mind. American Journal of Preventive Medicine, 47(3 SUPPL. 2), S163–S169. https://doi.org/10.1016/j.amepre.2014.06.005.

    Article  PubMed  Google Scholar 

  • Bridge, J. A., Horowitz, L. M., & Campo, J. V. (2017). ED-SAFE-can suicide risk screening and brief intervention initiated in the emergency department save lives? JAMA Psychiatry, 74(6), 555–556. https://doi.org/10.1001/jamapsychiatry.2017.0677.

    Article  PubMed  Google Scholar 

  • Brodsky, S. L. (1988). Fear of litigation in mental health professionals. Criminal Justice and Behavior, 15(4), 492–500. https://doi.org/10.1177/0093854888015004006.

    Article  Google Scholar 

  • Campbell, M. A., French, S., & Gendreau, P. (2009). The prediction of violence in adult offenders: A meta-analytic comparison of instruments and methods of assessment. Criminal Justice and Behavior, 36(6), 567–590. https://doi.org/10.1177/0093854809333610.

    Article  Google Scholar 

  • Cannon, T. D., Cadenhead, K., Cornblatt, B., Woods, S. W., Addington, J., Walker, E., … Heinssen, R. (2008a). Prediction of psychosis in youth at high clinical risk: A multisite longitudinal study in North America. Archives of General Psychiatry, 65(1), 28–37. https://doi.org/10.1001/archgenpsychiatry.2007.3.

  • Cannon, T. D., Cadenhead, K., Cornblatt, B., Woods, S. W., Addington, J., Walker, E., … Heinssen, R. (2008b). Prediction of psychosis in youth at high clinical risk: A multisite longitudinal study in North America. Archives of General Psychiatry, 65(1), 28–37. https://doi.org/10.1001/archgenpsychiatry.2007.3.

  • Cannon, T. D., Yu, C., Addington, J., Bearden, C. E., Cadenhead, K. S., Cornblatt, B. A., … Kattan, M. W. (2016). An individualized risk calculator for research in prodromal psychosis. American Journal of Psychiatry, 173(10), 980–988. https://doi.org/10.1176/appi.ajp.2016.15070890.

  • Carrión, R. E., Cornblatt, B. A., Burton, C. Z., Tso, I. F., Auther, A. M., Adelsheim, S., … McFarlane, W. R. (2016). Personalized prediction of psychosis: External validation of the NAPLS-2 psychosis risk calculator with the EDIPPP project. American Journal of Psychiatry, 173(10), 989–996. https://doi.org/10.1176/appi.ajp.2016.15121565.

  • Chan, M. K. Y., Bhatti, H., Meader, N., Stockton, S., Evans, J., O’Connor, R. C., … Kendall, T. (2016). Predicting suicide following self-harm: Systematic review of risk factors and risk scales. British Journal of Psychiatry, 209(4), 277–283. https://doi.org/10.1192/bjp.bp.115.170050.

  • Cohen, A. S. (2019). Advancing ambulatory biobehavioral technologies beyond “proof of concept”: Introduction to the special section. Psychological Assessment, 31(3), 277.

    Article  PubMed  Google Scholar 

  • Cohen, A. S., & Elvevåg, B. (2014). Automated computerized analysis of speech in psychiatric disorders. Current Opinion in Psychiatry, 27(3), 203–209.

    Article  PubMed  PubMed Central  Google Scholar 

  • Gaynes, B. N., West, S. L., Ford, C. A., Frame, P., Klein, J., & Lohr, K. N. (2004). Screening for suicide risk in adults: A summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 140(10), 822–835+I. https://doi.org/10.7326/0003-4819-140-10-200405180-00023.

    Article  PubMed  Google Scholar 

  • Grove, W. M., Zald, D. H., Lebow, B. S., Snitz, B. E., Nelson, C., Snitz, B. E., et al. (2000). Clinical versus mechanical prediction: A meta-analysis. Hedges & Olkin, 12(1), 19–30. https://doi.org/10.1037/1040-3590.12.1.19.

    Article  CAS  Google Scholar 

  • Hafeman, D. M., Merranko, J., Goldstein, T. R., Axelson, D., Goldstein, B. I., Monk, K., … Birmaher, B. (2017). Assessment of a person-level risk calculator to predict new-onset bipolar spectrum disorder in youth at familial risk. JAMA Psychiatry, 74(8), 841–847. https://doi.org/10.1001/jamapsychiatry.2017.1763.

  • Harrison, S. L., de Craen, A. J. M., Kerse, N., Teh, R., Granic, A., Davies, K., … Stephan, B. C. M. (2017). Predicting risk of cognitive decline in very old adults using three models: The framingham stroke risk profile; the cardiovascular risk factors, aging, and dementia model; and oxi-inflammatory biomarkers. Journal of the American Geriatrics Society, 65(2), 381–389. https://doi.org/10.1111/jgs.14532.

  • Heeringa, S. G., Gebler, N., Colpe, L. J., Fullerton, C. S., Hwang, I., Kessler, R. C., … Ursano, R. J. (2013). Field procedures in the Army Study to assess risk and resilience in servicemembers (Army STARRS). International Journal of Methods in Psychiatric Research, 22(4), 276–287. https://doi.org/10.1002/mpr.1400.

  • Hoffmire, C., Stephens, B., Morley, S., Thompson, C., Kemp, J., & Bossarte, R. M. (2016). VA suicide prevention applications network: A national health care system-based suicide event tracking system. Public Health Reports, 131(6), 816–821. https://doi.org/10.1177/0033354916670133.

    Article  PubMed  PubMed Central  Google Scholar 

  • Holmlund, T. B., Foltz, P. W., Cohen, A. S., Johansen, H. D., Sigurdsen, R., Fugelli, P., … & Elvevåg, B. (2019). Moving psychological assessment out of the controlled laboratory setting: Practical challenges. Psychological Assessment, 31(3), 292.

  • Insel, T. R. (2008). Assessing the economic costs of serious mental illness. American Journal of Psychiatry, 165(6), 663–665. https://doi.org/10.1176/appi.ajp.2008.08030366.

    Article  PubMed  Google Scholar 

  • Joseph, J., Kremen, W. S., Franz, C. E., Glatt, S. J., van de Leemput, J., Chandler, S. D., … Twamley, E. W. (2017). Predictors of current functioning and functional decline in schizophrenia. Schizophrenia Research, 188, 158–164. https://doi.org/10.1016/j.schres.2017.01.038.

  • Kennedy, M., & Gill, M. (1997). Patient litigation following a homicide—Implications for the assessment and managment of risk. International Review of Psychiatry, 9(2–3), 179–186. https://doi.org/10.1080/09540269775376.

  • Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Chatterji, S., Lee, S., Ormel, J., … Wang, P. S. (2009). The global burden of mental disorders: An update from the WHO World Mental Health (WMH) surveys. Epidemiologia E Psichiatria Sociale, 18(1), 23–33. https://doi.org/10.1017/S1121189X00001421.

  • Kessler, R., & Glasgow, R. E. (2011). A proposal to speed translation of healthcare research into practice: Dramatic change is needed. American Journal of Preventive Medicine, 40(6), 637–644. https://doi.org/10.1016/j.amepre.2011.02.023.

    Article  PubMed  Google Scholar 

  • Kessler, R. C., Warner, C. H., Ivany, C., Petukhova, M. V., Rose, S., Bromet, E. J., … Ursano, R. J. (2015). Predicting suicides after psychiatric hospitalization in US army soldiers: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry, 72(1), 49–57. https://doi.org/10.1001/jamapsychiatry.2014.1754.

  • Large, M., Kaneson, M., Myles, N., Myles, H., Gunaratne, P., & Ryan, C. (2016). Meta-analysis of longitudinal cohort studies of suicide risk assessment among psychiatric patients: Heterogeneity in results and lack of improvement over time. PLoS ONE, 11(6), e0156322. https://doi.org/10.1371/journal.pone.0156322.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Nelson, H. D., Denneson, L. M., Low, A. R., Bauer, B. W., O’Neil, M., Kansagara, D., et al. (2017a). Suicide risk assessment and prevention: A systematic review focusing on veterans. Psychiatric Services, 68(10), 1003–1015. https://doi.org/10.1176/appi.ps.201600384.

    Article  PubMed  Google Scholar 

  • Nelson, B., McGorry, P. D., Wichers, M., Wigman, J. T. W., & Hartmann, J. A. (2017b). Moving from static to dynamic models of the onset of mental disorder a review. JAMA Psychiatry, 74(5), 528–534. https://doi.org/10.1001/jamapsychiatry.2017.0001.

    Article  PubMed  Google Scholar 

  • O’Hagan, M., Cornelius, V., Young, A. H., & Taylor, D. (2017). Predictors of rehospitalization in a naturalistic cohort of patients with bipolar affective disorder. International Clinical Psychopharmacology, 32(3), 115–120. https://doi.org/10.1097/YIC.0000000000000163.

    Article  PubMed  Google Scholar 

  • Passmore, K., & Leung, W. C. (2002). Defensive practice among psychiatrists: A questionnaire survey. Postgraduate Medical Journal, 78(925), 671–673. https://doi.org/10.1136/pmj.78.925.671.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Peek, C. J., Glasgow, R. E., Stange, K. C., Klesges, L. M., Peyton Purcell, E., & Kessler, R. S. (2014). The 5 r’s: An emerging bold standard for conducting relevant research in a changing world. Annals of Family Medicine, 12(5), 447–455. https://doi.org/10.1370/afm.1688.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Pestian, J. P., Sorter, M., Connolly, B., Bretonnel Cohen, K., McCullumsmith, C., Gee, J. T., … Murphy, C. (2017). A machine learning approach to identifying the thought markers of suicidal subjects: A prospective multicenter trial. Suicide and Life-Threatening Behavior, 47(1), 112–121. https://doi.org/10.1111/sltb.12312.

  • Rothwell, P. M. (2005). External validity of randomised controlled trials: “To whom do the results of this trial apply?”. Lancet, 365(9453), 82–93. https://doi.org/10.1016/S0140-6736(04)17670-8.

    Article  PubMed  Google Scholar 

  • Rubin, A., Dolev, T., & Zilcha-Mano, S. (2016). Patient demographics and psychological functioning as predictors of unilateral termination of psychodynamic therapy. Psychotherapy Research. https://doi.org/10.1080/10503307.2016.1241910.

    Article  PubMed  Google Scholar 

  • Schoenbaum, M., Kessler, R. C., Gilman, S. E., Colpe, L. J., Heeringa, S. G., Stein, M. B., … Cox, K. L. (2014a). Predictors of suicide and accident death in the army study to assess risk and resilience in servicemembers (army starrs) results from the army study to assess risk and resilience in servicemembers (Army STARRS). JAMA Psychiatry, 71(5), 493–503. https://doi.org/10.1001/jamapsychiatry.2013.4417.

  • Schoenbaum, M., Kessler, R. C., Gilman, S. E., Colpe, L. J., Heeringa, S. G., Stein, M. B., … Cox, K. L. (2014b). Predictors of suicide and accident death in the army study to assess risk and resilience in servicemembers (Army STARRS) results from the army study to assess risk and resilience in servicemembers (Army STARRS). JAMA Psychiatry, 71(5), 493–503. https://doi.org/10.1001/jamapsychiatry.2013.4417.

  • Seidman, L. J., Shapiro, D. I., Stone, W. S., Woodberry, K. A., Ronzio, A., Cornblatt, B. A., … Woods, S. W. (2016). Association of neurocognition with transition to psychosis: Baseline functioning in the second phase of the north American prodrome longitudinal study. JAMA Psychiatry, 73(12), 1239–1248. https://doi.org/10.1001/jamapsychiatry.2016.2479.

  • Stuart, M. E., & Weinrich, M. (1998). Beyond managing medicaid costs: Restructuring care. The Milbank Quarterly, 76(2), 251–280.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Torous, J., & Baker, J. T. (2016). Why psychiatry needs data science and data science needs psychiatry connecting with technology. JAMA Psychiatry, 73(1), 3–4. https://doi.org/10.1001/jamapsychiatry.2015.2622.

    Article  PubMed  Google Scholar 

  • Vassos, E., Di Forti, M., Coleman, J., Iyegbe, C., Prata, D., Euesden, J., … Breen, G. (2017). An examination of polygenic score risk prediction in individuals with first-episode psychosis. Biological Psychiatry, 81(6), 470–477. https://doi.org/10.1016/j.biopsych.2016.06.028.

  • Velligan, D. I., Weiden, P. J., Sajatovic, M., Scott, J., Carpenter, D., Ross, R., … Expert Consensus Panel on Adherence Problems in Serious and Persistent Mental Illness. (2009). The expert consensus guideline series: Adherence problems in patients with serious and persistent mental illness. The Journal of Clinical Psychiatry, 70(Suppl. 4), 1–46. http://doi.org/10.4088/JCP.7090su1cj.

  • Vitacco, M. J., Tabernik, H. E., Zavodny, D., Bailey, K., & Waggoner, C. (2016). Projecting risk: The importance of the HCR-20 risk management scale in predicting outcomes with forensic patients. Behavioral Sciences & The Law, 34(2–3), 308–320. https://doi.org/10.1002/bsl.2221.

    Article  Google Scholar 

  • Walsh, C. G., Ribeiro, J. D., & Franklin, J. C. (2017). Predicting risk of suicide attempts over time through machine learning. Clinical Psychological Science, 5(3), 457–469. https://doi.org/10.1177/2167702617691560.

    Article  Google Scholar 

  • Wand, T. (2012). Investigating the evidence for the effectiveness of risk assessment in mental health care. Issues in Mental Health Nursing, 33(1), 2–7. https://doi.org/10.3109/01612840.2011.616984.

    Article  PubMed  Google Scholar 

  • Wilbert, J. R., & Fulero, S. M. (1988). Impact of malpractice litigation on professional psychology: Survey of practitioners. Professional Psychology: Research and Practice, 19(4), 379–382. https://doi.org/10.1037/0735-7028.19.4.379.

    Article  Google Scholar 

  • Wu, E. Q., Birnbaum, H. G., Shi, L., Ball, D. E., Kessler, R. C., Moulis, M., et al. (2005). The economic burden of schizophrenia in the United States in 2002. Journal of Clinical Psychiatry, 66(9), 1122–1129. https://doi.org/10.4088/JCP.v66n0906.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

This project was funded by Grant 231395 from the Research Council of Norway awarded to Brita Elvevåg.

Author information

Authors and Affiliations

  1. Department of Psychology, Louisiana State University, 236 Audubon Hall, Baton Rouge, LA, 70803, USA

    Alex S. Cohen, Taylor Fedechko, Elana K. Schwartz & Thanh P. Le

  2. Institute of Cognitive Science, University of Colorado, Boulder, USA

    Peter W. Foltz

  3. Analytic Measures Inc, Palo Alto, CA, USA

    Jared Bernstein, Jian Cheng & Elizabeth Rosenfeld

  4. Department of Clinical Medicine, University of Tromsø – The Arctic University of Norway, Tromsø, Norway

    Brita Elvevåg

  5. The Norwegian Centre for eHealth Research, University Hospital of North Norway, Tromsø, Norway

    Brita Elvevåg

Authors
  1. Alex S. Cohen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Taylor Fedechko
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Elana K. Schwartz
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Thanh P. Le
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Peter W. Foltz
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jared Bernstein
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jian Cheng
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Elizabeth Rosenfeld
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Brita Elvevåg
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alex S. Cohen.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Cohen, A.S., Fedechko, T., Schwartz, E.K. et al. Psychiatric Risk Assessment from the Clinician’s Perspective: Lessons for the Future. Community Ment Health J 55, 1165–1172 (2019). https://doi.org/10.1007/s10597-019-00411-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10597-019-00411-x

Keywords

Search

Navigation