Can psychiatrists predict the future?
Girish Vaidya
Consultant Child and Adolescent Psychiatrist, Medicolegal Expert Witness, Healthcare Analytics.
Today's leading news about the distressing deaths of three people and the care afforded to their attacker prompts me to write this. I have no additional knowledge of this case than what I have read in the media.
As a Consultant Child and Adolescent Psychiatrist and a medicolegal expert witness, I have been frequently asked about the future risks of harm to self and/or others in young people. I have also had the experience of being part of compensation claims arising from acts of fatal harm or near fatal harm as part of the claimant or defence.
What follows therefore is the general state of clinical knowledge and should not be applied to individual cases. This topic is not only complex but also critical, given the potential implications for patient care and public safety. Here, I delve into the current understanding and limitations of risk prediction in psychiatry, drawing on peer-reviewed literature and scholarly journals.
The Challenge of Predicting Suicide
More mentally unwell people die by suicide than by hurting someone else. Predicting suicide is a formidable challenge in psychiatric practice. Despite extensive research, the ability to accurately forecast suicide remains limited. Studies indicate that while certain risk factors, such as mental disorders, are associated with an increased risk of suicide, they do not provide a reliable basis for precise predictions. I work in a NHS service that provides mental health input for children looked after by local authority. Self harm in children and young people remains a concern for social workers, foster carers and residential support workers.
- Limitations of Risk Assessment Tools: Traditional risk assessment tools and scales often fall short in accurately predicting suicide. A meta-analysis revealed that no current tool achieves the desired accuracy threshold, leading to high false-positive and false-negative rates. This means that many individuals identified as high-risk do not attempt suicide, while some who do attempt suicide are not flagged as high-risk. The risk of suicide is often highest shortly after discharge from hospital.
- The Role of Clinical Judgment: Given the limitations of predictive models, structured professional judgement remains crucial. As psychiatrists we often use a holistic approach, focusing on individual patient needs and fostering a therapeutic alliance rather than relying solely on risk categorization. Multiple, exhaustive inputs from a range of relevant sources are critical to accurate risk assessment.
Violence Prediction: A Complex Interplay
The prediction of violent behavior, including assaults, is similarly fraught with challenges. While certain psychiatric symptoms and contextual factors can increase the risk of violence, they are not definitive predictors. I work in a NHS Forensic CAMHS service where we get referrals from a range of professionals about the risk of violence posed to others by young people. The violence can include physical as well as sexual.
- Contextual Influences: Factors such as substance abuse, socioeconomic conditions, and environmental stressors play a significant role in the potential for violence, often more so than psychiatric diagnoses alone. This underscores the importance of considering the broader context in which a person lives.
- Myths and Realities: It is a common misconception that individuals with mental illness are predominantly responsible for violent acts. Research has shown that this is not the case, and the majority of people with mental illness are not violent. Amongst neurodevelopmental disorders (ADHD, ASD), many children are reported to be violent to their parents (Child on Parent Violence is real, but underreported) and teachers. Effective treatments can (and do) reduce the threat of violence thereby changing life trajectories of these young lives.
Moving Beyond Prediction
Given the inherent uncertainties in predicting future harm, as a psychiatrist I often advise those consulting me to focus on comprehensive care strategies rather than attempting precise predictions. In particular, developing a better understanding of the young person's need for self-esteem and the availability of anchors in their lives.
- Needs-Based Approaches: Emphasizing the assessment of individual needs and circumstances can lead to more effective interventions. This approach aligns with the art of psychiatry, which involves understanding the unique factors that contribute to a patient's risk and working collaboratively to address them.
领英推荐
- Risk Management Over Prediction: Effective risk management involves planning for potential adverse outcomes and ensuring that interventions are in place to mitigate these risks. This includes developing safety plans, providing support, and engaging with patients and their families in decision-making processes.
- Maintaining 'therapeutic risk taking': Without therapeutic risk taking, we condemn our patients to extended periods of isolation. Clinicians need to take therapeutic risks, but would need to do so in a collaborative environment with patient safety being finely balanced with the risks of harm.
Conclusion
While psychiatrists cannot predict future events with certainty, they play a vital role in assessing and managing risk through comprehensive evaluation and personalized care. By acknowledging the limitations of prediction and focusing on therapeutic engagement, psychiatrists can better support their patients, their families and contribute to their overall well-being. This approach not only enhances patient care but also helps in addressing the broader public health challenge of suicide and violence prevention.
Citations (a select few):
Experienced Mental Health Leader. NHS employee and provides additional support to other organisations.
2 个月It’s a good summary of presenting issues. It’s sometimes important to say what we can’t do and what we can do. I think back to 1999 and 2000 when I was leading the design of early intervention psychosis services. I still have the teaching materials and some colleagues still in touch may recall the sessions. Early intervention services are one of the riskiest services to lead. You have limited collateral information A person is newer and you don’t have a lifetime of information on clinical safety risks on how they react in their psychosis, if a person is going to be to respond to their symptoms in their actions this may lead to offending behaviour You will have to make judgements based upon - empathy, connection and engagement on the potential future risks You won’t be able to predict who may end their life or who will enact extreme acts but you can predict relapse. Prepare yourself as a team this can and will happen So work to always reduce relapse and reduce the duration of untreated psychosis, the episodes of relapse because they are so incredibly damaging to a persons life outcome, maintain family connection / relationships and achievements. We can do that It’s 2024. It still stands
CEO at AIIC, Founder at Sushrut Designs Pvt. Ltd. incubated @ BHAU, COEP, Parenting Coach,
3 个月Coming from Dr Girish Vaidya , of course it is a well thought through article no doubt! My mind always wanders back into tribal people and their practices. Though they seem rustic, there could be valuable insights by looking at their modes, instead of outright dismissing them as illiterate/ uneducated, etc. After all, they too have practically the same human motivations and pitfalls. Just a thought: has any "official psychiatric" effort/ study been done about "mind management practices of tribal people"? Would love to know more.
Ex.Founder chair of National Association of GP tutors Uk. 1993.
3 个月Excellent effort to bring the issue of suicide and violence with mental illness. General observation in clinical practice just antidepressants do not prevent suicides. Knowledge of the underlying issues related to disturb thinking and family chemistry helps in some ability to predict the possibility of this extreme reaction. Again some success in prediction but prediction of Homicide is not predicted , forecast is not possible? Positive moral, psychological, philosophical and family support goes long way. A generalist observation of 38 years clinical encounters.
Helping stressed-out doctors recreate balanced lives, and enjoy work without feeling like they are selling out.
3 个月Good explanation. We have a lot of groups now with the aim of ending suicide and while this us laudable, I sadly don’t believe this is achievable. Many of the patients who have taken their own lives in my career have done this out of the blue. Your point about focussing on raising self esteem is a good one, and an additional challenge for children in the age of social media. Suicide is an end point of many other colliding events, factors and illnesses in their complexities and not a single issue. Thanks for talking about these issues.
Consultant Psychiatrist at claremont hospital
3 个月Thank you Girish, for highlighting the complexities of this topic.