Assessing Risk

Assessing risk is an important issue in both clinical and forensic psychiatry.  Whether a clinician is capable of predicting suicide, dangerousness or relapse is a controversial topic as well.  It is clear that the future cannot be predicted accurately all the time by even the best clinician.  However sometimes, there are logical means and methods that can be used in assessing risk.

Experienced clinicians are fairly good at assessing risk of suicide and violence.  One measure that can be utilized is determining whether a patient has a greater or lesser total risk, given the individual circumstances at hand.    Factors here may include: past behavior and threats, diagnosis, treatment history including refusal of treatment, whether or not there is participation in follow-up care, and the longstanding nature of one’s given pathology.

Risk Assessing Factors

Some features of presentation are beneficial in narrowing the field to the point where some important risk assessing factors can be noticed.  These might include:

  1. Psychosis, delusions, severe depression, unstable mood
  1. Instability, treatment refractoriness, particular past traits or behaviors
  1. Clinician’s personal experience with the patient
  1. Aggression, impulsiveness and assaultiveness
  1. Post-discharge living conditions and availability of other caregivers
  1. Marital problems and/or drug/alcohol abuse in the family setting
  1. Likelihood to participate in outpatient follow-up

If a single patient meets one or more of these conditions, this creates a narrower risk group and is then more useful for making decisions about predicting an individual patient’s future behaviors.

Foreseeability and Predictability

 Foreseeability refers to whether the doctor reasonably recognized and adequately dealt with a particular level of danger.  Unpredictability can be an important and tricky feature as well.  When seriously ill patients are also unpredictable or the environment they are placed in is dangerous or unpredictable, caution should be increased in the care of that patient.

 Risk of Using Checklists/Contracts

 Checklist and behavior contracts are somewhat concerning with respect to their accuracy of predicting the future.  They can lead to a false sense of security about the patient’s future behavior, are often done by undertrained staff members, and can lead to a treating physician relying on another person’s work instead of their own, which might lead directly to poor decision making when assessing risk.

Another key issue here is that when relying on the patients’ statements, it becomes abundantly clear that the truly suicidal patient does not always tell the truth about their future plans.  Still another issue is that by relying on a few short questions, the interviewer is tempted to the quick assessment tool rather than communication and collaboration to make decisions about important safety matters, thereby placing themselves as significantly underinformed in the specifics of the case.

Use of Contracts

Another way that clinicians often try to assuage their concerns about danger is by utilizing no-suicide and no-violence contracts.  This is considerably risky, recalling that truly serious suicidal or homicidal impulses must already be very strong to overcome our internal prohibitions against self-destruction and inappropriate violence.  Also, even less pivotal promises such as following through with aftercare are often unreliable in these patients and therefore these contracts should be thought of in that same context.

Example 1

 Mr. Q. was referred to the clinic by his primary care physician for severe depression, refusing to sign a Release of Information and therefore his current psychiatrist was not contacted.

On interview, the patient reported feelings of betrayal and paranoia and refused to speak about his psychiatric history.  After refilling his medications (the ones he said he was taking), and exacting a promise from him that he would not hurt himself or anyone else, he was sent home.

He killed his primary care physician, his girlfriend and himself the next day.

Example 2

 Dr. F.  had no prior psychiatric history when he was arrested for prescribing unnecessary narcotics to undercover officers.  That evening, after an almost-lethal overdose, he was hospitalized.  After a brief treatment in the ICU, he told the clinicians that his action was “silly” and that he wanted to leave the hospital, also stating that if he were hospitalized, it would be humiliating to him to be with other patients who might recognize him.  His wife concurred that he was “just fine”.

He was nevertheless hospitalized at an outlying facility for two weeks and the patient again protested his confinement.  Although not being actually committable, hi may not have actually been ready for discharge.  He promised to call if he needed help and after being discharged, killed himself the day after he was released.


While the number of psychiatric medical malpractice claims in relatively small, the consequences of malpractice can be devastating resulting in suicide, homicide, or other deaths. More recent statistics suggest a substantial increase in the number of psychiatric medical malpractice claims.

About the Author

Fred R. Moss, MD is a psychiatrist and expert witness with over 26 years of experience. He received his MD from Northwestern University with his residency in Psychiatry. He is board certified by the American Board of Psychiatry and Neurology. He can be reached at 916-671-0007 or