Australasian psychiatry : bulletin of Royal Australian and New Zealand College of Psychiatrists
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Australas Psychiatry · Oct 2010
Clinical decisions in psychiatry should not be based on risk assessment.
Risk assessments that place patients in high or low risk categories have been widely adopted by mental health services in an attempt to reduce the harms associated with psychiatric disorders. This paper examines the effects of categorization based on the results of a risk assessment. ⋯ Patients who are classified as high risk share the cost of efforts to reduce harm in the form of additional treatment and restrictions, although the majority will not go on to commit a harmful act. Clinical decisions made on the basis of risk assessment also divert resources away from patients classified as low risk, even though a significant proportion do go on to a commit harmful act. We argue that psychiatric professionals should discuss the risks of treatment and of non-treatment with patients (or with their substitute decision-makers) and should maintain a duty to warn about the consequences of not having treatment. However, assessment of risk of harm should not form the basis for clinical decision making. We should aim to provide optimal care according to the treatment needs of each patient, regardless of the perceived risk of adverse events.
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Australas Psychiatry · Oct 2010
Shared decision-making: benefits, barriers and current opportunities for application.
Patient preference and involvement are two important aspects for many psychiatric treatment decisions. Shared decision-making (SDM) has been proposed as the optimal model to include patient preferences and involve patients in such decisions. Decision-making tools called decision aids (DA) are the most common application of SDM. DAs have been demonstrated to increase patients' knowledge, reduce decisional conflict, and reduce the proportion of patients who are passive in the decision-making process or remain undecided. Unfortunately, there are few DAs available for treatment decisions for psychiatric disorders and implementing SDM can be a challenge for mental health professionals. There are also issues unique to psychiatry related to the development and implementation of DAs that need consideration. Despite this, mental health professionals can and do still employ SDM techniques. This article offers an overview of the skills required to implement a SDM model and the resources currently available. ⋯ The core features of SDM are advocated for in clinical guidelines, but more resources are needed to ensure these recommendations are implemented in practice. In particular, the benefits of freely available DAs developed according to international standards need to be assessed for suitability and effectiveness.
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Suicide is a global health priority. It is important to analyse the effects of investment in mental health services on suicide rates. This paper presents and discusses recent changes in suicide rates and diagnostic mix among clients of the mental health service in Auckland during a time of service growth. ⋯ As access to services expands the proportion of suicides that occur in known clients will paradoxically increase. Service expansion may have contributed to the falling population suicide rate in Auckland.