Beyond Suicide and Homicide: Critical Risks in Psychiatric Assessment
Psychiatric patients face substantial risks beyond suicide and homicide, including self-harm without suicidal intent, accidental death (particularly from overdose and trauma), medical illness mortality, victimization (including being victims of homicide), elopement/wandering, medication non-adherence leading to decompensation, and iatrogenic harm from treatment itself.
Primary Risk Categories to Assess
According to the APA Practice Guidelines for Psychiatric Evaluation 1, your comprehensive risk assessment must include:
Self-Directed Harm Risks
- Self-injury and self-harm (distinct from suicide attempts) - assess skin for stigmata of trauma or self-injury 1
- Substance use and overdose risk - particularly critical as research shows 32% of deaths after psychiatric emergency care are from external causes including overdose 2
- Accidental injuries - psychiatric patients show dramatically elevated mortality from accidents, with standardized mortality ratios (SMRs) of 318 for women and 466 for men 3
Violence and Aggression Risks
Beyond homicide assessment, evaluate:
- Current aggressive or psychotic ideas, including thoughts of physical or sexual aggression 1
- Past legal or disciplinary consequences of aggressive behaviors 1
- Exposure to violence or aggressive behavior in the patient's history 1
- Family history of violent behaviors in biological relatives when aggressive ideas are present 1
Victimization Risks
This is a commonly overlooked but critical category:
- Risk of being a victim of homicide - psychiatric patients have SMRs of 632 for women and 609 for men for death by homicide 3
- Risk from others - this is less frequently assessed but essential 4
- Vulnerability to exploitation, abuse, or assault in their living situation
Medical Mortality Risks
The evidence is striking here: 46% of psychiatric emergency service patients who died within one year died from medical causes 2, yet this receives insufficient attention:
- Cardiovascular and metabolic complications - assess vital signs, BMI, and cardiopulmonary status 1
- Neurological conditions - evaluate coordination, gait, involuntary movements 1
- Infectious diseases including HIV, hepatitis C, tuberculosis 1
- Endocrinological disorders 1
- Medication side effects and interactions - document all current medications and their side effects 1
Age is independently associated with all-cause and medical mortality after psychiatric visits 2, making older patients particularly vulnerable.
Substance-Related Risks
These deserve special emphasis:
- Opioid use disorders - associated with all-cause and external mortality 2
- Stimulant use disorders - similarly associated with increased mortality 2
- Alcohol use disorders - show the highest risks of death by homicide and accident among psychiatric diagnoses 3
- Accidental deaths were most common in forensic studies, with two-thirds of substance-related disorder patients dying accidentally 5
Functional Decline Risks
- Nutritional status deterioration - assess general appearance and nutritional status 1
- Loss of housing or social support - evaluate psychosocial stressors including financial, housing, and interpersonal problems 1
- Treatment non-adherence leading to decompensation
- Inability to care for basic needs
Iatrogenic and System-Related Risks
These are the least frequently considered 4:
- Adverse medication effects including metabolic syndrome, movement disorders, sedation leading to falls
- Polypharmacy complications
- Inadequate medical monitoring - notably, 12 patients who died natural deaths in healthcare facilities had less severe reported symptoms than expected and lacked correct clinical diagnosis before death 5
- Coercive interventions causing physical or psychological harm
Critical Assessment Components
When evaluating these risks, the APA guidelines mandate 1:
Document specific risk factors influencing each category:
- Psychosocial stressors (financial, housing, legal, occupational, interpersonal problems, lack of social support) 1
- Trauma history and exposure to violence 1
- Access to means (not just firearms for suicide, but also substances, unsafe environments)
- Protective factors including reasons for living, social support, therapeutic alliance 1
Physical examination findings:
- Height, weight, BMI, vital signs 1
- Skin examination for trauma, self-injury, or drug use stigmata 1
- Coordination, gait, involuntary movements 1
Common Pitfalls to Avoid
Overemphasis on dramatic risks (suicide/homicide) while neglecting medical and accidental mortality - this is the most significant gap in current practice 2, 4
Failure to assess victimization risk - psychiatric patients are at substantially higher risk of being murdered than the general population 3
Inadequate attention to substance use disorders - these confer the highest mortality risks across multiple categories 2, 3
Missing medical illness in psychiatric settings - symptoms may be attributed to psychiatric conditions when serious medical illness is present 5
Ignoring age-related vulnerability - older psychiatric patients have significantly elevated mortality risk 2
Limited engagement with protective factors and recovery-oriented approaches - focusing only on negative risks without identifying strengths 4
Your risk formulation must be individualized, documented with specific influencing factors, and updated as the clinical situation evolves 1. The rationale for your risk assessment and treatment selection should be explicitly documented 1.