Assessing Digital Risk in Psychiatric Patients: Mixed Methods Study of Psychiatry Trainees’ Experiences, Views, and Understanding (Preprint)

Abstract

BACKGROUND The use of digital technology can help people access information and support for their mental health problems but can also expose them to risk, such as bullying or pro-suicide websites. It may be important to consider internet-related risk behaviour (digital risk) within a generic psychiatric risk assessment, but no studies have explored the practice or acceptability of this among psychiatrists. OBJECTIVE We sought to explore psychiatry trainees’ experiences, views, and understanding of digital risk in psychiatry. We predicted that clinician awareness would be highest amongst trainees who work in child and adolescent mental health services. METHODS We conducted a cross-sectional survey of psychiatry trainees attending a UK regional trainees’ conference to investigate how they routinely assess patients’ internet use and related risk of harm, and their experience and confidence in assessing these risks. We then conducted focus groups to further explore trainees’ understandings and experiences of digital risk assessment. We used descriptive statistics and chi-squared tests to present quantitative data and used thematic analysis to identify key themes in the qualitative dataset. RESULTS The cross-sectional survey was completed by 113 psychiatry trainees (response rate 36%), from a range of sub-specialties and experience levels. Half of trainees (50%) reported treating patients exposed to digital risk, particularly trainees sub-specialising in child and adolescent psychiatry (77% versus 44%, p=0.02). However 67% reported not feeling competent to assess digital risk. Child and adolescent psychiatrists were more likely than others to ask patients routinely about specific digital risk domains, including reckless online behaviour (90% versus 66%, p=0.03), pro-suicide websites (95% v 70%, p=0.01) and online sexual behaviour (81% versus 54%, p=0.02). Although 84% participants reported using a proforma to record general risk assessment, only 5% of these prompted assessment of internet use. Only 9% of trainees had received digital risk training and 73% overall reported they would value this. Our thematic analysis of transcripts from three focus groups (comprising n=11 trainees) identified two main themes: barriers to assessment and management of digital risk, and the double-edged sword of online use. Barriers reported included the novelty and complexity of the internet, a lack of confidence and guidance in addressing internet use directly, and an ongoing tension between assessment and privacy. Child and adolescent psychiatrists most commonly reported anxiety about compromising their rapport with younger patients in the pursuit of a thorough digital risk assessment. Despite reporting many experiences of digital risks, all trainees felt that digital engagement brought their patients many discernable benefits by promoting social inclusion and connecting them with society and culture. CONCLUSIONS Despite it being common for psychiatrists to encounter patients subject to digital risk, trainee psychiatrists lack competence and confidence in its assessment. Training in digital risk, and the inclusion of prompts in standardized risk proformas, would promote good clinical practice and prevent a potential blind spot in general risk assessment.