Predictive accuracy of risk scales following self-harm: Multicentre, prospective cohort study

Abstract

BackgroundScales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.AimsTo evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.MethodA multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.ResultsIn total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0–5) for the SAD PERSONS scale, to 97% (95% CI 93–99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2–47) for the Modified SAD PERSONS Scale to 47% (95% CI 41–53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50–0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69–0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P<0.001).ConclusionsRisk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.

Is it time to abandon care planning in mental health services? A qualitative study exploring the views of professionals, service users and carers

“…Organizational processes reported in the current study focussed on paternalistic, formulaic approaches to risk, serving organizational accountability agendas related to the origination of care planning as a result of concerns about safety and fragmented community care . The findings support the recent literature demonstrating that actuarial risk assessments can be used by professionals to manage uncertainty in a manner that distances service users from potential solutions . To better integrate care plans with people's everyday lives, risk management should be separated from holistic needs elicitation.…”

“…12 The findings support the recent literature demonstrating that actuarial risk assessments can be used by professionals to manage uncertainty in a manner that distances service users from potential solutions. [33][34][35] To better integrate care plans with people's everyday lives, risk management should be separated from holistic needs elicitation. The latter could be elicited through tailored dialogue between service users and professionals with the former developed separately through formulaic and less engaging processes.…”

Risk assessment scales to predict risk of hospital treated repeat self-harm: A cost-effectiveness modelling analysis

“…Clinical data used to populate the model were obtained from a prospective cohort study evaluating 12 risk scales following hospital-treated self-harm in five hospitals in England. Full details of the study are 13 reported elsewhere (Quinlivan et al, 2017). In short, that study involved 514 patients aged 18 years 14 and over who were referred to liaison psychiatry service following self-harm and consented to take 15 part in a multi-site prospective cohort study evaluating the predictive accuracy of risk scales following 16 self-harm between March 2014 and January 2015.…”

“…The assessment scales used in the study were selected on the basis of a systematic review of the 22 diagnostic accuracy of risk scales following self-harm (Quinlivan et al, 2014b) and a cohort study of 23 their diagnostic accuracy (Quinlivan et al, 2017). Clinician and patient global ratings of risk of repeated 24 self-harm within six months (using a 1-10 Likert-type scale) were also included.…”

“…The predictive accuracy of each scale -sensitivity (correctly predicting repeat self-harm) and 6 specificity (correctly predicting patients who did not repeat self-harm) -was obtained by comparing 7 positive/negative assessment results with repeat self-harm episodes (Quinlivan et al, 2017). 8 9 Self-harm episodes 10…”