Keeping Your Patients Safe: A Guide to Primary Care Management of Mental Health and Addictions-related Risks and Functional Impairments

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Patients with mental disorders are often at high risk to themselves and others.1,2 The purpose of this tool is to support primary care providers (family physicians and primary care nurse practitioners) in reducing harm in adult patients (18+) who exhibit signs, symptoms, or behaviours suggestive of a mental health condition. Considerations and resources are included in the tool to aid in decision making. The objectives of this tool are to assist primary care providers (PCPs) to:

  • Identify serious risks as a result of a patient’s symptoms and behaviours
  • Assess and intervene when a patient is at high probability of harming themself or others
  • Reduce risk and manage immediate symptoms while diagnostic clarification is taking place

The schematic below outlines the steps PCPs can take to reduce risk pending diagnostic clarification and ongoing management.

Click on the sections below to get started:

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Exploring symptoms and functional impairments to identify risk

Investigate the impact of a patient’s symptoms and behaviours on their daily functioning (e.g. unsafe driving) to consider potential risks (e.g. harm to self or others).3,4,5 With the patient’s consent, include family and/or other caregivers as part of this discussion.

Consider the following domains in your assessment:2

Personal Care: activities of daily living (e.g. cooking, cleaning, bathing, selecting appropriate attire, financial management, housekeeping, transportation, shopping, medication compliance)

Dependents: caring for children, impaired adults, elderly adults, pets

Licenses: driver’s license, pilot’s license, medical license, firearms license, law license, machine operator’s license

Relationships: spouse or significant other, children, parents, colleagues, friends, community, medical team, substitute decision maker

Work/Education: appropriate attendance, ability to perform role-defined tasks, safety, completion of assignments

Talking Points
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Talking Points

Ask patient: “How is your day-to-day life affected as a result of your [insert patient’s symptom/behaviour]?”

The following resource may be helpful to investigate the impact of a patient’s symptoms and behaviours
  • Assessing Functional Impairment: This resource consists of two components:2
    • A list of signs, symptoms, and behaviours commonly associated with risk and functional impairment that if observed in the patient, triggers further exploration/investigation
    • A patient discussion aid to help PCPs investigate the impact on several functional domains.

Assessing level of risk and identifying the appropriate intervention

Weigh the factors

Use discussions† with the patient to identify factors that increase susceptibility to risk. Based on your assessment of warning signs, means and opportunities, determine if protective factors mitigate the immediate risk of harm to self or others.

Protective factors

Examples of protective factors3,5,7,10

  • Strong perceived relationships with loved ones (e.g. children, parents, partners, friends, pets, other dependents)
  • Strong, positive social networks
  • Belief systems with strong prohibitions related to the identified risk (e.g. strong religious affiliation with prohibition against homicide)
  • Optimistic outlook, identification of future goals, responsibilities/ duties to others (e.g. childrearing)
  • A reasonably safe and stable environment
  • Employment
  • Using or connected to community services

Warning signs and risks

Examples of factors that increase susceptibility to risk:

  • Social and familial risk situation and/or lack of support
  • Financial uncertainty
  • Domestic violence
  • Recent stressful events
  • Expressed hopelessness
  • Recent suicidal/self-harm behaviour
  • Family history of suicide

Consider any factors that increase risk potential (e.g. background, history, environment and/or circumstance)3,6,7,8

Probe to understand opportunities / means to harm9,10

  • What are the available means of suicide or of harm to self or others? (e.g. firearms license, access to weapons, medications, etc.)
  • Are caregivers able to sufficiently monitor and protect this person from harming themselves or others?
  • Are there vulnerable individuals in the person’s environment who cannot protect themselves? (e.g. children, elderly, other dependents, etc.)

Probe† to determine if there are warning signs indicative of risk of harm to self or others

  • Suicide5
    • Is the patient expressing or having suicidal ideation, intent, or planning?
    • Is there evidence of suicidal behaviours, poor judgment, or poor impulse control?
    • Is there a history of suicidal or para-suicidal behaviour?
  • Self-Harm5,9
    • Is the patient engaging in self-harm or is there evidence of self-harming behaviour?
    • Is the patient verbalizing intent to self-harm?
    • Does the patient have a history of self-harm behaviour?
  • Harm to others9
    • Is the patient verbalizing or thinking about harm to others?
    • Has the patient caused others to fear for their safety?
    • Is the patient expressing intense anger towards or fear of others?
    • Is the patient making physical gestures about hurting others?
    • Has the patient caused physical harm to others?

Probe to assess the presence and strength of protective factors

  • Ask patient:
    • What or who has prevented or stopped you from [insert risk] until now?
    • If [protective factor] is no longer present, what or who else could prevent or stop you from [insert risk]?

† Directly ask the patient and/or family members (with patient’s consent) about the above warnings signs, as patients often do not verbalize their thoughts or intentions unprompted3

Identify the intervention

Based on your exploration of the risk and/or protective factors, assess the probability* and severity of adverse outcomes to identify the appropriate intervention using the matrix below. Determine the level of risk using scale below. Patients may cross risk levels – use clinical judgment to guide your assessment. See Interventions for details on initiating appropriate interventions according to the level of risk.

*The predictive ‘risk for harm’, as based on key signs and symptoms has yet to be validated: probe and use clinical judgment to guide your assessment. In situations of ambiguity or uncertainty, it is better to overestimate than underestimate the magnitude of risk.

Interventions

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High immediate risk

Obtain ED Consult

A patient is at high-immediate risk of harm when life-threatening impairments (e.g. loss of life or limb) are imminent as a result of their actions/behaviours. These patients should be referred to the ED or local crisis support services for further assessment, where available and appropriate.

The intent of the following section is to assist PCPs in making key decisions, once it has been determined that a patient needs to be sent to the ED for further assessment. The aim is to reduce risks associated with transfers from community settings to hospital ED and to ensure that the level of risk is understood by the receiving ED.

If there are concerns that a patient may be a danger to you or your staff, do not prevent this patient from leaving your office. Allow patient to leave, immediately complete Form 1, and contact your local police to provide them with the completed Form 1.

NOTE: Discharge planning plays a role in suicide prevention by ensuring ongoing support and care for the patient after an ED visit. PCPs can either be a part of the development of a discharge plan with the hospital, or can be included in the discharge plan as a point of contact for the patient to follow up with. Complete a Form 1 if PCP has any concern that a patient will not go to the ED voluntarily.

Tips for communicating with your patient
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Talking points

  • “As a health care provider, I am committed to ensuring that your health and safety are a priority.
  • “I am very concerned about your safety and I believe that you need to go to the emergency department immediately.”
  • “I appreciate that you may not agree with my decision and that it may cause you temporary discomfort; however, I truly believe that it will prevent you from long-term suffering and keep you safe.”
  • “Here is what I am going to do…”
Tips for completing Form 1
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Tips for completing Form 1

  • Form 1 is used by a physician to legally bind a patient to undergo a psychiatric assessment, under the Mental Health Act (OHIP Billing code: K623 – $95)
  • Neither the risk nor the mental health diagnosis need to be certain; possibility is sufficient
  • Physician can complete a Form 1 based on the information provided by others, as long as the patient has been examined in the past 7 days
  • To increase the likelihood that the patient is admitted for assessment, be sure to stress risk and safety concerns

An Application for Psychiatric Assessment, otherwise known as a “Form 1”, is the first step on the path to involuntary admission. The following are tips to completing a Form 1.

  1. You do not need to be certain of the risk or of the mental disorder; you are requesting an assessment because you are uncertain.
  2. A Form 1 provides physicians with two options to complete – Box A or Box B
    • Box A is used most often
    • Box B can only be used if the individual has previously been found incapable of consent to treatment of the mental disorder.
      • Step 1: Complete the data fields requesting the physician’s name and contact information in addition to the patient’s name and address.
        NOTE: The date you enter in this section is the day when you personally examined the patient, which may not be the current date and can be up to 7 days prior to the date you are completing the Form 1.
      • Step 2: Decide whether section “Box A” or section “Box B” is applicable and complete one Box, not both.

Completing Box A:

The first part is titled ‘The Past/Present Test.’ This part relates to the identified concerns. Check the appropriate boxes and provide supporting evidence from your own observations or from concerns expressed by others.

The second part is titled ‘The Future Test.’ This part mainly relates to information suggesting the possibility of a mental disorder. The first step in The Future Test is checking boxes that apply to the actual harm or impairment you believe may occur. These differ from the first set of check boxes in The Past/Present Test, which refer to threats, attempts, violent behavior, eliciting fear or impaired self care. The check boxes in The Future Test are asking you to clarify your opinion that the threats, attempts, etc., will likely result in actual harm. The second step in The Future Test is to provide narrative information, based on your observations or facts from others, suggesting a mental disorder. Information can include:

  • Concrete signs and symptoms or related functional impairments
  • Prior history of confirmed mental disorder

Completing Box B:

While not as commonly used, Box B can be useful as an early intervention, i.e. certification at a lower level of disturbance based on past history. Box B is only to be completed if your patient:

  • Has a recurrent or ongoing mental health condition that has been previously certifiable when not treated, but has shown clinical improvement when treated;
  • Is incapable of consent to treatment, and has a substitute decision-maker who is providing consent;
  • Is currently suffering from the same or similar mental health condition that was previously successfully treated, and you believe that without treatment, harm or impairment to self or others, or substantial mental/physical suffering, is likely to occur.

Please refer to examples of completed forms and additional documents for clarity:

Tips for completing a brief note to accompany your patient to the ED
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Talking points

  • Include the length of time that you have known the patient and examples of why this behaviour is atypical for your patient
  • Explicitly state the adverse outcome of concern and your reasons for an emergent assessment
  • Include PCP’s contact information, and consider faxing note directly to the ED

Medium to high risk

Mandatory and permissive reporting

Patients’ functioning in their daily lives may be affected by their symptoms and behaviours. The following section is intended to support providers to better understand functional impairments and assess whether intervention is needed.

NOTE: It is crucial that patients are involved in making decisions for their care. For high-risk situations, it is necessary for PCPs to make quick decisions to ensure the safety of their patients and others. However, when there is time to assess patients’ needs, the options for care should be presented to them, where possible, to ensure a collaborative approach to management.

Referral to Community Mental Health Supports and Services

PCPs can refer patients to several community-based mental health and addictions support organizations within Ontario, including supportive counselling, withdrawal management, crisis intervention, residential addictions treatment, early psychosis intervention, and vocational/employment programs.

NOTE:
PCPs should ask patients about potential time and transportation barriers for the service to which they are being referred to. Additionally, when determining options for patients it is important to ask them about preferred language of service and take into consideration culturally appropriate care options.

Talking Points
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Talking Points

Ask patient:

  • When family/caregivers are known by the PCP to be included within a patient’s circle of care, PCPs can ask if these individuals require additional support caring for the patient with mental health and addictions

Low Risk

Immediate interventions can be provided pending diagnosis, such as symptom-specific pharmacotherapy, psychological intervention and environmental management. Discuss various options to develop a personalized plan that incorporates a patient’s goals and values (i.e., preferred language of service and culturally appropriate care options). This section outlines considerations for symptom and risk management pending diagnosis.

Lifestyle modifications5,11,12
  • Work to develop management plan with patient
  • Encourage a patient to actively participate in their own management planning
  • Discuss protective factors and supports in patient’s life and identify which protective factors can be fostered
  • Encourage positive lifestyle changes, such as exercise, positive leisure time, and social engagement
  • Offer advice on sleep hygiene and healthy eating as needed
  • Discuss removal of risk-related items from the home (e.g. firearms, alcohol, unnecessary medications and poisons)
  • If a patient is at risk for suicidal behaviour, work with them to develop a crisis and safety plan
    • Safety plan should include contact phone numbers for family/friends (emergency contacts), therapist contact information, and coping and problem solving skills that the person can perform independently
    • The Wellness Recovery Action Plan provides supports and resources to assist a patient develop a crisis plan
Psychotherapy13
  • Providers and their patient can initiate effective psychotherapy. Some online cognitive behavioural therapy treatments have been shown to be as, or more effective, than individual therapy with a live therapist.

Ongoing monitoring and follow-up

Consider the following:
  • Monitor and assess the patient’s progress of care goals, clinical outcomes, satisfaction and unmet needs
  • Liaise and manage care transitions or changes in care status to facilitate continuity of care (e.g. warm handoffs as patient transitions in and out of hospital and/or specialist care)
  • Identify appropriate point of contact for the patient with respect to any care coordination issues
  • Participate in multi-disciplinary case conferences to develop a care plan based on the patient’s care goals. Additionally, with the patient’s consent, maintain regular communication with hospital or community mental health and addictions services to foster an ongoing shared care relationship.

Schedule a follow-up appointment to monitor patient, reassess risk, and track the effectiveness of intervention.

Supporting materials

Mandatory and permissive reporting

Mandatory and Permissive Reporting for Physicians
  • CPSO Policy Statement #6-12 Mandatory and Permissive Reporting The College of Physicians and Surgeons of Ontario (CPSO) have documented all instances of mandatory reporting (e.g. child abuse or neglect; impaired driving ability; safety related to pilots or air traffic controllers, railway workers and maritime workers; and occupational health and safety) and permissive reporting (e.g. disclosure to prevent harm) requirements.
Safety of Dependents & Family Members
Identifying Potential Workplace Hazard
  • Contact the Ministry of Labour: 1-877-202-0008, option #3. Information will be forwarded to the investigation unit. It is important that the physician knows the employer and employment location of the patient to file a concern.
  • If a health provider is concerned that a patient could pose a potential hazard to themselves or to others in the workplace, the health provider is advised to contact the Ontario Ministry of Labour to file a concern. This can be done anonymously.
    **Providers must comply with the requirements, policies, and guidelines set out by their respective regulatory college regarding the completion of permissible reports and medical documents. Please see the following resources for more information:

Reporting to the Ministry of Transportation

Referral to Community Mental Health Supports and Services

For providers

ConnexOntario
For a complete list of types of mental health and addictions services, visit ConnexOntario for a directory, operating hours and descriptions of local mental health, addictions, and problem gambling services.

ConnexOntario has helplines open 24/7:

  • Mental health 1-800-531-2600
  • Addictions 1-800-565-8603

Includes resources, such as ‘Family Initiatives’ that ‘pertain to family groups participating in the planning and evaluation of care delivery, as well as the provision of services, such as self-help, peer support, education, advocacy, etc. These services can be helpful for family members supporting an individual with mental health and addictions concerns.

For patients
  • OCFP’s Collaborative Mental Health Network (CMHN)
    The Collaborative Mental Health Network provides mentoring support and education to enhance the capacity of family physicians to provide comprehensive and quality care to patients with complex conditions involving mental illness or addictions.
  • Ontario Peer Development Initiative
    Consumer/survivor initiatives and peer support organizations may be helpful for the recovery of patients.
  • ECHO Ontario Mental Health
    ECHO Ontario Mental Health at CAMH and University of Toronto aims to help primary care providers build capacity in the treatment of mental health and addictions.

Psychotherapy

Mood & Anxiety Disorders:
  • MoodGYM– Online Cognitive Behavioural Therapy
  • Ecouch – Cognitive, behavioural and interpersonal therapies
  • 211Ontario: Mental Health / Addictions – An online database of programs and resources in local communities
  • Canadian Mental Health Association: Ontario Services & Support – A listing of programs delivered by community agencies, hospitals or health clinics
  • Centre for Mindfulness Studies – Provides mindfulnessbased cognitive therapy, mindfulness-based stressed reduction, mindful self-compassion and specialized mindfulness training to the general public, healthcare providers and social service professionals
  • Bounce Back – A free skill-building program managed by the Canadian Mental Health Association (CMHA). It is designed to help adults and youth 15+ manage low mood, mild to moderate depression and anxiety, stress or worry. Delivered over the phone with a coach and through online videos

Additional supporting materials and resources that may be useful for PCPs:

NOTE: These supporting materials are hosted by external organizations, and as such the accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

References

  • [1]

    Silveira J, Rockman P. Mental disorders, risks, and disability: Primary care needs a novel approach. Canadian Family Physician. 2016;62(12):958-960.

  • [2]

    Silveira J, Rockman P, Fulford C, Hunter J. Approach to risk identification in undifferentiated mental disorders. Canadian Family Physician. 2016;62(12):972-978.

  • [3]

    Perlman CM, Neufeld E, Martin L, Goy M, Hirdes JP. Suicide Risk Assessment Inventory: A Resource Guide for Canadian Health Care Organizations. 2011. Toronto, ON: Ontario Hospital Association and Canadian Patient Safety Institute.

  • [4]

    Allan CL, Behrman S, Ebmeier KP. Primary care management of patients who self-harm. Practitioner. 2012;256(1751):19-22, 2-3.

  • [5]

    National Institute for Health and Clinical Excellence (NICE). Self-harm: longer-term management. London (UK): National Institute for Health and Clinical Excellence (NICE). 2011. (Clinical guideline:133).

  • [6]

    U.S. Preventive Services Task Force. Screening for suicide risk in adolescents, adults, and older adults in primary care: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(10):719-26.

  • [7]

    Centres for Disease Control and Prevention, National Centre for Injury Prevention and Control, Division of Violence Prevention. Child Abuse and Neglect: Risk and Protective Factors. [Internet]. 2016.

  • [8]

    Centres for Disease Control and Prevention, National Centre for Injury Prevention and Control, Division of Violence Prevention. Suicide: Risk and Protective Factors. [Internet].2015.

  • [9]

    DiGregorio RV, Green-Hernandez C, Holzemer SP. Primary Care, Second Edition: An Interprofessional Perspective. 2015. Springer Publishing Company, LLC.

  • [10]

    Centres for Disease Control and Prevention, National Centre for Injury Prevention and Control, Division of Violence Prevention. Sexual Violence: Risk and Protective Factors [Internet]. 2016.

  • [11]

    Centre for Addiction and Mental Health. The CAMH Suicide Prevention and Assessment Handbook. [Internet]. 2011.

  • [12]

    Durbin S, Ker K, Rawal S, Chan J, Ho A, Au Billie, Lofchy J. Psychiatry–Toronto Notes. 2009.

  • [13]

    Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a metaanalysis.PloS ONE. 2010;5:e13196.