In a risk assessment the questions that come most readily are about the illness — mood, sleep, appetite, hopelessness, plans. They are the right questions and they are not sufficient. A large share of self-harm presentations follow a specific precipitating event within days: a marital or family row, an examination result, a debt demand, a public humiliation, a broken relationship.
So add one question and give it room: what happened in the week before this? It changes the assessment in two ways. It identifies people whose risk is high now and whose mental state examination is close to normal, which the symptom-led interview will call low risk. And it tells you what to act on — the row, the debt, the exam — which is often more tractable in the next fortnight than the depression is.
It also changes who you talk to. A precipitant usually involves somebody else in the household, and that person is the one who can remove the pesticide from the shed or hold the tablets for a fortnight.
- Ask the precipitant question in every self-harm and every low-mood assessment, not only the obvious ones.
- Record the precipitant in the notes so the next clinician sees the risk state, not only the diagnosis.
- Convert it into an action: who at home can hold medication, who can be called at 2am.
- Set the review interval by the precipitant's timeline — before the court date, not in six weeks.
Why it matters
The symptom-led interview misses the patient in acute crisis with a near-normal mental state.
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