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Original papers: Helen Smith and Tom White Feasibility of a structured risk assessment tool in general adult psychiatry admissions Psychiatr Bull 2007; 31: 418-420 [Abstract] [Full text] [PDF]

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Use of the HCR-20 in general adult psychiatry

Amar Shah   (11 December 2007)

Use of the HCR-20 in general adult psychiatry 11 December 2007
Amar Shah, ST3 Psychiatry Camden & Islington Mental Health & Social Care Trust Send letter to journal: Re: Use of the HCR-20 in general adult psychiatry amar_shah{at}doctors.org.uk Amar Shah	Smith and White (2007) are to be commended for their efforts in introducing a structured risk assessment tool on the general adult psychiatric wards. There are however, some problems in their use of the HCR-20 tool that undermine their conclusions about feasibility of implementation. The HCR-20 scale is intended to help structure professional judgement on risk of violence. It is not clinically very useful to use the scale as an actuarial instrument, by summing up the number of risk factors in order to stratify the patient into a high-risk or low-risk group. This approach tells us very little about the patient's individual risk factors and how best to manage them. The HCR-20 scale takes into account both static and dynamic variables, and hence applying the tool only on admission is not helpful as many of the clinical and risk management items may be amenable to change. If a tool such as the HCR-20 is to be implemented clinically in an effort to better assess and manage risk of violence, it should be used to structure regular multidisciplinary discussion on risk, consider future scenario planning, inform risk judgements and decision-making, and guide risk management strategies. The items of the HCR-20 scale have been chosen based on accumulating evidence-base of variables related to violence in mentally ill patients and prisoners. Structured professional judgement tools such as the HCR-20 recognise risk assessment as a dynamic and continuous process which is mediated by changing conditions, and move the emphasis from one of prediction to risk management. Declaration of interest : None