Recognising Signs of Deterioration in a Person’s · Recgognising Signs of Deterioration in a Person's Mental State 3 Executive Summary The purpose of this report is to present the

Recognising Signs of Deterioration in a Person’s

Mental State: An Updated Literature Review

Final Report

Dr Cadeyrn Gaskin

May 2019

Table of Contents

2 Recgognising Signs of Deterioration in a Person's Mental State

Table of Contents

Executive Summary ................................................................................ 3

1. Introduction ........................................................................................ 4

2. Method ................................................................................................ 6

3. Findings .............................................................................................. 7

3.1 Dynamic Appraisal of Situational Aggression ......................................... 7

3.2 Concise Health Risk Tracking Scale ...................................................... 8

4. Discussion ........................................................................................... 9

Acronyms .............................................................................................. 11

References ............................................................................................ 12

About the Researcher............................................................................ 15

Executive Summary

Recgognising Signs of Deterioration in a Person's Mental State 3

Executive Summary

The purpose of this report is to present the findings of an updated review of peer-reviewed and grey literature on mental state deterioration published since the

completion of Recognising Signs of Deterioration in a Person’s Mental State: Final Report. The updated literature review incorporates research published from May 2017 to April 2019. Searches of five electronic databases returned 707 papers,

three of which met the selection criteria for this review. The grey literature search yielded no additional information. No new tools for recognising the range of signs

that might be expected to be indicative of deterioration in a person's mental state were found. The three papers contained studies on two instruments: Dynamic Appraisal of Situational Aggression (DASA) and Concise Health Risk Tracking

(CHRT) scale. DASA facilitates assessment of the risk of imminent aggression, and was described in the previous report. The CHRT scale was developed to assess

suicide risk over time. There continues to be significant clinical and scientific interest in developing and validating tools for assessing risk of adverse outcomes (e.g., aggression and suicide). Limited attention, however, has been paid to

developing a tool to facilitate the recognition of mental state deterioration more broadly.

Introduction


1. Introduction

Being able to recognise and respond to clinical deterioration depends upon knowing what signs to look for. When it comes to identifying acute physiological

deterioration, several signs are well-established, including respiratory rate, oxygen saturation, heart rate, blood pressure,

temperature, and level of consciousness.1 As yet, however, there are no generally accepted

signs of deterioration in a person's mental state.

The Australian Commission on Safety and Quality in Health Care (the Commission) has

been working on expanding the concept of clinical deterioration to incorporate

deterioration in a person's mental state. In support of this work, two research reports have been prepared: Recognising and

Responding to Deterioration in Mental State: A Scoping Review2 and Recognising Signs of

Deterioration in a Person’s Mental State: Final Report.3 The second of these reports built upon

the findings of the first. Two questions that were central to both reports were:

What are the signs of deterioration in a person's mental state?

What tools are available to measure deterioration in a person's mental state?

Research on the signs of deterioration in a person's mental state is under-developed. In a submission to the Scoping Review, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) suggested that signs of deterioration

could be identified using the mental state examination.2 With this approach, deterioration would be observed as adverse changes in one or more features of

mental state, such as affect and mood, thought (stream, form, and content), cognition (memory and orientation), perception, and behaviour. Another possible way of recognising deterioration emerged from research conducted for the second

report.3 Here, five indicators of deterioration were identified: (1) reported change; (2) distress; (3) loss of touch with reality or consequences of behaviours; (4) loss

of function; and (5) elevated risk to self, others or property. For either of these approaches to be fit for purpose they would need to undergo extensive evaluation of their validity, reliability, and utility across the diversity of healthcare

professions, settings, and people requiring care.

Several tools have been developed that show promise in supporting the recognition of acute deterioration in particular healthcare settings or in enabling

the tracking of changes in specific aspects of mental state. Tools identified in the previous two reports include early warning signs journaling,5 mental health thermometer,6 mental state examination scale (MSES),7, 8 Five-Item Daily

Symptom Index (DI-5),9-11 Dynamic Appraisal of Situational Aggression (DASA),12-

Terminology Review

Mental state is “broadly understood to refer to a person’s intellectual capacity, emotional state, and general mental health based on clinical observations and interviewing. Mental state comprises mood, behaviour, orientation, judgment, memory,

problem‑solving ability, and contact with reality.” 2

Deterioration refers to “a change for the worse in a person’s mental state, compared with the most recent information available for that person, which may indicate a need for additional care.”3

Signs are objective findings with specific connotations (for example, loose associations are a sign of a thought disorder).4

Introduction


14 Brøset Violence Checklist (BVC),15-18 Imminent Risk Rating Scale (IRRS),19 and Life-Death Implicit Association Test (IAT).20 Two of these tools were designed to

assist in the recognition of deterioration in a person's mental state (early warning signs journaling and MSES). The extent to which these tools could be effectively

used outside of the psychiatric care settings in which they were developed, however, is unclear. The other tests were developed to measure specific aspects of mental state, including psychological well-being (mental health thermometer),

psychological distress (DI-5), risk of aggression and violence (DASA, BVC, IRRS), and suicidality (IAT). No tool was found that healthcare providers from different

disciplines could use to recognise deterioration in a person's mental state across healthcare settings.

The purpose of the present review is to provide an update on the evidence for

recognising and tracking signs of acute mental health deterioration. The aim was to determine whether any tools had been developed since the latest report.3

Method


2. Method

The search strategy used in the previous two reports2, 3 was replicated, albeit with a revised timeframe. Five electronic databases were searched for relevant papers:

Academic Search Complete, CINAHL Complete, Health Business Elite, MEDLINE Complete, and PsycINFO. The search terms were: psychiatric, mental health, inpatient, mental state, deteriorat*, risk assessment, risk management, adverse

event, adverse outcome, and patient safety. The search was limited to peer-reviewed papers published during or after May

2017 (the previous review covered the period July 2013 until May 20173). The search was current as at 13 April 2019.

The search strategy for grey literature involved

the Google search engine using terms such as deterioration, mental state, and assessment.

Additional searches were undertaken of the following organisations’ websites: American Psychiatric Association (www.psych.org),

National Institute for Health and Clinical Excellence (www.nice.org.uk), The Joint

Commission (www.jointcommission.org), The Royal College of Psychiatrists

(www.rcpsych.ac.uk), RANZCP (www.ranzcp.org), United States Department of Health and Human Services (www.hhs.gov), UK Department of Health (www.gov.uk), and World Health

Organization (www.who.int).

The reference lists of included papers were scanned to identify tools and other literature pertinent to this review.

Studies were included in the review if they were focused on tools for identifying

and tracking signs of deterioration in a person’s mental state. There are two types of tools of potential relevance. First, tools designed to assess deterioration in a person's mental state directly with a single administration. Second, tools

developed to measure mental state that, when administered to the same person on more than one occasion, are able to detect changes over short periods of time

(for example, over a few hours, ideally, or several days). With evidence from the previous two reviews suggesting few tools were likely to be found, studies were

included where the time between assessment points was up to one month. Having a cut-off point was necessary to conduct the review, and tools that are sensitive to change over periods of up to one month may have potential to be used to

identify and track deterioration in a person's mental state over much shorter time spans.

Search Strategy

01. psychiatric 02. mental health 03. inpatient 04. mental state 05. deteriorat* 06. risk assessment 07. risk management 08. adverse event 09. adverse outcome 10. patient safety 11. 1 or 2 12. 4 or 5 or 6 or 7 or 8 or 9 or 10 13. 3 and 11 and 12

Findings


3. Findings

The search of the electronic databases yielded 707 papers (Academic Search Complete, n=219; CINAHL Complete, n=97; Health Business Elite, n=5; MEDLINE

Complete, n=203; and PsycINFO, n=183). Duplicate papers (n=252) were removed, leaving 455 to be assessed for inclusion in the review. Of these papers, 433 were excluded based upon their titles. The abstracts of the remaining 22

papers were read, and a further 12 papers were excluded. The reasons why papers were excluded at this point were:

Risk assessments (for example, measures of the risk of future violence)

were conducted on single occasions (n=6 papers) Researchers did not report on the use of a tool (n=3) The tool did not measure an aspect of mental state (n=1)

Authors described the development of an incident reporting form (n=1) The study focused on the efficacy of a risk reduction intervention (n=1).

The full texts of the remaining 10 papers were read, and 7 papers were excluded.

The reasons for exclusion were:

Risk assessments were conducted on single occasions (n=3 papers) The tools did not measure an aspect of mental state (n=2)

Researchers did not report on the use of a tool (n=1) The administration frequency of the tool was unclear (n=1).

The remaining 3 papers were included in the review. Scanning the reference lists

of these papers did not result in the identification of any further papers for inclusion in this review.

The grey literature search did not identify any recently developed tools for the recognition of deterioration in a person's mental state. The Google search returned

links to Commission documents and to papers already included in the review. The search of the RANZCP website returned its submission to the Scoping Review.2 No

other relevant documents were found.

The papers included in this review focused on the DASA21, 22 and the Concise Health Risk Tracking (CHRT) scale.23 The DASA was described in the previous review,3 so the present review will focus on the new research that was located.

3.1 Dynamic Appraisal of Situational Aggression

The DASA is a tool for assessing the risk of imminent aggression in psychiatric

inpatients.24.Two recent papers on the DASA were found during the search.21, 22 Both studies were conducted in secure psychiatric hospitals and confirmed that the DASA has strong predictive validity. Researchers in one study showed that

combining the DASA scores based on all three shifts during a day was a better predictor of aggressive incidents on the next calendar day than scores from a

single shift.22 Scores from one shift had a moderate predictive ability for aggression on the next three shifts. In the other study, researchers found that there may be a need to adjust the original DASA risk bands to ensure patients at

elevated risk of aggression are identified. 21

Findings


3.2 Concise Health Risk Tracking Scale

The CHRT scale is a tool designed to assess suicide risk over time.25 Both self-report (CHRT-SR) and clinician rating (CHRT-CR) measures have been developed,

with each having 12- and 7-item versions. The items represent three domains: (1) hopelessness, (2) interpersonal attachment/social support, and (3) active suicidal ideation and behaviour. Items (e.g., “I have a plan to kill myself”) are

responded to on a 5-point Likert scale, anchored with strongly agree and strongly disagree.

The paper meeting the selection criteria for this review is focused on the self-

report version of the tool.23 Reporting on two studies, the researchers provided supporting evidence for the psychometric properties of the CHRT-SR. Among the findings was evidence that tool was sensitive to decreases in suicide risk over time

following discharge. Assessments were conducted on the day prior to discharge and at 2-, 4- , and 8-weeks post-discharge. These reductions in suicide risk were

consistent with clinical expectations.

Discussion


4. Discussion

The main finding from this review is that no tools appear to have recently been developed to support the recognition of deterioration in a person's mental state.

Two measures were identified during the search (DASA and CHRT), neither of which were designed to provide coverage of the range of signs that might be expected to be indicative of deterioration in a person's mental state. Rather, the

DASA and CHRT facilitate the assessment of risk of aggression and suicide, respectively.

In addition to identifying papers on these two tools, research on mental state

deterioration was located during the search.26, 27 In one Melbourne-based study, researchers sought to understand the patient and service characteristics associated with unplanned admissions to acute

psychiatric inpatient units following telephone-based mental health triage assessments.26

These unplanned admissions were interpreted as being indicative of mental state deterioration. In comparison to patients who

did not require admission following triage assessments, those with unplanned

admissions were more likely to have been subject to legal orders under the Victorian

Mental Health Act (odds ratio [OR]=13.66; 95% confidence interval [CI] 7.01, 26.62), to have presented with a psychotic episode

(OR=2.34; 95% CI 1.45, 3.78), to have been referred by family (OR=2.45; 95% CI 1.09,

5.50) or healthcare providers (OR=2.20, 95% CI 1.01, 4.77), and to have been assigned urgent (OR=3.13; 95% CI 1.79, 5.47), very urgent (OR=2.96; 95% CI 1.54,

5.71), or emergency (OR=2.38; 95% CI 1.06, 5.38) triage codes. Treatment adherence (OR=0.61; 95% CI 0.38, 0.99) and being on a pension (OR=0.49; 95%

CI 0.29, 0.83) were protective against admission. These findings seem consistent with those of the second report to the Commission3 in that two indicators of deterioration seem to be reported change (aligned with referral by family or

healthcare providers) and loss of touch with reality of consequence of behaviours (aligned with presenting with a psychotic episode).

A second study from some of the same researchers demonstrated an association

between physiological and mental state deterioration.27 Patients requiring emergency responses for aggressive or violent behaviour (Code Greys) in four acute care hospitals were less likely to have documented physiological

assessments during the 12 hours before the Code Grey responses. The patients were also more likely to have had physiological abnormalities relating to confusion,

conscious state, heart rate, and respiratory rate. Confusion was the abnormality most strongly associated with Code Grey responses (OR=16.51; 95% CI 9.92, 27.46).

Like in the previous two reviews,2, 3 the tools identified in the present review predominantly focus on risk assessment. Given that mental health clinicians use the terms change and risk more than deterioration,2 this outcome is unsurprising.

Terminology Review

Odds ratios describe, for example, the odds of an event happening (e.g., unplanned admissions) given the presence versus absence of a potential causative factor (e.g., experiencing a psychotic episode).

Confidence intervals describe the range of values within which a given population parameter (e.g., odds ratios) would be expected to fall. At the 95% level, it would be expected that 95% of confidence intervals would contain the population parameter.

Discussion


There are many more risk assessment tools available than have been included in these reviews. Taking violence risk prediction for forensic inpatients as a narrow

example, 11 instruments are in common use.28 These tools tend to be focused on specific risks, such as aggression and suicide, rather than mental state, more

broadly. In addition, much of the research seems to be focused on whether single assessments are useful for predicting adverse events over subsequent weeks or months. Nine papers were excluded from the present review because the studies

involved single assessments of risk.

In conclusion, no new tools for recognising deterioration in a person's mental state were located during this review update. Tools identified in the previous two

reviews (early warning signs journaling and MSES), as well as the five indicators developed in the last project, remain options for recognising deterioration in a

person's mental state. These three options represent significantly different ways of identifying deterioration. Unfortunately, none of these approaches has undergone substantive work on their validity, reliability, and utility across a range

of healthcare settings.

Acronyms


Acronyms

BVC Brøset Violence Checklist

CHRT Concise Health Risk Tracking

CHRT-CR Concise Health Risk Tracking Self-Report – Clinician Rating

CHRT-SR Concise Health Risk Tracking Self-Report – Self-Report

CI confidence interval

DASA Dynamic Appraisal of Situational Aggression

DI-5 Five-Item Daily Symptom Index

IAT Life-Death Implicit Association Test

IRRS Imminent Risk Rating Scale

MSES mental state examination scale

OR odds ratio

RANZCP Royal Australian and New Zealand College of Psychiatrists

References


References

1. Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for recognising and responding to

acute physiological deterioration (2nd ed.). Sydney: ACSQHC, 2017.

2. Craze L, McGeorge P, Holmes D, Bernardi S, Taylor P, Morris-Yates A, et al. Recognising and responding to deterioration in mental state: a scoping

review. Sydney: ACSQHC, 2014.

3. Gaskin C, Dagley G. Recognising signs of deterioration in a person’s mental

state. Sydney: ACSQHC, 2018.

4. Trzepacz PT, Baker RW. The psychiatric mental status examination. New York: Oxford University Press; 1993.

5. Walker S, Kelly M. The introduction of an early warning signs journal in an adolescent inpatient unit. Journal of Psychiatric and Mental Health Nursing.

2011;18:563-8.

6. Newnham EA, Doyle EL, Sng AA, Hooke GR, Page AC. Improving clinical outcomes in psychiatric care with touch-screen technology. Psychological

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11. Restifo E, Kashyap S, Hooke GR, Page AC. Daily monitoring of temporal trajectories of suicidal ideation predict self-injury: a novel application of

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12. Chu CM, Thomas SDM, Daffern M, Ogloff JRP. Should clinicians use average

or peak scores on a dynamic risk‑assessment measure to most accurately

References


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16. Rechenmacher J, Müller G, Abderhalden C, Schulc E. The diagnostic

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About the Researcher


About the Researcher

Recognising Signs of Deterioration in a Person’s Mental State: An Updated Literature Review

was undertaken for the Commission by Dr Cadeyrn Gaskin (Principal Researcher) of Gaskin

Research.

Dr Cadeyrn Gaskin

Dr Cadeyrn Gaskin has over 15 years of experience in health and social research,

focusing mainly in the areas of mental health, healthcare practices, disability, and physical activity. He has worked with government, peak bodies, healthcare

providers, universities, and healthcare practitioners across Australia and New Zealand. He undertakes primary research, compiles extensive reviews of literature, provides research advice, and supports the development of guidelines

for practice. He has authored over 100 peer-reviewed publications and reports.

Documents

Recognising Signs of Deterioration in a Person’s · Recgognising Signs of Deterioration in a Person's Mental State 3 Executive Summary The purpose of this report is to present the