Primary Care Guidelines for Common Mental Illness

1
Primary Care Guidelines for Common Mental
Illness
These primary care mental health guidelines are
designed to help primary care practitioners
assess and plan care for adults who are
presenting with a range of mental health
problems. They have been designed and written by
the primary care LIT committee and Haringey LES
team with input from experts in the field
throughout Haringey using Haringey's previous and
CIs existing guidelines as a foundation. They
were written in line with 2007 national
guidelines check for updates from this date.
These guidelines are designed to be used
directly fromyour computer, although can be
printed off as a paper version. They are intended
to help you make clinical decisions rather than
direct your actions. When viewing on the web,
when any underlined item is clicked on you will
be connected to that page or relevant external
web site (although HTPCT and BEHMHT cannot be
responsible for the content or accuracy of any
external web site). If you have any questions or
need to contact someone about these guidelines
please contact one of the LES team in the first
instance. The LES team. July 2007 Dorian Cole
(Clinical Specialist 020 8442 6870) Dr Martin
Lindsay (GP MH lead North East PBC 020 8493
9100) Dr Belinda Agoe (GP MH lead central PBC
020 8888 3227) Dr Muhammed Akunjee (GP MH lead
South East PBC 020 8881 9606) Dr Robert Mayer
(GP MH lead West PBC 020 8340 6628)
Contents (click on heading to go to
page) Depression Identification and
assessment Depression Management Antidepressants
drug choice guidance Anxiety Identification
and management Anxiety drug treatment
guidance Eating disorders Psychosis and
schizophrenia identification, assessment and
referral Psychosis and schizophrenia management
following discharge from complex care
team Psychosis and schizophrenia managing
physical health Assessing and managing risk to
self Assessing and managing risk to others
Where you see this sign, click on it to be
directed to the latest NICE guidelines for that
condition
NICE
1st edition September 2007. Written by
Haringey PC LIT. Developed from Haringey and CI
guidelines.
2
Primary Care Guidelines for Common Mental
Illness Depression - Identification Assessment
Mild Depression At least 2 core symptoms plus
at least 2 additional. Person has some difficulty
continuing with ordinary activities but does not
cease to function.

• First Questions to ask
• Have you been bothered by feeling down, depressed
  or hopeless? How bad is this?
• Have you lost interest in things? Do you get less
  pleasure from things you used to enjoy?
• Are you more tired than usual?
• If yes to the above, prompt further about
  individual symptoms (see core symptom box)

• Core Clinical Symptoms
• depressed mood, and/or
• loss of interest, and/or
• loss of energy fatigue
• Additional Symptoms
• poor concentration
• reduced self-esteem self-confidence
  
  
  
  
• disturbed sleep
• change in appetite or weight
• feelings of guilt or worthlessness
• agitation/slowing
• pessimism/ hopelessness
• suicidal thoughts or acts
• Most of the day for at least 2 weeks
• Other clinical signs
• Tired all the time
• Irritability
• Loss of libido
• Medically unexplained physical symptoms

Dysthymia Mild depression gt2yrs

• Ante and Post Natal Care
• 1st contact enquire about past/current mental
  health history
• If high risk or actual symptoms/diagnosis, GP to
  communicate with midwife, HV and hospital
  services
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance

Moderate Depression At least 2 core symptoms
plus at least 3/4 additional. Person usually has
considerable difficulty in continuing with normal
social work activity.

• Higher Risk Groups
• Past history of depression
• Family history of depression
• Women who are pregnant and up to 6 months post-
  childbirth
• Socially isolated
• Those with ongoing difficult relationships
• Concurrent physical illness
• Multiple adverse events eg. loss, bereavement,
  childhood separation or abuse
• Drug alcohol misusers
• Carers
• Those in residential care

Severe Depression All 3 typical symptoms plus at
least 4 additional, some of which are severe.
Person shows considerable distress agitation
(or retardation) unlikely to be able to
continue with normal activity.
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Draft 1 july 2007. Written by Haringey PC LIT.
Developed from Haringey and CI guidelines
3
Primary Care Guidelines for Common Mental
Illness Depression - Management
Primary Care and psychological Management
Listen Support Inform Educate Patient
leaflet Problem-Solve Increase Activity
Exercise Increase social support
Consider other family members Book prescription
Guided Self-help, Computerised CBT and other
brief talking therapy useful consider referral
to Graduate Mental Health Workers (Health in
Mind) . Also consider social care input Harts,
60
Clinical judgement
Pharmacological Management Currently no evidence
to suggest that antidepressant medication is
effective in mild depression. Prescribe only if
clinically indicated.
Primary Care Management Listen Support
Inform Educate Problem-Solve Self-help
and book prescription Increase Activity
Exercise Increase social support
Consider other family members Also consider
social care input Harts, 60
Patient choice
Pharmacological Management Consider prescribing
antidepressants first line choice Fluoxetine or
Citalopram. Second line choice venlaflaxine
Psychological Management Consider referral for a
specific talking therapy Graduate Mental Health
Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
under 18 CAMHS on 020 8442 6467 18 to 65 yrs
call START on 020 8442 6714 Over 65 call 020
8442 6702
BEHMHT will consider crisis and/or inpatient needs
Primary Care Management Assess, Identify
risks/stressors and protectors see guidelines
on assessing risk. Consider other family members
for support and issues of risk (ie impact on
children). Negotiate and write a clear plan of
care. Give information to patient and carer of
out of hour support.
Pharmacological Management Prescribed
antidepressants- first line choice Fluoxetine or
Citalopram. Second line choice venlaflaxine
Psychological Management Refer to START for
consideration for talking therapy such as CBT,
IPT, CAT
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Draft 1 july 2007. Written by Haringey PC LIT.
Developed from Haringey and CI guidelines
4
Primary Care Guidelines for Common Mental
Illness Antidepressants - Drug Choice Guidance
Key Facts

• When an antidepressant is to be prescribed in
  routine care it should be an SSRI (as effective
  and less severe side effects than tricyclics)
• Prescriptions when possible should be generic.
  PCT recommend 1st line Fluoxetine or
  Citalopram.
• If SSRI is not effective, different type of
  medication should then be offered. PCT recommend
  2nd line - Venlafaxine
• Patients seem to have better outcomes if given
  GOOD, CLEAR INFORMATION about anti-depressants
  explain drugs plus give a Patient Information
  Leaflet

Questions to consider when choosing
antidepressants

• Is the patient at risk of suicide? YES
  SSRIs (Fluoxetine or Citalopram). consider
  issues of toxicity in overdose
• Is sedation needed? YES Mirtazapine or
  Older tricyclics
• Will anticholinergic effects be particularly
  problematic ? YES SSRIs, Venlafaxine
• Does the patient have significant other illness?
  YES avoid tricyclics, check BNF for
  individual drugs eg. CV/hepatic/renal
  imparirment
• Is the patient taking OTC or prescribed
  medications? YES check BNF for significant
  interactions
• Does the patient have symptoms of anxiety? YES -
  see anxiety guidelines
• Is the patient pregnant or breastfeeding? YES
  avoid drugs in 1st trimester if possible. Only
  use if benefits of treatment outweigh possible
  risks to foetus/baby of not treating the
  mother. Discuss with psychiatrist or psychiatric
  pharmacist. For complex cases National Centre
  for Drugs in Pregnancy 0191 232 1525

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Adapted from Bazire, S. Psychotropic Drug
Directory, 2005 Prices from Drug Tariff July
2007
Draft 1 july 2007. Written by Haringey PC LIT.
Developed from Haringey and CI guidelines
Adapted from Basire, S. Psychotropic Drug
Directory, 2001-2
5
Primary Care Guidelines for Common Mental
Illness Antidepressants - Drug Treatment
Guidance
Initiating medication
Treatment Regime

• Choose drug in line with drug choice guidelines
  overleaf
• Aim for the minimum effective dose
• Agree follow-up plan Review every 1-2 weeks at
  start of treatment. Monitoring of suicide risk
  essential if high risk. If low risk, every two to
  four weeks
• Provide good, clear drug counselling plus a
  patient information leaflet

RESPONSE
No response or poorly tolerated (CHECK
COMPLIANCE FIRST)
RESPONSE
Drug Counselling
RESPONSE

• Advise the patient
• That it may take 2-4wks to start noticing the
  positive effects (4-8wks in older people)
• Of the common side effects they are likely to
  experience
• That they need to keep taking the medication even
  when they feel better
• That antidepressants are NOT addictive but must
  not stop suddenly
• Of dosing titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
  they have been taking medication
• That they should consult you before stopping
  taking the medication

No response or poorly tolerated (CHECK
COMPLIANCE FIRST)
No response or poorly tolerated (CHECK
COMPLIANCE FIRST)
RESPONSE
NO RESPONSE (CHECK COMPLIANCE FIRST)
Poorly tolerated
Link to United Kingdom psychiatric pharmacy group
web site
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Draft 1 july 2007. Written by Haringey PC LIT.
Developed from Haringey and CI guidelines
6
Primary Care Guidelines for Common Mental
Illness Anxiety - Identification Management

• Predisposing factors
• Life events/ stressors
• Anxious personality

• Primary care management
• Educate about anxiety
• Provide self-help information support
• Book prescription
• Encourage relaxation techniques, regular exercise
  and sleep stress management
• Avoid over-investigation of physical symptoms and
  help patient make links between anxiety
  presenting physical symptoms
• Manage comorbidity substance use
• Watchful waiting

Common Anxiety Disorders in Primary Care
(co-existence should be considered)

• Mixed Anxiety Depression (MAD)
• Low or sad mood loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms

• Assessment
• Screening questions
• How are you feeling in yourself?
• Have you found yourself worrying a lot?
• Consider other causes of symptoms e.g.
  thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine
• duration of symptoms
• severity of impairment
• degree of avoidance
• degree of accompanying depression
• Assess risk

Mild

• Generalised Anxiety Disorder (GAD)
• Excessive anxiety worry about several events
  or activities
• Trouble controlling these feelings
• Symptoms present at least half the days in last
  6 mths

• Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
  
• May be associated with agoraphobia

• Primary care psychological management
• Consider referral for talking therapies, in
  particular guided self help (Health in Mind)
• CBT, as second line treatment if symptoms are
  causing significant distress or impairment of
  functioning

Moderate
Other Anxiety Disorders

• Pharmacological management
• Medication should be a third line treatment in
  the management of anxiety
• Drugs may be indicated if
• significant depressive symptoms (esp. in Mixed
  Anxiety Depression)
• persistent or very disabling anxiety symptoms
• Short term only

• Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or neutralise these
• Repetitive physical or mental behaviours
• Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a
  traumatic event that impairs functioning
• Intrusive memories flashbacks/ nightmares
• Avoidance behaviour
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months
  of symptoms

• Core Symptoms
• Mental symptoms eg. feeling on edge,
  apprehension, worry about future, fear of
  something bad happening, difficulty
  concentrating, depressive symptoms
• Physical tension arousal eg. restlessness,
  muscle tension, inability to relax, sweating,
  stomach or chest pains, dizziness, overbreathing
  NB. May present as physical complaint
• Behaviour change eg. avoidance of feared
  situations

• Discuss with START (020 8442 6714) if
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm

Severe
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Draft 1 july 2007. Written by Haringey PC LIT.
Developed from Haringey and CI guidelines
7
Primary Care Guidelines for Common Mental
Illness Anxiety - Drug Treatment Guidance
NB. Self-management strategies talking
therapies should be the first line treatments for
anxiety disorders. Medication may be considered
for acute distress, for persistent or disabling
anxiety symptoms, or where there are significant
depressive symptoms
Anxiety Disorder
Licensed Drug

• Benzodiazepines ( avoid short acting such as
  Lorazapam)
• Up to 7 days. With caution.

No specific drug licensed. Follow antidepressant
prescribing guidelines. Consider drug anxiolytic
properties.

• 1 - Paroxetine
• 2 - Venlafaxine
• 3 - Buspirone

Preferred options as advised by the Haringey
TPCT pharmacy team

• 1 - Citalopram
• 2 - Paroxetine

• 1 - Fluoxetine
• 2 - Paroxetine
• 3 - Sertraline
• 4 - Clomipramine

• Paroxetine

Only consider pharmacotherapy for symptomatic
management in one-off/ short-term circumstances
e.g. beta-blockers/ benzodiazapines for air
travel
Treatment Regime

• When using antidepressant medication to treat
  anxiety disorders, start therapy at ¼-½ of normal
  recommended dose for depression to minimise risk
  of exacerbating the anxiety (activation
  syndrome) and increase compliance. Use syrup if
  necessary.
• Key message Start Low, Go Slow
• Titrate to therapeutic dose If symptoms show
  improvement after 12wks of treatment, continue
  for a minimum of one year. Withdraw drug slowly.

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Draft 1 july 2007. Written by Haringey PC LIT.
Developed from Haringey and CI guidelines
8
Primary Care Guidelines for Common Mental
Illness Eating Disorders- Identification
Management
Monitor for 8 weeks Give information Book
prescription Use of self help books Food
diary Explore extent of problem Consider
involvement of family Consider referral if
failure to respond

• Core Clinical Symptoms
• ANOREXIA NERVOSA
• Body weight maintained 15 below expected for age
  and height/ BMI lt 17.5kg/m2
• Weight loss self-induced by
• Restricting intake
• Self induced vomiting and/or purging
• Excessive exercise
• Use of drugs
• Morbid dread of fatness
• Self set low weight threshold
• Disturbance of endocrine system
• Anorexia Nervosa has the highest death rate of
  any psychological disorder
• BULIMIA NERVOSA
• Bingeing, with preoccupation with food and
  craving
• Attempts to counteract excess calorie intake by
• Self induced vomiting
• Self induced purging
• Alternating periods of starvation and bingeing
• Use of drugs and/or neglect of insulin use in
  diabetes

Mild Anorexia BMI gt17kg/m2 No additional co
morbidity

• Assessment
• Height and Weight, BMI (weight kg /height m
  squared)
• Consider
• Other causes of weight loss, inc thyroid disease,
  stimulant use
• Investigations Full blood count, blood chemistry,
  pulse, blood pressure
• Other difficulties associated with binging and
  purging ie Tooth decay
• Symptoms of depression (difficult to treat until
  nutritional state is successfully being treated)

Mild and moderate Bulimia

• Moderate Anorexia
• BMI 15 17kg/m2
• No evidence of system failure

under 18 CAMHS on 020 8442 6467 18 to 65 yrs
call START on 020 8442 6714
The Phoenix Wing, St Ann's Hospital, St Ann's
Road, London N15 3TH Telephone Number 020 8442
6387Fax Number 020 8442 6192
Severe Bulimia Daily purging Electrolyte
imbalance Co-morbidity
Severe Anorexia BMI lt15kg/m2 Rapid weight
loss Evidence of system failure
Urgent referral and admission to acute medical
hospital if life-threatening
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Draft 1 july 2007. Written by Haringey PC LIT.
Developed from Haringey and CI guidelines
9
Primary Care Guidelines for Common Mental
Illness Psychosis and Schizophrenia Assessment
referral
Assessment (PSQ Bebbington and Nayani, 1995)
Urgent /Emergency Referral to START 020 8442 6714
Acutely disturbed
Hypomania   Over the past year, have there been
times when you felt very happy indeed without a
break for days on end?  If yes - Was there an
obvious reason for this? Did your relatives or
friends think it was strange or complain about
it?  Thought insertion  Over the past year, have
you ever felt that your thoughts were directly
interfered with or controlled by some outside
force or person?  If yes - Did this come about
in a way that many people would find hard to
believe, for instance, through telepathy?  Paranoi
a   Over the past year, have there been times
when you felt that people were against you? If
yes - Have there been times when you felt that
people were deliberately acting to harm you or
your interests?          Have there been times
when you felt that a group of people were
plotting to cause you serious harm or
injury?  Strange experiences  Over the past
year, have there been times when you felt that
something strange was going on?  If yes - Did
you feel it was so strange that other people
would find it very hard to believe? Hallucinations
Over the past year, have there been times when
you heard or saw things that other people
couldn't?  If yes- Did you at any time hear
voices saying quite a few words or sentences when
there was no-one around that might account for
it? 
Significant impact on dependant children?
Urgent referral to Children Services on 020 8489
5402

• Ante and Post Natal Care
• 1st contact enquire about past/current MI
  history
• If high risk or actual symptoms/diagnosis, GP to
  communicate with midwife, HV and hospital
  services
• Refer to START - agree and write care plan Also
  consider social care input Harts,
• See woman every month ante and post natal

New diagnosis of psychosis first presentation
Referral to START 020 8442 6714 (NB START will
refer patients to Early Intervention Service
when established)

• Discussion with Link worker/psychiatrist refer
  to START with patients agreement.
• Consider referral to START depending on
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk

Patient new to the area - with previously
diagnosed psychosis

• Prodromal Period
• Early signs of deterioration in personal
  functioning
• Changes in affect, cognition, thought content,
  motivation and behaviour
• 50 do not develop frank psychosis
• active follow up in primary care

In all cases consider starting antipsychotic
medication Risperidone is first line treatment

• Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education opportunities

• Higher Risk Groups
• Family history of psychoses
• Past history of psychoses
• Drug misusers
• Onset most commonly in 2nd or 3rd decade
  but can occur at any age

Known patient (sole management in Primary Care)
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Draft 1 july 2007. Written by Haringey PC LIT.
Developed from Haringey and CI guidelines
10
Primary Care Guidelines for Common Mental
Illness Psychosis and Schizophrenia Management
following discharge from CMHT (inc Support and
Recovery Teams)
Concordance and repeat prescriptions Monitor
repeat prescription picked up Check for side
effects Use pt leaflet
Work with patient to help improve general
well-being and feelings of worth Access to
employment and education Tomorrow's People,
Richmond Fellowship, New deal, Job centre Plus.
Consider referral/signposting to therapeutic
network, and or day services Book prescription
for stress and esteem issues Stress management
and relaxation skills Structure and activity
planning and Problem solving Debt
management Also consider social care input
Harts, 60 and Services for All
Patients needs stable Specialist input no longer
required
Depot medication Agree plan Competent practice
nurse Appointments opportunity to assess
Sole Primary Care Management
Discharge Planning and Care Plan Pt
identified Plan agreed Dates agreed
Physical Health Proactive plan utilise health
action plan Assess and review at least once a
year Target smoking, eating and exercise behaviour
SMI Register On list Care plan in place Reviewed
at least once a year
Crisis and Contingency Plan in place (CPA)
Shared Care In agreement with psychiatrist,
explicitly agrees who is doing what, when, how,
why and with whom.

• If acute relapse instigate crisis and
  contingency plan
• Discussion with Link worker or psychiatrist
• refer to START with patients knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk

Carers Cares assessment and needs Support and
counselling for carers (Health in Mind) Regular
review of carers needs Is there a child carer?
assess needs and refer to children services
Relapse Indicators Why, When, Who, How To refer
back to START
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Draft 1 july 2007. Written by Haringey PC LIT.
Developed from Haringey and CI guidelines
11
Primary Care Guidelines for Common Mental
Illness Psychosis and Schizophrenia - Physical
Health Care
Provide routine physical health checks at least
1x every year. Record on SMI register
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health

• Consider
• Primary prevention (use standard scoring
  systems)
• Secondary prevention in those with established
  heart disease
• Specific monitoring in relation to certain
  antipsychotic drugs (see BNF)

Monitor increased risk of cardiovascular disease
Promote healthy lifestyle
For example, good diet and exercise Actively
encourage smoking cessation
Promote wider well being activity Goal setting,
problem solving, access to education and
employment. Stress management referral to
Therapeutic Network and Day services
EPS/akathisia
Lethargy Weight gain/diabetes Effects on
eyes Sexual dysfunction
Monitor drug side effects
Focus on
Neurological
Metabolic and endocrine
Weight
Other side effects of medication

• Consider
• Extrapyramidal side effects
• Tardive dyskinesia

• Consider
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine disorders
  (high prolactin), eg amenorroea, glalactorrhoea

Consider routine weight monitoring
Photosensitivity and chlorpromazine
Cover key areas on regular basis agree frequency
with service user and document in notes
Regular monitoring
Primary and secondary care services
identify/allocate and document responsibilities
for monitoring physical health
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Draft 1 july 2007. Written by Haringey PC LIT.
Developed from Haringey and CI guidelines
12
Primary Care Guidelines for Common Mental
Illness Assessing Managing Risk to Self
Suicide/Self-Harm

• Suicide risk factors
• History of prior attempts
• Current severity of depressive or other mental
  illness
• Alcohol drug misuse
• Social isolation
• Low self esteem and perception of being a burden
• Rejected by loved ones
• Life-threatening/ chronic physical illness
• Being an single young man
• Impulsivity
• Recent discharge from psychiatric hospital
• Significant anniversaries
• Suicides in the family

• The suicide rate in Haringey is 11.7/100 000
  compared with the nation rate of 8.5/100 000
  (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into
  someones head or increase the risk - patients
  are often relieved to have the chance to talk
  about their fears

ASSESSMENT
MANAGEMENT
Ideation
Lower Risk
Are you feeling like life is not worth
living or Have you had thoughts about harming
or killing yourself?

• Review routinely
• Enquire about risk again as appropriate
• Identify protective factors

No
Yes
Intention
No
Moderate Risk
Have you felt like acting on these
thoughts or Have you considered actually ending
your life?
Clinical judgement consider that patient may
be withholding information
Yes
Planning
Have you made any plans or preparations about
how you would do this? Prompt method, suicide
note etc.
No

• Consider risk of harm due to
• Self-neglect
• Domestic violence
• Sexual vulnerability
• Child abuse
• Adult and elder abuse
• Risk from partner

Yes
Risk
How likely is it that you might act on these
plans? and Have you ever tried to harm yourself
or end your life before? Or (if psychotic) Have
you heard voices telling you to harm yourself?
Unlikely/No
Higher Risk

• Discuss directly with START or out of hours
  service 020 8442 6714
• If children in family also consider referral
  to children services

Likely/Yes
Remember Any previous
suicide attempts are the biggest indicator of
future risk Thoughts of self-harm related to
psychotic symptoms may increase risk.
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Draft 1 july 2007. Written by Haringey PC LIT.
Developed from Haringey and CI guidelines
13
Primary Care Guidelines for Common Mental
Illness Assessing Managing Risk - Harm to
others

• There is no exact formula which can be used to
  assess the risk of harm to others the following
  outlines some important factors to consider
• Clinical judgement is a key factor - concerns
  may sometimes be difficult to define . If unsure
  about what action to take, seek advice from ICS,
  your link worker or psychiatrist

Difficulty of assessing risk
ASSESSMENT
MANAGEMENT
Ideation/ Mental State

• Harm to others - risk factors
• Prior history of violent behaviour
• Diagnosis of schizophrenia, paranoid psychosis,
  personality disorder, severe depression
• Alcohol drug misuse
• Unstable living arrangements
• Low educational attainment
• Unstable employment
• Being a younger man
• History of suffering chronic violence

Lower Risk

• Review routinely
• Enquire about risk again as appropriate
• Identify protective factors

No
Yes
Intention
Moderate Risk
No
Yes
Planning
Clinical judgement consider that patient may be
withholding information
No
Higher Risk
Yes

• Urgent telephone referral to START
• If immediate risk call police on 999

Risk
Unlikely/No
Likely/Yes

• Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team on
  020 8442 6987

Remember Previous history of violent behaviour
is the biggest indicator of future risk.
Violent thoughts related to acute psychotic
symptoms may increase risk.
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Draft 1 july 2007. Written by Haringey PC LIT.
Developed from Haringey and CI guidelines
14
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15
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