Psych CASC / OSCE · Emergency psychiatry
Suicidal crisis safety planning and least-restrictive care — CASC communication station
MRCPsych/FRANZCP-style station: assess residual suicide risk, co-create a safety plan, discuss voluntary versus involuntary care principles without inventing statute numbers, and arrange disposition.
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Target exams
Station brief
Format. Communication and clinical reasoning station, approximately 7–10 minutes after reading time. You are the psychiatry registrar in ED. [1]
Candidate instructions. Assess residual suicide risk after medical clearance from a near-lethal overdose, explore means and supports, co-create a safety plan, and discuss options for voluntary admission versus least-restrictive alternatives. If she refuses, outline how you would approach capacity and involuntary care principles without inventing section numbers. The examiner plays the patient. [2][3]
Candidate scenario
The patient is oriented, not intoxicated, and says: “I don’t want to die now, but I might if I go home alone. Please don’t section me.” Partner has removed remaining tablets from the house. She has major depression on history, no psychosis. [1]
Marking domains
- Empathic engagement and structure
- Specific risk enquiry (ideation, plan, intent, means, protective factors) without false precision of a single category
- Means restriction and collaborative safety planning
- Clear voluntary care offer and crisis follow-up plan
- Accurate capacity/least-restrictive legal principles if refusal emerges
- Avoids stigmatising language and invented statute numbers [1][3]
Reveal assessor key
Open. Introduce role, privacy, time; acknowledge the overdose as serious and that she survived for a reason worth exploring. [1]
Risk enquiry. Ask about ongoing ideation, intent, plan, timing, alcohol, prior attempts, hopelessness, and what has changed since the overdose. Note that near-lethal attempts mark high clinical concern even if she now minimises risk — do not hide behind a “low risk” label.[1][2]
Safety plan. Warning signs, internal coping, people to contact, professional crisis numbers, means reduction (already partly done), reasons for living, timed follow-up. Invite partner involvement with her consent. [1]
Disposition conversation. Prefer voluntary admission or intensive crisis support if residual risk or home supports are inadequate. If she refuses and you judge incapacity for the treatment decision with serious risk, explain that the law may allow treatment under local Mental Health legislation using the least restrictive option, with regular review — you will involve seniors and will not invent legal section codes in conversation. If capacitous refusal with manageable residual risk and strong supports, a carefully documented discharge plan may be possible — but near-lethal attempt usually biases toward higher intensity care. [3]
Close. Summarise shared plan, check understanding, provide written crisis contacts. [1]
References
- [1]Large M, Myles N, Myles H, et al. Suicide risk assessment among psychiatric inpatients: a systematic review and meta-analysis of high-risk categories Psychol Med, 2018.PMID 28874218
- [2]Large MM, Ryan CJ Suicide risk categorisation of psychiatric inpatients: what it might mean and why it is of no use Australas Psychiatry, 2014.PMID 24871970
- [3]Spencer BWJ, Gergel T, Hotopf M, et al. Unwell in hospital but not incapable: cross-sectional study on the dissociation of decision-making capacity for treatment and research in in-patients with schizophrenia and related psychoses. Br J Psychiatry, 2018.PMID 29909778