Some helpful documents for understanding the development and status of GRiST

Source Description Uploaded File
GRiST Team

A description of the main features of GRiST and how it can help organisations and individuals identify and manage mental health issues.

Patient Education and Counseling

Objectives: To develop a decision support system (DSS), myGRaCE, that integrates service user (SU) and practitioner expertise about mental health and associated risks of suicide, self-harm, harm to others, self- neglect, and vulnerability. The intention is to help SUs assess and manage their own mental health collaboratively with practitioners.

Methods: An iterative process involving interviews, focus groups, and agile software development with 115 SUs, to elicit and implement myGRaCE requirements.

Results: Findings highlight shared understanding of mental health risk between SUs and practitioners that can be integrated within a single model. However, important differences were revealed in SUs’ preferred process of assessing risks and safety, which are reflected in the distinctive interface, navigation, tool functionality and language developed for myGRaCE. A challenge was how to provide flexible access without overwhelming and confusing users.

Conclusion: The methods show that practitioner expertise can be reformulated in a format that simultaneously captures SU expertise, to provide a tool highly valued by SUs. A stepped process adds necessary structure to the assessment, each step with its own feedback and guidance.  Practice Implications: The GRiST web-based DSS ( links and integrates myGRaCE self- assessments with GRiST practitioner assessments for supporting collaborative and self-managed healthcare.


IEEE Xplore

Clinical Decision Support Systems (CDSSs) need to disseminate expertise in formats that suit different end users and with functionality tuned to the context of assessment. This paper reports research into a method for designing and implementing knowledge structures that facilitate the required flexibility. A psychological model of expertise is represented using a series of formally specified and linked XML trees that capture increasing elements of the model, starting with hierarchical structuring, incorporating reasoning with uncertainty, and ending with deliv- ering the final CDSS. The method was applied to the Galatean Risk and Safety Tool, GRiST, which is a web-based clinical decision support system ( for assessing mental- health risks. Results of its clinical implementation demonstrate that the method can produce a system that is able to deliver expertise targetted and formatted for specific patient groups, different clinical disciplines, and alternative assessment settings. The approach may be useful for developing other real-world systems using human expertise and is currently being applied to a logistics domain.

Journal of Mental Health
Background: Research into mental-health risks has tended to focus on epidemiological approaches and to consider pieces of evidence in isolation. Less is known about the particular factors and their patterns of occurrence that influence clinicians’ risk judgements in practice.
Aims: To identify the cues used by clinicians to make risk judgements and to explore how these combine within clinicians’ psychological representations of suicide, self-harm, self-neglect, and harm to others.
Method: Content analysis was applied to semi-structured interviews conducted with 46 practitioners from various mental-health disciplines, using mind maps to represent the hierarchical relationships of data and concepts.
Results: Strong consensus between experts meant their knowledge could be integrated into a single hierarchical structure for each risk. This revealed contrasting emphases between data and concepts underpinning risks, including: reflection and forethought for suicide; motivation for self-harm;
situation and context for harm to others; and current presentation for self-neglect.
Conclusions: Analysis of experts’ risk-assessment knowledge identified influential cues and their relationships to risks. It can inform development of valid risk-screening decision support systems that combine actuarial evidence with clinical expertise.
Declaration of interest: This research was funded by a NHS NEAT grant.
Medical Informatics & The Internet in Medicine

Current tools for assessing risks associated with mental-health problems require assessors to make highlevel judgements based on clinical experience. This paper describes how new technologies can enhance qualitative research methods to identify lower-level cues underlying these judgements, which can be collected by people without a specialist mental-health background. Content analysis of interviews with 46 multidisciplinary mental-health experts exposed the cues and their interrelationships, which were represented by a mind map using software that stores maps as XML. All 46 mind maps were integrated into a single XML knowledge structure and analysed by a Lisp program to generate quantitative information about the numbers of experts associated with each part of it. The knowledge was refined by the experts, using software developed in Flash to record their collective views within the XML itself. These views specified how the XML should be transformed by XSLT, a technology for rendering XML, which resulted in a validated hierarchical knowledge structure associating patient cues with risks. Changing knowledge elicitation requirements were accommodated by flexible transformations of XML data using XSLT, which also facilitated generation of multiple data-gathering tools suiting different assessment circumstances and levels of mental-health knowledge.

Medical Informatics and the Internet in Medicine

Effective clinical decision making depends upon identifying possible outcomes for a patient, selecting relevant cues, and processing the cues to arrive at accurate judgements of each outcome’s probability of occurrence. These activities can be considered as classification tasks. This paper describes a new model of psychological classification that explains how people use cues to determine class or outcome likelihoods. It proposes that clinicians respond to conditional probabilities of outcomes given cues and that these probabilities compete with each other for influence on classification. The model explains why people appear to respond to base rates inappropriately, thereby overestimating the occurrence of rare categories, and a clinical example is provided for predicting suicide risk. The model makes an effective representation for expert clinical judgements and its psychological validity enables it to generate explanations in a form that is comprehensible to clinicians. It is a strong candidate for incorporation within a decision support system for mental-health risk assessment, where it can link with statistical and pattern recognition tools applied to a database of patients. The symbiotic combination of empirical evidence and clinical expertise can provide an important web-based resource for risk assessment, including multi-disciplinary education and training.

GRiST Team

Final newsletter from the GRaCE-AGE project that sums up its successes and lays out the sustainable activities from it.

AMIA Annual Symposium Proceedings, 2016

When assessors evaluate a person's risk of completing suicide, the person's expressed current intention is one of the most influential factors. However, if people say they have no intention, this may not be true for a number of reasons. This paper explores the reliability of negative intention in data provided by mental-health services using the GRiST decision support system in England. It identifies features within a risk assessment record that can classify a negative statement regarding current intention of suicide as being reliable or unreliable. The algorithm is tested on previously conducted assessments, where outcomes found in later assessments do or do not match the initially stated intention. Test results show significant separation between the two classes. It means suicide predictions could be made more accurate by modifying the assessment process and associated risk judgement in accordance with a better understanding of the person's true intention.

REFERENCE AS: Zaher, N. A., & Buckingham, C. D. (2016). Moderating the Influence of Current Intention to Improve Suicide Risk Prediction. AMIA Annual Symposium Proceedings, 2016, 1274–1282.

Innovation in Medicine and Healthcare

One of the main challenges of classifying clinical data is determining how to handle missing features. Most research favours imputing of missing values or neglecting records that include missing data, both of which can degrade accuracy when missing values exceed a certain level. In this research we propose a methodology to handle data sets with a large percentage of missing values and with high variability in which particular data are missing. Feature selection is effected by picking variables sequentially in order of maximum correlation with the dependent variable and minimum correlation with variables already selected. Classification models are generated individually for each test case based on its particular feature set and the matching data values available in the training population. The method was applied to real patients’ anonymous mental-health data where the task was to predict the suicide risk judgement clinicians would give for each patient’s data, with eleven possible outcome classes: zero to ten, representing no risk to maximum risk. The results compare favourably with alternative methods and have the advantage of ensuring explanations of risk are based only on the data given, not imputed data. This is important for clinical decision support systems using human expertise for modelling and explaining predictions.

GRaCE-AGE project

This is the first newsletter from the GRaCE-AGE project. We will release another one in a similar format to this at the end of the year. In the meantime, we will release news as and when it comes using articles posted into the GRaCE-AGE group.