The mental health clinical assessment is more than a verbal communication exchange. Although the focus of the interview may be on mental health, the clinician should be prepared to assess both the mental and physical health conditions of their patients. Clinicians need to be aware that patients with mental disorders often have a lack coordination of their healthcare.1 These patients often have multiple medication prescribers, resulting in polypharmacy. Communication exchanges between psychiatry and primary care services are often fragmented even if they are co-located because of underdeveloped shared care practices.12,13 Moreover, patients with severe and persistent mental illness (SPMI) have a shortened life span and are less likely to receive the same level of primary medical care compared with patients without mental disorders.14–18 Barriers to medical care include patient paranoia, ambivalence, and disorganization, accounting for missed appointments; stigma toward mental disorders; and poor communication among primary care and psychiatric clinicians.19,20 For example, a significant number of patients who take antipsychotics are not adequately monitored for diabetes and dyslipidemia.21–24 Therefore, the interviewer should be aware of the significant health disparity in this population because best practices for medical monitoring become the standard of care.18,22,25–27
Sidebar: Clinical Controversy...
Stigma and discrimination often negatively affect the lives (e.g., employment prospects) of individuals labeled mentally ill. Consumer advocating organizations such as the National Alliance on Mental Illness (www.nami.org) are committed to help increase awareness about the issues and perceptions surrounding mental illness.
Because coordination of care is often lacking, permission from the patient to obtain “collateral information,” such as psychiatric and medical diagnoses, laboratory test results, medication lists, and other verbal or written records, should be obtained before the interview is completed. Collateral information can be obtained by asking the patient to sign a release of information (ROI), which is mandatory in order to contact significant others, family members, and clinicians.28
In summary, the clinician should be prepared to assess the mental and physical health of the patient, which is discussed in more detail in the Mental Status Examination and Physical Examination and Laboratory Assessment sections later in this chapter.
The interview should be conducted in a quiet, nonstimulating, and comfortable area where the patient and the interviewer feel at ease.8 The setting should be appropriate to the patient’s level of acuity and the potential for risk to the patient and clinician. The interviewer should introduce him- or herself and explain what is about to happen in order to establish a trusting relationship (therapeutic alliance). Generally, open-ended questions come first followed by questions focused on more specific or personal data. Open-ended questions allow the patient to provide descriptions and other information in his or her own words. Even though more specific questions may then be necessary to fill in the gaps, beginning in this manner minimizes the risk of “leading” the patient. Patients can respond to specific questions and “yes” or “no” questions with answers they think the interviewer wants to hear. The interviewer must listen carefully and remain nonjudgmental about the information offered by the patient to develop trust and rapport and to ensure completeness and accuracy of the information. Motivational interviewing (MI) is another technique that can be useful for engaging the patient if conflicting issues arise such as discussions around tobacco, drugs, or alcohol use.29 The MI approach to patient interactions is described by the acronym OARS (open-ended questions, affirmations, reflective listening, and summary).29–31 More comprehensive descriptions and training opportunities for MI are available in other sources.29,31,32
Whether a clinician takes notes or just listens during the interview is an individual decision; the primary considerations are accurately recalling the details of the examination and assuring that the patient is comfortable with the note taking. eTable 20-2 provides examples of questions useful for gathering mental health information toward the completion of the clinical interview. Before any conclusions are made during a patient interview, the impact of culture on the patient’s presentation should be considered. Something that sounds delusional in one culture can be the norm in another culture. If a clinician is unclear whether culture of origin accounts for some of the patient’s symptoms, he or she should obtain an ROI to consult with a family member or someone else familiar with the patient’s culture of origin. The Cultural Formulation Interview (CFI) found in the assessment tools of DSM-5 can also be used to assist the clinician who suspects that cultural influences may be affecting the diagnostic assessment.9,11
eTable 20-2 Examples of Interview Questions for Assessing Patients with Mental Disordersa |Favorite Table|Download (.pdf)
eTable 20-2 Examples of Interview Questions for Assessing Patients with Mental Disordersa
Tell me what your typical day is like.
Do your thoughts go faster than you can say them?
Have you noticed a change in the amount of sleep that you require?
Have you spent a lot of money lately, and what did you spend it on?
Do you have a lot of extra energy?
(To assess hallucinations and delusions, see Schizophrenia section below.)
How do you spend your time?
Do you cry without any reason?
Do you still enjoy the same hobbies or activities that you once did?
Has your weight changed recently?
Have you had changes in your energy level recently?
Do you have any guilty feelings?
Do you find it difficult to remember phone numbers, names of friends, appointments, and so on?
(To assess sleep and suicidal potential, see Sleep and Suicide sections below.)
How do people treat you?
Do you feel that people plot against you?
Do you ever feel that you are watched or spied on?
Do you have any special abilities?
Does anyone ever try to mess with you or bother you?
Do others read your thoughts?
Does the TV or radio ever tell you things?
Do you hear voices that other people don’t hear?
What do they say? How many voices?
How often do they bother you?
Do the voices ever tell you to kill yourself or someone else?
Have you ever heard your name called when there is no one there?
Have you ever seen anything strange that you can’t explain?
Do you ever see things that bother you and no one else?
Do you want to act on what the voices say?
- Thought Broadcasting or Insertion
If I stood by you, could I hear your thoughts?
Does your head ever act like a radio?
Do you feel that others can put thoughts in your head?
What reasons did your family give you for coming here?
What brought you here?
Do you consider yourself in need of help?
What does your medication do for you?
Tell me about your sleep.
How many hours do you sleep each night at present?
How many hours do you usually sleep at night?
Do you sleep all through the night?
Is there a reason for your waking up?
Do you have trouble falling asleep?
How do you feel when you wake up?
Do you feel your life is not worth living?
Do you ever think of killing yourself? How often?
Do you see things improving in the future?
Do you think you will try to kill yourself now?
How would you do it?
Do you have the means to hurt yourself?
Patient assessments can be challenging when symptoms of the condition prevent effective engagement with the clinician. Whereas excited patients may exhibit speech that is rapid and unorganized, depressed patients may respond with few words. Patients in the manic phases of bipolar disorder may not pause as they speak (pressured speech), making it difficult for the interviewer to interject. In all cases, the interviewer can regain control by politely redirecting the patient back toward the question.
The interviewer should always be prepared to adjust his or her communication approach based on the responses or reactions of the patient. Often, as in the disease of schizophrenia, a patient may demonstrate poor insight and judgment. It can be common for the clinician to react negatively with anger if the patient seems to be manipulating and not adherent with treatment. Instead of reacting negatively, one principle in MI is to “roll with resistance” in which the clinician accepts the patient’s perspective and encourages the patient to explore his or her own solutions.29 In another situation, patients with psychosis may be paranoid and appear guarded or frightened by the interviewer’s questions. During any patient encounter, clinicians should be aware of strong emotions such as fear, anger, or frustration and be careful not to judge or react to the patient. Overall, the best approach is to remain calm and respectful, use shorter or closed-ended questions, and seek only essential information until the patient is less paranoid. Patients can become agitated and occasionally violent. Often violence is preceded by increased psychomotor agitation as evidenced by pacing, speaking in a loud voice, or gripping the arms of the chair. When there is concern about safety, the interviewer should avoid any behavior that could be misconstrued as threatening, such as touching or unnecessary staring, and should interview the patient in the presence of another healthcare provider. Both the patient and interviewer should have equal access to leave the room if either becomes too uncomfortable. If a patient becomes threatening to the interviewer, the interviewer should not hesitate to leave the room and call for help. If a patient describes suicidal thoughts, he or she should be further assessed using the questions outlined in eTable 20-2. If concerns about the patient’s safety persist, further assessments should be directed to the appropriate type of care, including either an emergency department visit or direct hospitalization for patients at immediate risk of harming themselves. A suicidal patient should never be left alone. Asking a patient about suicidal thoughts will not increase the risk. The risk is greater if these questions are never asked or signs of distress are ignored. In summary, applying MI skills or just remaining calm, quiet, and respectful may deescalate the agitated patient, preserve the therapeutic alliance, and improve overall treatment adherence.29
Sidebar: Clinical Controversy...
Mental health professionals are not immune from stereotyping people with mental disorders, which can negatively impact how professionals assess and manage patients. A team approach to patient care is one way to help guard against personal biases influencing clinical decision making.
Both the patient’s and the patient’s family history of mental disorders provide important information when formulating a diagnosis and treatment plan. Information should include the current and previous psychiatric diagnoses, clinical presentation of each mental disorder, time frame between episodes, level of functioning between episodes, length of each episode, total duration of the mental disorder, and treatment given during each episode as well as response to those treatments. Baseline functioning or the highest level of functioning achieved in the last few years is important because it helps to define a treatment goal. Information on the history of the current episode and reasons for presenting to the clinician should also be gathered. A family history should include a medication history of the immediate relatives because a family member’s response to a given medication might predict an individual patient’s response to that same medication.
A social history should include educational and occupational background; religion; marital status; substance-use patterns, including tobacco, alcohol, and caffeine; and current living situation. By understanding a patient’s living environment and social situation, strategies to foster treatment adherence, reduce stress, and increase social support can be developed. To probe this area initially, the clinician can ask patients to describe their social support network. This can be followed by more specific questions such as: “To whom are you closest?” or “In whom do you confide?”
A thorough medication history is one of the most important contributions a clinician can make to treatment planning. The history should include medications for both psychiatric and medical conditions and list all medications, including over-the-counter and herbals, taken by the patient. The history should also report how each drug was tolerated and describe the responses to a single drug or combination of drugs. All allergies must be noted. Because most psychiatric medications have a delayed onset of effect, it is important to determine whether an adequate trial (dose and duration) was provided before the patient is deemed “nonresponsive” to that drug. If a patient has a history of nonadherence, specific causes should be investigated. Causes of nonadherence may include, but are not limited to, drug cost, complicated dosing schedules, lack of insight, and adverse effects.
Mental Status Examination
The mental status examination (MSE) is a key patient assessment tool in psychiatry and is analogous to the physical examination in medicine. The MSE is completed through a direct patient interview and provides a systematic method of organizing and reporting current behaviors, thoughts, perceptions, and functioning. The MSE has several components (e.g., Appearance, Attitude, Activity, Speech and Language, Mood and Affect) and is combined with other aspects of the patient workup (history of present illness, physical examination, appropriate laboratory tests, and medical and psychiatric history) to give a full picture of the presenting problem and factors contributing to the mental disorder.7,8,10 The addition of symptom rating scales incorporated into the MSE can greatly enhance the clinical assessment. Consistent identification and tracking of symptoms with rating scales can even enable both the clinician and patient to mutually construct specific treatment goals and measure clinical progress such as changes in symptom frequency or severity over weeks or months.33 Although terminologies can be misleading, the MSE should not be confused with the Mini Mental Status Exam (MMSE),which is discussed in the Systematic Measurement of Cognitive Function section later. The components of the MSE include:
Appearance and Attitude Toward the Examiner
The appearance of the patient throughout the interview should be noted, including age, dress, grooming and hygiene, use of cosmetics, and facial expressions. A description of appearance also should include unusual physical characteristics and the general state of physical health. The interviewer should note whether the patient is cooperative, mute, hostile, paranoid, guarded, or withdrawn.
Motor activity may be excessive or diminished. Overactivity during the interview can range from hand wringing; restless leg movements; and picking at clothing, skin, or hair to severe back and forth pacing in the room. Underactive patients move less than expected. Patients with rigid posture, an absence of movement, and failure to communicate may be catatonic or paranoid or experiencing medication-induced adverse effects.
The quantity, flow, and speed of speech and the amount of eye contact should be noted. The appropriateness and degree of eye contact varies significantly among cultures, and before poor eye contact is interpreted, the patient’s cultural background should be considered. Speech should be assessed as to whether it proceeds logically in a goal-directed manner or whether the content is vague and poorly organized. Abnormal speech characteristics include thought blocking, whereby the person suddenly stops speaking without any obvious reason. Thought blocking usually occurs when a hallucination or delusion intrudes into the person’s thinking or when upsetting issues are discussed. Circumstantial speech lacks a clear direction because of excess unnecessary information, but the circumstantial patient eventually will make his or her point. In tangential speech, however, the ultimate point is never made. Perseveration is repetition of an original answer to subsequent questions. Flight of ideas is overproductive, rapid speech during which the patient jumps rapidly from one idea to the next. Mutism is identified when the patient does not respond even though he or she is aware of the discussion.
Affect describes the patient’s current emotional tone, as expressed through facial expression, body posture, and tone of voice, all of which can be objectively observed by the clinician. Mood describes feelings, which are subjectively reported by the patient. Changes in facial expression and the presence of tears, flushing, sweating, or tremors should be noted. Affect can be described further by its range, appropriateness, intensity, and stability. For example, in individuals with schizophrenia or depression, the affect can be flat, whereby no change in expression occurs throughout the interview. In contrast, during a manic episode, the affect is very intense and often excited. Blunted affect denotes that the range of emotional expression is reduced but not absent. An example of inappropriate or incongruent affect is when a patient laughs in a situation that would be expected to produce sadness. A rapidly shifting affect from one extreme to the other is described as labile.
Thought and Perceptual Disturbances
A variety of thought disturbances can occur in mental disorders. Many of these disturbances generally indicate the presence of psychosis or impaired reality testing. Delusions are fixed, false beliefs that are not based in reality or consistent with the patient’s religion or culture. Delusions can be paranoid, somatic, or grandiose in nature. Delusions are often unshakable, and although the clinician can challenge the delusional thinking, one should not attempt to talk a patient out of a delusion. The lack of awareness of a mental disorder (anosognosia) can often accompany delusions. Thought broadcasting is the belief that one’s thoughts are audible to others. Hallucinations are false sensory impressions or perceptions that occur in the absence of an external stimulus. Hallucinations can be auditory, visual, olfactory, tactile, or gustatory and can be continuous or intermittent. In contrast, illusions are visual misperceptions involving a misinterpretation of a real sensory stimulus. For example, a person experiencing an illusion may react in fear if he or she momentarily misperceives the wind moving a curtain to be an intruder. This phenomenon does not always indicate a psychiatric disorder and can be seen in persons without mental disorders. Not all thought disturbances are indicative of psychosis. For example, the couplet of obsessions and compulsions can indicate the presence of obsessive-compulsive disorder, which is not considered to be a psychotic disorder. Obsessions are unwanted thoughts or ideas that intrude into a person’s thinking. Compulsions are actions performed in response to the obsessions or to control anxiety associated with the obsession.
The MSE assesses sensorium, attention, concentration, memory, and higher cognitive functions such as orientation and abstraction. If deficits in memory and concentration are primary or secondary complaints of the patient or these deficits are apparent during the interview, more formal or standardized mental status testing (e.g., MMSE) may be required. The clinician should document whether the patient has received medications with sedative properties because the outcome of the examination can be altered if central nervous system depressants were recently taken.
Sensorium, or level of consciousness, refers to the alertness of the patient, and if he or she is not fully alert, the amount of stimulation needed to awaken the patient. Attention and concentration can be further assessed using serial subtraction by 7s (“serial 7s”) or 3s or by having the patient spell a five-letter word backward (e.g., d-l-r-o-w). General intelligence can be assessed loosely by asking factual information about current news items, recent presidents, or popular television shows or sporting events. Memory is the ability to recall prior information and experiences. There are many descriptors referring to specific types of memory such as working memory (i.e., the capacity to hold information such as a phone number in mind for a few seconds), short-term memory (i.e., the ability to recall newly acquired information after several minutes), and long-term or remote memory (historical facts) that are commonly assessed as part of the MSE. Orientation to time, place, person, and situation assesses short-term memory. Asking a patient to recall three objects 5 minutes after they are learned is the definitive test for short-term memory. Deficits in short-term memory may be seen in depression and anxiety, but this finding is the hallmark feature of dementia. Asking the patient to do a certain task (e.g., pick up a pen with his or her right hand and then fold a piece of paper and pass it to the examiner) or spelling a five-letter word in reverse are examples of testing working memory. Patients with cognitive deficits, such as those seen in dementias and schizophrenia, can exhibit deficits in working memory. Remote memory is assessed by asking patients to recall old facts about their lives, such as where they were born or where they went to school. Whereas remote memory usually remains intact the longest in patients with intellectual decline, the ability to create new memories is generally the first sign of a memory deficit. Abstraction is the ability to interpret information such as a proverb (e.g., “People in glass houses shouldn’t throw stones”) or identify similarities or differences between words (e.g., apple and orange). Abstraction is influenced by education, cultures, and linguistic fluency; thus, an inability to abstract is not always a sign of a psychiatric disorder. Persons with schizophrenia often provide concrete (literal or superficial interpretations) or bizarre responses to probes of abstraction.
Insight refers to patient awareness that he or she has a mental disorder and the impact of that disorder on his or her life. Anosognosia is a term used to define the complete lack of insight or awareness of a mental disorder. Because lack of insight is associated with high morbidity and mortality rates among patients with mental disorders, there is much interest in this area as a focus of research.34 For example, the symptom of poor insight is thought to be the main cause of poor judgment such as nonadherence with prescribed medications.29,34,35 Levels of insight may be variable based on the level of acuity of the mental disorder.
Judgment is the ability to make decisions appropriate to the situation and can be impaired in people with a variety of mental disorders. Judgment can be assessed by asking patients how they would handle either their current or a hypothetical situation. As with insight, judgment also can be fluid. For example, intoxicated patients can demonstrate poor insight and judgment only to improve over several hours as their blood alcohol concentration decreases.
In summary, the MSE is the clinician’s observations and expert opinion based on the patient’s history, verbal responses, nonverbal reactions, appearance, and behaviors. The MSE is primarily used to establish the patient’s diagnosis, target symptoms, response, and treatment plan. In addition to the MSE and based on the discretion of the clinician, a physical examination, laboratory assessments, objective rating scales, and psychological testing may be needed for a comprehensive mental health assessment and follow up. These assessment tools are described in the following sections.