ABC of mental health: Mental health assessmentBMJ 1997; 314 doi: http://dx.doi.org/10.1136/bmj.314.7093.1536 (Published 24 May 1997) Cite this as: BMJ 1997;314:1536
- Teifion Davies
Psychiatry in health care
Psychiatry is a branch of medicine: it deals with those disorders in which mental (emotional or cognitive) or behavioural features are most prominent. The cause, presentation, and course of such disorders are influenced by diverse factors; their symptoms can be bewildering to patients and their relatives; and their management may require social and psychological as well as medical interventions. It is not surprising that this complex situation can lead to misunderstandings of the role of psychiatrists (who are neither social workers nor jailers) and myths about the practice of psychiatry.
The bulk of mild mental disorder has always been managed by family doctors. However, patients referred to psychiatrists are increasingly likely to be managed at home by community mental health services or, if admitted to an acute psychiatric ward, to be discharged after a short stay. Many former long stay patients have been discharged to the community with varying degrees of support and supervision. This series of articles will deal with the principles and practice of managing mental health problems.
There is a myth that psychiatric management cannot proceed without obtaining an extensive history that delves into all aspects of a patient's life. Diagnosis can take only a few minutes, but time must be spent fleshing out the initial impressions, assessing immediate risks, and collecting information about personal and social circumstances that modify symptoms or affect management and long term prognosis.
Accuracy is achieved by close attention to the pattern of evolution of presenting symptoms and examination of a patient's mental state, supplemented by a small number of specific questions. A complete psychiatric assessment requires a detailed personal history, which, if the doctor is not familiar with the patient, may be built up over a series of interviews. The important point is that such detail comes into play only once the basic problem has been clearly ascertained.
Good interview technique
Interview technique is important in all branches of medicine. A good psychiatric interview comprises a series of “nested” processes of gathering information in which gathering of general information is followed by specific questions to clarify ambiguities and confirm or refute initial impressions.
Open questions–The interview begins with open questions concerning the nature of the present problem, followed by more focused questions to clarify chronological sequences and the evolution of key symptoms. Open questions encourage patients to talk and to concentrate on the present situation and help to establish a rapport.
Closed questions–Specific closed questions (equivalent to the systematic inquiry of general medicine) should follow only once a clear outline of the underlying disorder has emerged. These questions form a checklist of symptoms often found in variants of the likely disorder but not mentioned spontaneously by the patient (such as diurnal variation of mood in severe depression).
Choice questions–Sometimes patients are not accustomed to answering open questions. This is often so with adolescents and children, who are more used to being told how they feel by adults. In this case a choice question may be more useful. This suggests a range of possible answers to the patient but always allows for replies outside the suggested range: “Do you feel…, or…, or something else?”
Prevalence of psychiatric morbidity
All mental disorders–>20% of adults at any time suffer mental health problems; 40% of general practice consultations involve mental health problems
Depression (including mixed anxiety and depression)–10% of adults depressed in a week; 55% depressed at some time
Anxiety disorders–3-6% of adults have clinically important symptoms (about 1% each for phobias, obsessive-compulsive disorder, and panic disorder)
Suicide–5000 deaths and more than 100 000 attempts annually; 5% of all years of life lost in people aged under 75 years
Self harm–1 in 600 people harm themselves sufficiently to require hospital admission; 1% of these go on to kill themselves
Schizophrenia (and other functional psychoses)–0.4% of people living at home; 1% lifetime risk; 10 patients on a typical general practice list, but 10 000 not registered with a general practitioner
Bipolar affective disorder–0.5-1% of adults
Personality disorder–5-10% of young adults
Alcohol related disorder–4.7% of adults show alcohol dependence
Drug dependence–2.2% of adults living at home
Anorexia nervosa–1% of adolescent girls
Examples of open and closed questions
What are the problems that brought you to see me (to hospital)?
Could you say a little more about them?
Is there anything else you want to mention (worrying you)?
Tell me about your daily routine (your family, your upbringing).
Are there any questions you want to ask me?
When did these problems (thoughts, feelings) begin?
How do they affect you (your life, your family, your job)?
Have you experienced anything like this in the past?
What do you think caused these problems?
What exactly do you mean when you say you feel depressed (paranoid, you can't cope)?
At times like these, do you think of killing yourself?
Do you hear voices (or see images) when nobody seems to be there?
Do you feel like…, or like…, or like something else?
The first and most important stage entails getting a clear account of current problems, including social circumstances and an estimate of concurrent physical illness (including substance misuse) that might influence the presentation.
Once the current situation is clear and rapport has been established, closed questions should be used to elicit specific items of history. Topics covered at this stage include patients' prior psychiatric and medical problems (and their treatment), use of alcohol and prescribed and illicit drugs, and level of functioning at home and at work. Initial suspicions of risk to the patient or others should be clarified gently but thoroughly.
On each topic the interview should move smoothly from open questions to more closed, focused questions
Risk assessment–It is a myth that asking about suicidal ideas may lead patients to consider suicide for the first time. Fleeting thoughts of suicide are common in people with mental health problems. Importantly, intensely suicidal thoughts can be frightening, and sufferers are often relieved to find someone to whom they can be revealed. Persecutory beliefs, especially those focusing on specific people, should be elicited clearly since they are associated with dangerousness. Patients who ask for total confidentiality–“Promise you won't tell anyone”–should be reassured sympathetically but firmly that the duty to respect their confidence can be overridden only by the duty to protect their own or others' safety.
Mental state examination
This bears direct analogy with the physical examination and is an attempt to elicit in an objective way the signs of mental disorder. The emphasis is now on the form as well as the content of the responses to well defined questions covering a range of mental phenomena. For example, the form of a patient's thought may be delusional, and the content of the delusions may concern beliefs about family or neighbours.
Relevant physical examination is an important part of the assessment and should follow as soon as is practicable. Usually, this will require only simple cardiovascular (pulse, blood pressure) and neurological (muscle tone and reflexes, cranial nerves) examination. Similarly, laboratory investigations should be performed as indicated, considering a patient's past health and intended treatment. The choice may be influenced by
Known or suspected concurrent physical disease
Alcohol or substance misuse
Intended drug treatment (especially antidepressants or antipsychotics)
Concurrent medication (several drugs potentiate the cardiac effects of antidepressants and antipsychotics).
An electrocardiogram is now mandatory before starting certain antipsychotic drugs.
Dos and don'ts in the psychiatric interview
Do let the patient tell his or her story
Do take the patient seriously
Do allow time for emotions to calm
Do inquire about thoughts of suicide or violence
Do offer reassurance where possible
Do start to forge a trusting relationship
Do remember that listening is doing something
Don't use closed questions too soon
Don't pay more attention to the case notes than to the patient
Don't be too rigid or disorganised: exert flexible control
Don't avoid sensitive topics (such as ideas of harm to self or others) or embarrassing ones (such as sexual history)
Don't take at face value technical words the patient might use (such as depressed, paranoid)
Put your patient at ease–it is an interview not an interrogation
Be neutral–avoid pressure to “take sides” or to collude with or against the patient
Important items of mental state examination
Appearance–Attire, cleanliness; posture and gait
Behaviour–Facial expression; cooperation or aggression; activity, agitation, level of arousal (including physiological signs)
Speech–Form and pattern; volume and rate; is it coherent, logical, and congruent with questioning?
Mood–Apathetic, irritable, labile; optimistic or pessimistic; thoughts of suicide; do reported experience and observable mood agree?
Thought–Particular preoccupations; ideas and beliefs; are they rational, fixed, or delusional? Do they concern the safety of the patient or other people?
Perception–Abnormalities including hallucinations occurring in any modality (auditory, visual, smell, taste, touch)
Intellect–Brief note of cognitive and intellectual function; is the patient orientated in time, place, and person? Is the patient able to function intellectually at level expected from his or her history?
Insight–How does the patient explain or attribute his or her symptoms?
The full mental state examination may be built up over several interviews by elaboration of these topics using increasingly direct, closed questioning.
The second broad phase of assessment involves gathering information to place the present complaint in the context of a patient's psychosocial development, premorbid personality, and current circumstances. This phase also follows the scheme of open and then closed questioning, but, because of the breadth of the issues to be covered, it is often the longest component of a psychiatric assessment.
Much of this information may not be available initially, or may take too long to collect in a busy surgery or accident and emergency department. There is no reason to delay urgent management while this information is sought. Similarly, sensitive issues such as a patient's psychosexual history should not be avoided but can be elicited more easily when the patient's trust has been gained.
Making sense of psychiatric symptoms
Although psychiatric symptoms can be clearly bizarre, many are recognisable as part of normal experience. The situation is identical to the assessment of pain: a doctor cannot experience a patient's pain or measure it objectively but is still able to assess its importance. A pattern can be built up by comparing the patient's reported pain–its intensity, quality, and localisation– with observation of the patient's behaviour and any disability associated with it. Similarly, patients' complaints of “feeling depressed” may be linked to specific events in their life, to a pervasive sense of low self esteem, or to somatic features such as disturbed sleep and diurnal variation in mood.
Another myth is that the vagueness of psychiatric features makes diagnosis impossible. In fact, psychiatric diagnoses based on current classification systems are highly reliable. It is true that there are no pathognomonic signs in psychiatry–that is, most psychiatric signs in isolation have low predictive validity, since similar features may occur in several different disorders. It is the pattern of symptoms and signs that is paramount.
In practice, sense may be made of the relation between features and disorders by envisaging a hierarchy in which the organic disorders are at the top, the psychoses and neuroses in the middle, and personality traits at the bottom. A disorder is likely to show the features of any of those below it in the hierarchy at some time during its course but is unlikely to show features of a disorder above it. Thus, a diagnosis of schizophrenia depends on the presence of specific delusions and hallucinations and will often include symptoms of anxiety, depressed mood, or obsessional ideas; it is much less likely if consciousness is impaired (characteristic of delirium, which is higher in the hierarchy). Conversely, personality factors will influence the presentation of all mental (and physical) disorders since they are at the foot of the hierarchy.
Value of the psychiatric interview
The interview is more than an information gathering process: it is the first stage of active management. This may be the first opportunity for a patient to tell his or her full story or to be taken seriously, and the experience should be beneficial in itself. The length of the interview should allow time for intense emotions to calm and for the first steps to be taken towards a trusting therapeutic relationship. The balance between information gathering and therapeutic aspects of the interview is easily lost if, say, a doctor works relentlessly through a pre-set questionnaire.
Some troublesome terms used in psychiatry
Psychosis is best viewed as a process in which the patient's experience and reasoning do not reflect reality. Psychotic symptoms (hallucinations and delusions) may occur transiently in several physical and mental disorders and are not pathognomonic of any disorder. Psychotic disorders are ones that are characterised by psychotic symptoms
Neurosis is a portmanteau term for disorders in which anxiety or emotional symptoms are prominent. It is falling from use since it is difficult to define, has been applied too broadly, and gives no guide to aetiology, intensity, or course
Delusion is a false belief held with absolute conviction and not amenable to argument (incorrigible) or to explanation in terms of the patient's culture. It may be bizarre, but this is not necessarily so
Hallucination is a false perception arising without an external stimulus: it is experienced as real and vivid, and occurring in external space (that is, “outside” the patient's head). In contrast, an illusion is a misinterpretation of a real external stimulus
For a disturbed patient who is bewildered by his or her bizarre experiences, the interview may be a critical period and the doctor should not waste it
Summarising the findings
A bare diagnosis rarely does justice to the complexity of a presentation, nor does it provide an adequate guide to management. The formulation is a succinct summary of a patient's history, current circumstances, and main problems: it aims to set the diagnosis in context. It is particularly useful in conveying essential information, as when making a referral to specialist psychiatric services. An adequate referral to such services should include
Description of the presenting complaint, its intensity and duration
Relevant current and past medical history and medication
Note of mental state examination
Estimate of degree of urgency in terms of risk to the patient and others
Indication of referer's expectations (assessment, advice, admission)
The most urgent requests should be reinforced by telephone.
Role of voluntary organisations
Several local and national voluntary organisations are concerned with mental health. They may provide telephone advice or support, counselling, day centres, and volunteers or befriending services. Many patients benefit from the counselling or mutual support offered by such organisations, self help groups, and charities. These include patients with severe or protracted mental disorders and their carers, and many others who are distressed by unpleasant circumstances but are not suffering from a mental disorder and so do not require a referral to specialist mental health services.
Example of referral letter to specialist psychiatric services
Mr A is a 35 year old married man with a three year history of severe depression controlled by antidepressant drugs. He was brought to my surgery by his brother, having tried to break into a church in response to grandiose religious delusions. He also showed irritable mood and pressure of speech suggesting a manic episode. He agrees to attend hospital today. Please assess urgently in view of the risk to himself and others.
From NHS Executive, Mental Illness, PO Box 643, Bristol BS99 1UU
Mental health: towards a better understanding
Mental health and older people
Can children and young people have mental health problems?
From Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG on various mental health topics
The artwork is by Sandra Dionisi and reproduced with permission of the Stock Illustration Source. Data on the prevalence of psychiatric morbidity come from government departments, Mental Health Foundation, MIND, MORI, and SANE.
Teifion Davies is senior lecturer in community psychiatry, United Medical and Dental Schools, St Thomas's Hospital, London, and consultant psychiatrist to Lambeth Healthcare Trust.
The ABC of mental health is edited by Teifion Davies and T K J Craig, professor of community psychiatry, United Medical and Dental Schools, St Thomas's Hospital, London.