Mental Health Assessment

Definition
Purpose
Demographics
Description
Follow-up after the Assessment
Risks

Definition

A mental health assessment is an examination used to ascertain whether or not a patient is functioning on a healthy psychological, social, or developmental level. A mental health assessment can also be used to aid diagnosis of some neurological disorders, specific diseases, or possible drug abuse.

Purpose

Mental health assessments are performed to screen for mental health disorders such as depression or anxiety, or as part of their continuing evaluation. They can also be used to help diagnose neurological pathology, such as Alzheimer’s disease. A mental health assessment may be indicated if a person is having difficulty at work, school, or in social situations. For example, a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) or a personality disorder may begin with a mental health assessment as part of their discovery. Mental health assessments may also be done if substance abuse is suspected.

Demographics

A mental health assessment can be done for patients of any age or gender. The mental health assessment of a child or adolescent is based on developmental stage as appropriate for age. An adult mental health assessment may be done to screen for new diagnoses, assess patients with an existing diagnosis for changes in severity, or to assess the need to modify current a treatment plan.

WHO PERFORMS THE PROCEDURE?

A general practitioner may perform a brief mental health assessment during a routine examination. However, if there are symptoms of a mental disorder present, the patient may be referred to a specialist for a more thorough mental health assessment. A specialist for a mental health assessment may be a psychologist or a psychiatrist.

A psychologist is a health care professional who is not a medical doctor. A psychologist may have a degree called a PsyD (doctor of psychology), or a PhD (doctor of philosophy) in psychology. Psychologists can evaluate and counsel patients, and need to be licensed to practice. However in most states, psychologists cannot prescribe medication.

A psychiatrist is a medical doctor who specializes in the diagnosis and treatment of mental health problems. Psychiatrists can evaluate, counsel, and prescribe medications to treat mental health problems. Some psychiatrists further specialize in specific areas of mental health, such as psychiatry for adolescents. Psychiatrists need to be licensed to practice. They should be board-certified through the Board of Psychiatry and Neurology, a board that is validated by the American Board of Medical Specialties.

Description

Patient History

History taking is an important component of the mental health assessment. The health history of a patient includes their medical health history, family health history, medications they are currently on, and social history. Social history is a critical component, including history of drug use, physical or emotional abuse, and exposure to traumatic situations. It also covers the “chief complaint,” or description of the patient’s current issue in the context of the patient’s life, both past and present. Health care professionals who perform a mental health assessment need to obtain a thorough health history from the patient, because it places the current situation into the context of the overall health. For the current chief complaint, the health care provider will ask questions to form an overall picture of how the patient is feeling and any distressing emotions the patient is experiencing. A pertinent health history also includes information on

QUESTIONS TO ASK YOUR DOCTOR

• Why do I need a mental health assessment?
• Who will perform the assessment?
• How will the assessment be performed?
• How long is the assessment expected to take?
• What tests are involved in my mental health assessment?
• Are there any specific preparations I need to make before or after the assessment?
• What will the results of the assessment specifically indicate?
• When will the results be available?
• What are the risks of the assessment?
• Who else has access to the results of the assessment?
• Do any of my prescription medications, nonprescription medications, nutritional, or herbal supplements potentially affect the results of my mental health assessment?

any previous psychiatric illness, for both the patient and the patient’s family. It is important that the health care provider be made aware of not only current prescription medications, but also non-prescription medications, nutritional supplements, and herbal supplements or teas the patient is currently taking, as they may affect the patient’s mental status. History of suicide attempts or thoughts may be initially discussed during the history portion of the assessment.

Mental Status Examination

The mental status examination explores multiple aspects of the patient’s ability to function in a healthy, normal manner. The health care provider will assess the multiple components of the patient’s mental status through both direct questioning and objective observation.

GENERAL APPEARANCE. General appearance is assessed by observation on the part of the health care provider. Patient hygiene, grooming, excessive nervousness or physical activity, and apparent nutritional state are all pertinent to the mental status examination. General alertness, facial expressions, and eye contact are noted. The patient’s attitude toward the health care provider is also an important component, including whether the patient seems hostile, guarded, friendly, or cooperative.

KEY TERMS

Affect— The external manifestation of a mood or state of mind. Affect is usually observed in facial expression or other body language.

Attention Deficit Hyperactivity Disorder (ADHD)— A disorder involving a developmentally inappropriate degree of inattention and impulsivity. Hyperactivity may or may not be a component. This disorder usually appears in childhood and manifests itself as difficulty at home or school. It sometimes persists into adulthood where it may affect work, relationships, and other social situations.

Alzheimer’s Disease— A disease of the elderly involving progressive mental deterioration including loss of memory, judgment, and intellect; disorientation; confusion; general inability to mentally function in social situations. The disease may begin as early as late mid-life and results in eventual death. It is associated with specific physical changes to the brain that can be visualized using medical imaging techniques.

Autism— A childhood disorder that manifests as an inability to communicate with or relate to others, or interact in social situations in a healthy, normal manner. Autism may range from mild to severe and includes repetitive behaviors, the inability to cope with changes from routine activities, and obsessions with specific objects. Autism is sometimes associated with below-normal intelligence or anxiety.

Brain Lesion— Physical damage done to a specific part or location of the brain, that may result in specific symptoms or behaviors associated with that brain lesion.

Chemical Toxicity— State of physical illness induced by poisoning with toxic chemicals. Chemical toxicities may affect a person’s behavior or mental function.

Cognition— The mental activity of thinking, learning, and memory.

Compulsion— The uncontrollable impulse to perform specific acts. In mental health disorders, compulsions are often repetitive and carried out by the person in order to avoid feelings of anxiety.

Computed Tomography (CT scan)— A computer uses x-rays across many different directions on a given cross section of the body, and combines all the cross sections to create one image. CT scans can be used to visualize bodily organs including the brain, blood vessels, bones, and the spinal cord. Contrast dye is sometimes administered to the patient to help visualize structures.

Delusion— Conviction of a false belief or wrong judgment despite obvious evidence to the contrary.

Dementia— The progressive loss of cognitive and intellectual function of the brain including impaired memory, judgment, and disorientation, without the impairment of perception or consciousness. It is usually associated with a structural brain disease such as Alzheimer’s disease.

Developmental Disorder— A disorder or disability that occurs because of prenatal or early childhood events that affect cognition, language, motor, or social skills.

Flight of Ideas— A psychiatric term describing a thought disorder where streams of unrelated words or ideas enter a patient’s mind too quickly to be properly vocalized despite the rushed and rapid rate of the patient’s speech.

Hallucination— The perception of a person, object, event, or sensory stimulus that is not truly there. Hallucinations can be visual (seen), auditory (heard), olfactory (smelled), tactile (felt), gustatory (tasted), or a combination thereof.

Looseness of Association— A psychiatric term describing a thought disorder where a patient makes irrelevant connections between seemingly unrelated topics. In a mental health assessment the patient’s responses may not seem to correspond to the question asked by the health care provider.

Magnetic Resonance Imaging (MRI)— A diagnostic test where a magnetic field is applied to atoms within a patient’s body, aligns the atoms, and reads the energy pulses given off by the atoms in a manner that creates a three-dimensional picture of the patient’s internal structures. There is no exposure to radiation. An MRI is especially useful for visualizing soft tissue and for neurological imaging.

Metabolic Disturbance— A disturbance in the general function of the body’s basic life processes such as energy production. The body’s ability to provide the brain with appropriate nourishment can affect the mental status of the individual.

Obsession— A recurrent and persistent idea, thought, or impulse that the individual cannot repress.

Parkinson’s Disease— A neurological disease resulting from a deficiency of the neurotransmitter dopamine that is associated with specific recognizable movements, affects, and behavior patterns.

Personality Disorder— Group of behavioral disorders characterized by maladaptive patterns of behavior, social interactions, or lifestyles that deviate from the healthy normal. Personality disorders are distinct from psychotic disorders.

Phobia— An irrational and unfounded fear of a situation, place, or object that causes a state of panic.

Psychiatrist— A medical doctor (MD) who specializes in the treatment of mental health problems and can prescribe medication.

Psychologist— A health care professional (PsyD or PhD) who is not a medical doctor but can evaluate or provide counseling for patients with mental health issues.

Thyroid Dysfunction— A physical state that involves the failure of the thyroid gland to function properly. Thyroid dysfunction not only affects a person’s physical state, but may have secondary effects on their mental state as well.

MOOD AND AFFECT. Mood is the internal set of sustained emotions that the patient experiences, while affect is the external manifestation of mood as body language and facial expression. Patients are questioned as to what moods they have experienced for lengths of time, such as depression, tiredness, or anxiety. Affect may be described as normal; blunted or flat where the patient has little expression; expansive and inappropriate where the patient seems to be experiencing extremes of emotion that may not be appropriate to the setting.

SPEECH AND THOUGHT PROCESSES. Speech is examined for clarity, general coherence, appropriate inflection (not monotone), quantity that is unusually large or small, a rate that is unusually fast or slow, and appropriate volume. While asking questions during the examination, the health care provider will also monitor the responses given by the patient for specific thought processes or patterns of speech. The following examples may be observed by the health care provider or described by the patient: flight of ideas where the patient randomly changes from one topic to another; looseness of association where the patient makes irrelevant connections between seemingly unrelated topics; racing thoughts; excessively trailing off onto tangents; nonsensical speech; rhyming or creation of new words; halting speech; paucity of speech; or speaking in riddles.

THOUGHT CONTENT. Thought content may be evaluated through both direct questioning and observation of topics brought up by the patient. There are many types of thought content that may be pertinent to this section of the mental health assessment. Thought aspects of mental disorders may include the following: hallucinations that may be auditory, visual, tactile, or olfactory; auditory hallucinations involving commands for the patient to carry out specific actions; delusions of having special powers, status, or persecution by others; paranoid thinking; obsessions, compulsions, and ritualistic behaviors; phobias; thoughts of self-harm or suicide; homicidal thoughts.

COGNITION. An important aspect of the mental status examination is assessment of the patient’s cognitive state. Elements of this section include the following: assessment of general awareness and level of consciousness; orientation to person, current location, current date and time, and situation; ability to pay attention and concentrate; general memory tests; ability to follow directions; language comprehension and appropriate usage of language; ability to perform abstract reasoning by interpreting proverbs supplied by the health care provider.

Written and Verbal Tests

Written or verbal tests are used as part of a mental health assessment when there is a reason to apply the test to explore a specific potential diagnosis. There are standardized tests for many different mental disorders and disturbances. For example, depression is sometimes assessed using a specific set of standards or measurements called a rating scale. Other tests may evaluate intelligence levels, and aid in the diagnosis of dementia or developmental disorders such as learning disabilities or autism. These types of tests are controversial and do not stand alone to make a diagnosis, but rather may be used in addition to the other components of the mental health assessment. Each test may take from thirty minutes to several hours to complete, and be may administered over multiple days.

Adjunctive Tests

PHYSICAL EXAMINATION. Mental health assessments are sometimes helpful in diagnosing certain neurological disorders, and may be performed in the larger context of a neurological examination. The neurological examination includes a mental status exam, as well as assessing motor function, reflexes, sensory perception, posture, and gait. Diseases such as Parkinson’s disease or Alzheimer’s disease may initially be suspected as a result of the mental health assessment.

CLINICAL TESTS. Clinical tests may be necessary as an adjunct to the mental health assessment, to aid in diagnosis of specific neurological or neuropsychiatric disorders. For example, a patient with Alzheimer’s disease may require Magnetic Resonance Imaging (MRI) as an adjunct to the mental health assessment for a successful diagnosis. Clinical tests may also be used rule out non-mental health related illnesses. Some drugs of abuse, thyroid dysfunction, hormonal imbalances, prescription medications, chemical toxicities, metabolic disturbances, selective brain lesions, or types of tumors may all manifest in ways that affect the mental status assessment. Blood laboratory testing, Computed Tomography (CT scan), or an MRI may help to assess the presence or absence of these physical states.

Follow-up after the Assessment

Whether or not a patient requires further inpatient care, outpatient care, or medication is dependent upon the final diagnosis. Inpatient care is always indicated if the patients are unable to suitably care for themselves, suicidal, or homicidal.

Risks

The mental health assessment is a valuable tool in the diagnosis of mental health problems. However, some mental health problems are very difficult to diagnose. Mental health assessments may need to be performed multiple times before any medical conclusion is reached. Even with multiple mental health assessments and adjunctive tests, there is risk that an accurate diagnosis may still be missed.

Resources

BOOKS

Bickley LS. Bates Guide to Physical Examination and History Taking. Eighth Edition. Lippincott Williams & Wilkins: 2003.

Davidson T, Gulli LF, Nasser B. Gale Encyclopedia of Children’s Health. Thomson Gale, Detroit. 2006.

Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.

OTHER

Brannon, Guy E. “History and Mental Status Examination.” Emedicine (February 4, 2008). http://www.emedicine.com/Med/topic3358.htm [accessed April 3, 2008].

Practice Guideline for the Psychiatric Evaluation of Adults. Second Edition. American Psychiatric Association; 2006

ORGANIZATIONS

American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, Virginia, 22209-3901, 703-907-7300, [email protected], http://www.psych.org/.

Maria Basile, PhD