Mental status examination

Introduction

• 3% of ED presentations due to mental health
• 2/3 of these people are 15-44 (vs. 42% of population)
• 29% anxiety/neurosis; 21% substance abuse; 19% mood disorders and 17% psychosis
• 17.7% of patients admitted to hospital report mental health issue in last 12 months

MSE

• Initial assessment of:
  • Suicide risk
  • Violence risk
  • Absconding risk
• Formal MSE follows with assessment of:
  • Does patient have mental illness?
  • Is there a question of safety for patient or others?
  • Does patient have insight?
  • Will patient comply with suggested treatment?
  • Can patient be managed in community or not?
• Involves first-part (History) and second-part (observation)
• Working diagnosis is an important outcome

Brief suicide screening template

• Mental state
  • Active depression, psychosis, hopelessness/despair/grief/shame, anger/agitation or impulsivity
• Suicide attempts/thoughts
  • Continual/specific, formulated plan, intent, past hx of attempts, means, suicide note, risk of being found, organising personal affairs
• Substance abuse
• Lack of or hostile relationships
• Loss
  • Recent major perceived loss
  • Recent diagnosis of major illness or chronic illness

Aggression risk tool

• Alert on chart
• Previous history
• Aggressive behaviour/thoughts
• Homicidal ideation
• Access to weapons
• Intoxicated
• Middle-aged male

Risk of absconding

• Mode of arrval
  • Family/carer coercion
  • Police/QAS
  • Handcuffed
  • Voluntarily
• Past history of absconding
• Alert on chart
• Verbalising intent to leave
• Lack of insight into illness
• Poor/non-compliance with medication/treatment

MSE – Part 1 – History

• Demographics
  • Age, DOB, address, accommodation, other household members
  • Occupational hx
  • Social resources
  • PMHx
  • Previous admission
  • Previous mental health admissions
  • Forensic hx
  • Alcohol/drug use

MSE – Part 1 – History

• Presenting complaint
  • What has led to todays presentation over last few days?
  • Current social supports and relationships?
  • Current difficulties
• Mood and affect
  • Mood (internal feelings) and affect (external expression)
    • Mood may be incongruent, labile or inappropriate
    • Assess mood by activities of daily living, sleeping, weight gain, eating and general hygiene + ability to concentrate (neurovegetative symptoms of depression)
    • Leads on to suicide assessment

MSE – Part 1 – History

• Delusions and hallucinations
  • Hypnagogic (just before sleep) and hypopompoic (just after waking) are of less concern
  • Investigate themes of perceptual disturbances e.g. grandiose, persecutory, religious, suicide
• Insight and judgement
  • Levels from denial of illness to awareness of illness but inability to apply logic to future through to true insight
  • This determines level of supervision and treatment options

MSE – Part 2 – Observation

• General appearance and attitude
  • General self-care
  • Appropriate clothing for climate
  • Tattoos, track marks
  • Eye contact
  • Variation in facial expressions
  • Signs of agitation
  • Abnormal motor behaviours e.g. tardive dyskinesia
• Speech
  • Rate, volume and rhythmicity
  • Tone, inflection, content and structure

MSE– Part 2 – Observation

• Thought disorder
  • Circumstantiality: Long-winded explanations but eventually gets there
  • Distractable
  • Loosening of associations
  • Flight of ideas
  • Tangentiality
  • Clanging: Rhyming vs. sensical
  • Neologisms
  • Thought blocking: Thought process ceases and unable to be retrieved
  • Paucity

MSE – Part 2 – Observation

• Thought content
  • May revolved around similar themes as delusions/hallucinations
• Perception
  • Note any signs of active hallucination
• Cognitive assessment and physical examination
  • Assess orientation, concentration, memory, language and judgement

Last Updated on October 7, 2020 by Andrew Crofton