MENTAL HEALTH EVALUATION

The psychiatric interview stands as the primary instrument in psychiatry. Its purpose is to gain insight into the patient’s difficulties, identify signs and symptoms, understand the underlying causes and complexities, establish an accurate diagnosis, initiate therapy, and predict the likely course of the condition.

Determining What to Assess and How to Formulate a Diagnosis:

1. Gathering patient history.

2. Conducting a psychiatric evaluation.

3. Performing a physical examination.

4. Requesting necessary investigations, such as:

   • Biological tests (e.g., blood and urine analysis).

   • Radiological imaging (e.g., X-rays).

   • Psychological assessments.

   • Social background investigations (e.g., home visits).

   • Environmental context review.

Optimal Consultation Environment:

• Allocate sufficient time for the consultation.

• Ensure privacy during the session.

• The consultation room should be orderly; disarray can have a negative impact.

• Minimize interruptions, such as phone calls, which can make the patient feel unimportant.

• Consider the health worker’s attire and presentation (e.g., excessive jewelry or makeup) as it can be a distraction.

BUILDING A THERAPEUTIC ALLIANCE:

The quality of information obtained is directly linked to the patient’s perception of confidentiality and the level of trust they have in you. The health worker’s appearance can influence this trust. Patients are less likely to share personal and crucial diagnostic details with someone they distrust. Rapport is the fundamental, understanding, and trusting relationship between the patient and the healthcare provider.

KEY ELEMENTS OF RAPPORT:

• Demonstrate respect for the patient, irrespective of their appearance or socioeconomic background. This will be felt by the patient.

• Show compassion for their suffering and distress.

• Exhibit genuineness, goodwill, and an approach perceived by the patient as non-judgmental, interested, and concerned.

• If the patient is accompanied by a relative or friend and wishes them to be present, this should generally be respected. However, for sensitive information requiring confidentiality, the accompanying person may need to leave.

• Be mindful of cultural norms, for instance, regarding discussions on sexual history or appropriate attire in certain cultures.

Essential Actions:

• Clearly explain the purpose of the interview to the patient.

• Reassure the patient about the necessity of the information being gathered.

General Interview Principles:

• Actively observe and be attentive to the patient’s behavior (e.g., gait, physical presentation, and facial expressions).

• Recognize that assessment and evaluation are reciprocal processes (be aware that the patient is also evaluating you; demonstrate attentiveness and care in your listening).

• Accept the patient’s behavior (all behavior conveys meaning).

• Avoid engaging in arguments with the patient (be assertive without being confrontational).

• Do not make assumptions; strive to understand the patient’s perspective (ensure you comprehend their words and feelings).

• Emphasize the exploration of emotions (e.g., if a patient is crying, provide them an opportunity to express their feelings; delve into emotionally significant areas).

• Focus on their interpersonal connections (understanding their sense of belonging and love).

• Refrain from being judgmental.

• Show empathy towards the patient.

• Be comfortable with periods of silence.

The psychiatric assessment encompasses history gathering, a mental status examination, and relevant investigations. The history is obtained from the patient and potentially from family, relatives, or close friends.

Components of Psychiatric History:

• Identifying Information:

  • Patient’s Name

  • Age

  • Ethnic background/Tribe

  • Current Occupation

  • Religious Affiliation

  • Details of Next of Kin

  • Marital Status

  • Highest Educational Level Achieved

• Referral Information:

  • Source of Referral (e.g., healthcare professional, family, law enforcement).

  • Reasons for Referral (clearly state the primary reason).

• Presenting Complaints:

  • List the main symptoms and their duration.

• History of Present Illness:

  • Explore the patient’s current problems.

  • Investigate any previous occurrences of emotional or mental health issues.

  • Aim for a diagnostic understanding of the current state.

  • Consider possible differential diagnoses.

  • Identify potential stressors or causative factors.

  • Note any complications arising from the illness.

• Past Psychiatric and Medical History:

  • Document previous physical and emotional illnesses.

  • Record the types of investigations done and their results (including HIV testing).

  • List previous diagnoses.

  • Detail treatments received.

  • Note the outcomes of previous treatments.

• Family History:

  • Focus on parents and close relatives.

  • For each family member, note their relationship to the patient.

  • Record their current health status.

  • Determine if any family member is directly dependent on the patient and the patient’s feelings about it.

  • Identify any instances of mental illness within the immediate or extended family.

• Personal History:

  • Details of pregnancy, birth, and early development up to age 6 (more relevant for children).

  • Development from ages 6 to puberty (school experiences, peer interactions).

  • Adolescence to age 19 (sexual history, personal interests).

• Occupational History:

  • Nature of the patient’s work.

  • Level of job satisfaction and any workplace challenges.

• Marital History:

  • Age at the time of marriage.

  • Spouse’s occupation.

  • Health status of spouse and children.

  • Quality of the marital relationship.

• Forensic History:

  • Inquire about any past involvement with the legal system.

Mental Status Examination (MSE)

• Background:

  • The MSE is a structured evaluation of a person’s appearance, behavior, cognitive functions, and overall presentation.

• Appearance:

  • A person’s outward presentation offers valuable insights into their self-care, lifestyle, and everyday living capabilities. Note any distinctive features, clothing choices, grooming habits, and overall hygiene.

• Behavior:

  • Observe the patient’s actions during the examination.

  • Pay attention to non-verbal communication which reveals emotional state and attitude:

    • Facial expressions.

    • Body language and gestures.

    • Posture.

    • Eye contact.

    • Response to the assessment process.

    • Rapport and social engagement.

    • Level of alertness (e.g., calm, agitated).

    • Presence of anxious or aggressive behaviors.

    • Psychomotor activity and movements (e.g., hyperactivity, hypoactivity).

    • Any unusual physical features (e.g., tremors, slowed or repetitive movements).

• Affect:

  • Assess the range of emotional expression (e.g., restricted, blunted, flat, expansive).

  • Evaluate the appropriateness of the emotional response to the situation (e.g., appropriate, inappropriate, incongruous).

• Mood:

  • Explore feelings of happiness (e.g., ecstatic, elevated, lowered, depressed).

  • Assess levels of irritability (e.g., explosive, irritable, calm).

• Speech:

  • Speech characteristics can be very telling. Describe the behavior of speech as well as its content. Unusual speech patterns are sometimes associated with mood disorders, anxiety, schizophrenia, and organic conditions. Note:

    • Speech rate (e.g., rapid, pressured, slow).

    • Volume (e.g., loud, normal, soft).

    • Tonality (e.g., monotonous, tremulous).

    • Quantity (e.g., minimal, talkative).

    • Ease of conversation flow.

• Cognition:

  • This refers to the individual’s current ability to process information. Cognitive function is often affected by mental health problems. Assess:

    • Level of consciousness (e.g., alert, drowsy, intoxicated, stuporous).

    • Orientation to reality (awareness of time, place, and person – e.g., knowledge of the day, date, location, and personal details).

    • Memory functioning (including immediate or short-term recall, and memory for recent and past events).

• Thoughts:

  • Evaluate thinking based on its content and form/process.

    • Content: Determine the presence of:

      • Delusions (fixed false beliefs not aligned with the person’s background).

      • Overvalued ideas (unreasonable beliefs, e.g., in anorexia, the persistent belief of being overweight).

      • Preoccupations.

      • Depressive thoughts.

      • Thoughts of self-harm or suicide.

      • Aggressive or homicidal thoughts.

      • Obsessions (intrusive, repetitive thoughts often linked to compulsions).

• Perception:

  • Illusions: The person misinterprets real stimuli but acknowledges the distortion or that others perceive it differently.

  • Hallucinations: These are perceptual experiences that seem real to the individual. They can affect any sense, but auditory hallucinations are most common. In children, internal self-talk can be experienced as an auditory “voice.” Investigate command hallucinations (voices telling the person to do something). Note the level of fear or distress associated with hallucinations.

• Insight:

  • Assess the patient’s awareness of a potential mental health issue.

  • Evaluate their understanding of treatment options and their willingness to adhere to them.

• Judgment:

  • This refers to the person’s ability to make sound decisions in general.

  • It can be assessed by discussing recent decisions or by presenting practical dilemmas (e.g., “What would you do if you saw smoke coming from a house?”).

Physical Examinations:

• Record Vital Signs.

• Perform a Systemic Physical Examination.

• Order investigations, if deemed necessary.

Developing a Nursing Care Plan:

1. Organize findings into objective and subjective data categories.

2. Formulate Nursing Diagnoses (identifying patient needs).

3. Establish goals, select appropriate methods, and identify needed resources.

4. Implement the nursing care plan.

5. Evaluate the effectiveness of the care plan.