Mental Health Assessment

Mental Health Assessment

• A mental health assessment is a systematic examination of a person’s psychological, emotional, behavioral, social (and sometimes developmental or neurocognitive) functioning.
• Its aim is to understand how a person is coping, whether there are signs of mental illness or distress (e.g. depression, anxiety, psychosis, cognitive problems), and to help decide whether further diagnosis or treatment are needed.
• It can be used for people of any age children, adolescents, adults and adapted according to their life stage and specific concerns.

Mental Health Assessment

• Chief complaint (patient’s own words):
• Lead-in: “What brings you in today? Establish focus and the patient’s priorities.
• History of present illness (HPI):
• Onset/course: First noticed, duration, progression.
• Context/triggers: Stressors, sleep, substances, medical changes.
• Impact: Function (work, school, family), distress, coping.

Mental Health Assessment

Mental Health Assessment

• Psychiatric history:
• Diagnoses and episodes: Past symptoms, hospitalizations, self-harm, psychosis.
• Treatments: Medications, psychotherapy, ECT/TMS; response and adverse effects.
• Medical and surgical history:
• Comorbidities: Endocrine, neurologic, pain, infection.
• Medications/allergies: Interactions that impact mood or cognition.

Mental Health Assessment

Mental Health Assessment

• Substance use:
• Patterns and last use: Alcohol, cannabis, stimulants, opioids, benzos.
• Consequences: Withdrawal, tolerance, legal/occupational impact.
• Developmental and neurocognitive history (as relevant):
• Milestones, learning, attention: Screen for neurodiversity and cognitive changes.
• Family psychiatric history:
• Genetic load: Mood, psychosis, substance use, suicide, medical conditions

Mental Health Assessment

Mental Health Assessment

• Developmental and neurocognitive history (as relevant):
• Milestones, learning, attention: Screen for neurodiversity and cognitive changes.
• Family psychiatric history:
• Genetic load: Mood, psychosis, substance use, suicide, medical conditions.
• Psychosocial and cultural context:
• Supports and stressors: Relationships, finances, housing, safety.
• Identity and beliefs: Cultural/religious meanings of distress; explanatory models

Mental Health Assessment

Mental Status Examination

• Appearance & Behavior
• General appearance: Grooming, hygiene, clothing appropriateness, posture, eye contact.
• Behavior: Level of cooperation, agitation, psychomotor activity (retardation, hyperactivity, tics, mannerisms).
• Attitude: Hostile, guarded, friendly, seductive, indifferent.

Speech

• Speech is the expression of thoughts and feelings through spoken words, which involves the physical use of the voice and is distinct from language
• Rate: Slow, rapid, pressured.
• Volume: Soft, loud, monotone.
• Fluency: Hesitant, stuttering, slurred, coherent.
• Content: Spontaneous vs. minimal responses.

Mood & Affect

• Mood is the sustained, internal, and subjective emotional state (like feeling happy or sad), while affect is the external, observable, and more immediate expression of emotion (like smiling or frowning)
• Mood (subjective): Patient’s own description (“sad,” “anxious,” “angry”).
• Affect (objective):
• Range: Flat, blunted, restricted, full.
• Stability: Stable vs. labile.
• Congruence: Does affect match stated mood?
• Appropriateness: Is emotional expression suitable to context?

Thought Process

• A thought process is the mental activity of how a person thinks, reasons, and makes decisions by forming and organizing ideas
• Form of thought:
• Logical, coherent, goal-directed.
• Abnormalities: tangential, circumstantial, flight of ideas, loosening of associations, thought blocking.
• Stream: Poverty of thought, overabundance.

Thought Content

• Delusions: Persecutory, grandiose, somatic, nihilistic, religious.

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• Obsessions/compulsions: Repetitive intrusive thoughts or behaviors.

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• Phobias: Irrational fears.

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• Suicidal/homicidal ideation: Presence, intent, plan.

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• Preoccupations: Guilt, worthlessness, hypochondriasis

Perception

• Perception is the process of organizing, identifying, and interpreting sensory information to understand the world
• Hallucinations:
• Auditory (most common in psychosis), visual, tactile, olfactory, gustatory.
• Command hallucinations (high risk).
• Illusions: Misinterpretation of real stimuli.
• Depersonalization/derealization: Feeling detached from self or environment

Cognition

Cognition is the mental process of acquiring knowledge and understanding through thought, experience, and the senses

Orientation: Time, place, person, situation.

Attention & concentration: Serial 7s, digit span, spelling backward.

Memory:

Immediate (recall numbers/words).

Recent (events of the day).

Remote (childhood, historical facts).

Abstract thinking: Proverb interpretation, similarities/differences.

Intelligence estimate: Vocabulary, fund of knowledge.

Insight

• the capacity to gain an accurate and deep understanding of someone or something.
• Levels:
• Complete denial of illness.
• Partial acknowledgment but external attribution.
• Recognition of illness and need for treatment.
• Clinical importance: Predicts adherence to treatment

Judgment

• In mental health, "judgment" can refer to the patient's ability to make sound decisions, which is assessed during a mental status examination, or it can describe the negative impact of judgment (both self and from others) on mental well-being
• Social judgment: Responses to hypothetical scenarios (“What would you do if you found a stamped, addressed envelope on the street?”).
• Practical judgment: Real-life decision-making capacity.