Mental Status Assessment Sample Paper

Mental Status Assessment Sample Paper

Introduction

A mental health assessment is a critical part in the determination of the existence of a mental health complication, as well as in the establishment of the appropriate treatment methods. Some of the main components of a mental health assessment include a physical examination, laboratory tests, psychiatric history and a personal history of the patient (Patel & Singh, 2018). It is also critical to assess the patient’s appearance and general conduct, consciousness levels and attention span, mood and affect, speech, insight and higher cognitive functions. In this paper, I shall discus the risk assessment and diagnostic features of a mental health assessment.

Importance of a Therapeutic Relationship

A therapeutic relationship, also known as a therapeutic alliance, refers to the close and continuous association existing between a health care practitioner and an individual undergoing therapy. Further, as Torous and Hsin (2018) notes, therapeutic relationship aids in the betterment of a person’s life as it forms the basis of a safe space where an individual share his or her intimate thoughts, beliefs and emotions triggered by various circumstances in life. It is also critical in determining factors that may exacerbate an individual’s mental condition.

It is very important that the health care professional provides a safe, open and non-judgemental environment where the patient seeking therapy can feel at ease and open up to the therapist. Trust and respect are some of the vital components of an effective therapeutic relationship. The therapist must also demonstrate a sense of empathy towards his patients. There is need to establish boundaries by both parties as they help in defining acceptable and non-acceptable behaviours.

A good therapeutic relationship is one of the key steps towards recovery of the patient. One of the main components of a productive therapeutic relationship is trust. The patient must trust that his or her health care provider is competent and possesses the appropriate knowledge and know how to provide appropriate care. The patient must also be confident and trust that his or her therapist will remain professional and confidential consequently protecting the patient from harm and exploitation.

The establishment of a good therapeutic relationship leads to the establishment of a platform where the patient feels more at ease and easily opens up. The patient readily shares her concerns, a factor that enables the therapist to understand the patient’s feelings, thoughts and motives (Gopalkrishnan, 2018). Ideally, this aids in the determination of the patient’s condition and enables the therapist to initiate the most effective treatment options and other key strategies so as to effectively address the person’s concerns.

A good therapeutic relationship provides an avenue where the patient opens up to the therapist. The therapist is therefore able to comprehend the patient’s social and economic status, past psychiatric history, current medications and prevailing situations in the patient’s life. Comprehension of these various parameters is critical in the establishment of various factors that may be exacerbating the patient’s current mental health condition.

Importance of a Mental Status Examination

            A Mental Status Examination (MSE) is a well-structured assessment of an individual’s behavioural and cognitive functions. It examines the patient’s appearance and behaviour in general, concentration and attention levels, mood and affect; determining whether they are congruent or not, thought process and perception, insight and the patient’s higher functions; which include memory, orientation, intelligence and abstract thinking (Tarafder & Mukhopadhyay, 2018).

An accurately done mental status examination aids in eliciting signs and symptoms of obvious mental conditions and allows for determination of risk factors associated with various mental illnesses. According to Farooq et al. (2020), the mental status examination enables the observation and assessment of an individual’s current mental state. It also provides vital information that is applicable in the diagnosis of a disorder, prognosis determination and assessment of the response towards treatment and management. The Mental Status Examination is a vital assessment tool that aids health care professionals in differentiating various neurologic and psychiatric disorders.

Risk Assessment in MSE

            The Mental Status Examination gives an insight into a patient’s emotions, thought process and behavioural patterns at the time of the assessment. This helps in the determination of the presence of a mental health condition and points out the severity of the present condition. It also highlights the level of risk or exposure to risk factors that a patient poses to himself or herself, or to others in the immediate environment.

Risk assessment aims at identifying hazards and risk factors predisposing one to possible harm. It also aims at analysing and evaluating the risks commonly associated with the various hazards (Graney et al., 2020). The final aim is the elimination of the hazard or reduction in the level of risk in situations where it is impossible to eliminate the hazard. Assessment of the level and intent of risk is very important in psychiatric patients.

Assessment and management of the intent of risk of harm causation to self or to others in the society is very vital. It is important to note that cases exist where it is impossible to eliminate risk. However, even in such cases, it is possible to thoroughly assess and manage the level of risk with better patient outcomes. A history of violent conduct or posing a threat to other people is critical. A clear communication of the outcome of both the assessment and management of the risk is critical.

One of the major risks that a psychiatric patient poses to himself or herself is suicide. While conducting a mental status examination, the therapist takes note of the patient’s appearance, behaviour, speech, mood, thoughts, perceptions, cognition and level of insight (Chunduri et al., 2020). All these components are essential in determining the level of suicide risk that the patient poses. During assessment of the patient’s risk of suicide, it is important to consider the individual patient factors and other situational factors that increase the risk of suicide.

Factors greatly predisposing one to increased risk of suicide include gender, often with males at a greater risk. Others include extremes of age, lack of a reliable support structure, prior suicide attempts, and a family history of suicide and possible triggers. The number and severity of psychiatric symptoms, presence of hallucinations and the use of alcohol and other drugs of abuse greatly increase the risk. The mental status examination allows the determination of these factors and consequently allows for ease of assessment and management.

Importance of Physical Assessment

            Diagnostic overshadowing is harmful to patients as it denies them their right of receiving an appropriate diagnosis and consequently timely treatment. The practitioner can thus minimize or eliminate diagnostic overshadowing by being respectful and retaining confidentiality, ensuring that communication is directly with the patient and paying attention to non-verbal cues and signs (Geiss et al., 2018). In mental health, diagnostic overshadowing refers to a situation where an individual with a mental health condition receives delayed or non-standard treatment resulting from incorrect attribution of their physical symptoms.

A physical examination is a routine test performed by a health care practitioner to assess the overall health of a patient. It also provides an avenue to highlight the patient’s signs and symptoms and allows the health care practitioner to address any health concerns that the patient may have. Various additional tests can be conducted during the physical examination dependent on the patient’s age, medical and family history. There is need for routine physical examinations, at least once a year for routine checks with the goal of determining any conditions or diseases that may be treatable when diagnosed early.

A thorough physical examination helps in reducing diagnostic overshadowing as the health care practitioner can clearly identify signs and symptoms displayed by the patient at the time of the assessment. This ensures that the primary care provider does not downplay any signs and symptoms presented since they are clear from the examination done. It is clear to the health care practitioner that the patient is not exaggerating his condition. This facilitates early diagnosis of the condition and consequently timely and standard initiation of appropriate treatment. This ensures general positive outcomes.

Conclusion

As broached in this paper, a mental status examination is important in the establishment of diagnosis and the initiation of management. A thorough mental status examination enables the health care practitioner to have a good assessment of the patient’s psychological status. Psychiatric patients pose a great risk to themselves and to others in the society, and as such, assessment of level and intent of risk is critical while conducting a mental status examination.

Diagnostic overshadowing is a common occurrence with health care givers downplaying patient’s presentation resulting in delayed diagnosis and administration of inadequate treatment. A thorough physical examination by a health care practitioner is therefore very vital in reducing and eliminating diagnostic overshadowing. Additionally, this ensures timely diagnosis and treatment initiation resulting in positive health outcomes.

References

• Chunduri, S., Browne, S., Pollio, D. E., Hong, B. A., Roy, W., Roaten, K., & North, C. S. (2019). Suicide risk assessment and management in the psychiatry emergency service: psychiatric provider experience and perceptions. Archives of Suicide Research, 23(1), 1-14. https://doi.org/10.1080/13811118.2017.1414648
• Farooq, S., Tharani, A., Begum, S., & Parpio, Y. (2020). Implementation of Simulation: A Contemporary Strategy to Enhance Clinical Skills of Undergraduate Students in Mental Health Nursing. Issues In Mental Health Nursing, 41(8), 736-740. https://doi.org/10.1080/01612840.2019.1710011
• Geiss, M., Chamberlain, J., Weaver, T., McCormick, C., Raufer, A., Scoggins, L., & Edmonson, D. (2018). Diagnostic overshadowing of the psychiatric population in the emergency department: physiological factors identified for an early warning system. Journal of the American Psychiatric Nurses Association, 24(4), 327-331. https://doi.org/10.1177/1078390317728775
• Graney, J., Hunt, I. M., Quinlivan, L., Rodway, C., Turnbull, P., Gianatsi, M., & Kapur, N. (2020). Suicide risk assessment in UK mental health services: a national mixed-methods study. The Lancet Psychiatry, 7(12), 1046-1053. https://doi.org/10.1016/s2215-0366(20)30381-3
• Gopalkrishnan, N. (2018). Cultural diversity and mental health: Considerations for policy and practice. Frontiers In Public Health, 6, 179. https://doi.org/10.3389/fpubh.2018.00179
• Patel, R. M., & Singh, U. S. (2018). Prevalence study of cognitive impairment and its associated sociodemographic variables using mini-mental status examination among elderly population residing in field practice areas of a medical college. Indian journal of community medicine: official publication of Indian Association of Preventive & Social Medicine, 43(2), 113-116. https://dx.doi.org/10.4103%2Fijcm.IJCM_102_17
• Tarafder, S., & Mukhopadhyay, P. (2018). History Taking, Mental Status Examination and Assessment. Obsessive Compulsive Disorder: A Neuropsychological Approach, 62-82. http://dx.doi.org/10.4135/9789353280765.n3
• Torous, J., & Hsin, H. (2018). Empowering the digital therapeutic relationship: virtual clinics for digital health interventions. NPJ Digital Medicine, 1(1), 1-3. https://doi.org/10.1038/s41746-018-0028-2