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History and Mental Status Examination
Guy E Brannon, MD, Associate Clinical Professor of Psychiatry, Louisiana State University Health Sciences Center;
Director, Adult Psychiatry Unit, Chemical Dependency Unit, Clinical Research, Brentwood Behavior Health Company
Updated: Feb 4, 2008
Introduction
The history and Mental Status Examination (MSE) are the most important diagnostic tools a psychiatrist has to obtain information to make an accurate diagnosis. Although these important tools have been standardized in their own right, they remain primarily subjective measures that begin the moment the patient enters the office.
The clinician must pay close attention to the patient's presentation, including personal appearance, social interaction with office staff and others in the waiting area, and whether the patient is accompanied by someone
(ie, to help determine if the patient has social support). These first few observations can provide important information about the patient that may not otherwise be revealed through interviewing or one-on-one conversation.
When patients enter the office, pay close attention to their personal grooming. One should always note things as obvious as hygiene, but, on a deeper level, also note things such as whether the patient is dressed appropriately according to the season. For example, note whether the patient has come to the clinic in the summer, with 3 layers of clothing and a jacket. These types of observations are important and may offer insight into the patient's illness. Other behaviors to note may include patients talking to themselves in the waiting area or perhaps pacing outside the office door. Record all observations.
The next step for the interviewer is to establish adequate rapport with the patient by introducing himself or herself. Speak directly to the patient during this introduction, and pay attention to whether the patient is maintaining eye contact. Mental notes such as these may aid in guiding the interview later. If patients appear uneasy as they enter the office, attempt to ease the situation by offering small talk or even a cup of water.
Many people feel more at ease if they can have something in their hands. This reflects an image of genuine concern to patients and may make the interview process much more relaxing for them.
Legally, a mental status if conducted against the patient's will is considered assault with battery. Therefore, it is important to secure the patient's permission or to document that a mental status is being done without the patient's approval if in an emergency situation.
The time it takes to complete the initial interview may vary; however, with experience, interviewers develop their own comfortable pace and should not feel rushed to complete the interview in any time that is less than comfortable for either the interviewer or the patient. All patients require their own time during this initial interview and should never be made to feel they are being timed.
Beginning with open-ended questions is desirable in order to put the patient further at ease and to observe the patient's stream of thought (content) and thought process. Begin with questions such as "What brings you here today?" or "Tell me about yourself." These types of questions elicit responses that provide the basis of the interview. Keep in mind throughout the interview to look for nonverbal cues from patients. As they speak, for example, note if they are avoiding eye contact, acting nervous, playing with their hair, or tapping their foot repeatedly. In addition to the patient's responses to questions, all of these observations should be noted during the interview process.


As the interview progresses, more specific or close-ended questions can be asked in order to obtain specific information needed to complete the interview. For example, if the patient is reporting feelings of depression, but only states "I'm just depressed," determining both the duration and frequency of these depressive episodes is important. Ask leading questions such as "How long have you had these feelings?" or "When did these feelings begin?" and "How often do you feel this way?" or "How many days in the past week have you felt this way?"
These types of questions help patients understand what information is needed from them. For safety reasons, both the patient and the interviewer should have access to the door in case of an emergency during the interview process.
At some point during the initial interview, a detailed patient history should be taken. Every component of the patient history is crucial to the treatment and care of the patient it identifies. The patient history should begin with identifying patient data and the patient's chief complaint or reason for coming to the clinic. The patient's chief complaint should be a quote recorded just as it was spoken, in quotation marks, in the patient's record.
This also is where all history of illness is recorded, including psychiatric history, medical history, surgical history, and medications and allergies. Of interest, it is important to make direct inquiry to items such a family history of members being murdered—patients often do not volunteer this information.
Additionally, listing any family history of illness is important. This information can be very useful later, when determining treatment options. If a family member has a history of the same illness and had a successful drug regimen, that regimen may prove to be a viable option for the current patient. If possible, record the medications and dosages family members took for their illnesses. If these medications and dosages worked for family members, the chance is good that they may work for the current patient.
Obtain a complete social history. This addition to the patient history can be most crucial when discharge planning begins. Inquire if the patient has a home. Also ask if the patient has a family, and, if so, if the patient maintains contact with them. This also is the area in which any history of drug and alcohol abuse, legal problems, and history of abuse should be recorded.
Imperative to the recording of a patient's social history is any information that may aid the physician or other clinicians in making special accommodations for the patient when necessary. This would include an accurate record of the last grade completed in school, whether the patient was in special education classes, or if the patient required special assistance at work or school (ie, special listening devices for the hard of hearing).
Following completion of the patient's history, perform the MSE in order to test specific areas of the patient's spheres of consciousness. To begin the MSE, once again evaluate the patient's appearance. Document if eye contact has been maintained throughout the interview and how the patient's attitude has been toward the interviewer. Next, in order to describe the mood aspect of the examination, ask patients how they feel.
Normally, this is a one-word response, such as "good" or "sad."
Next, the interviewer's task is to define the patient's affect, which will range from expansive (fully animated) to flat (no variation). The patient's speech then is evaluated. Note if the patient is speaking at a fast pace or is talking very quietly, almost in a whisper. Thought process and content are evaluated next, including any hallucinations or delusions, obsessions or compulsions, phobias, and suicidal or homicidal ideation or intent.
Then, the patient's sensorium and cognition are examined, most commonly using the Mini-Mental State
Examination. The interviewer should ask patients if they know the current date and their current location to determine their level of orientation. Patients' concentration is tested by spelling the word "world" forward and backward. Reading and writing are evaluated, as is visuospatial ability. To examine patients' abstract thought process, have them identify similarities between 2 objects and give the meaning of proverbs, such as "Don't cry

over spilled milk." Once this is completed, perform the physical examination and needed laboratory tests to help exclude medical causes of presenting symptoms.
A compilation of all information gathered throughout the interview and MSE leads to the differential diagnosis of the patient. Once this diagnosis is established, a treatment plan is formulated. At this point, involving the treatment team (eg, social workers, nurses, others) is important to help carefully explain to patients what their treatment will entail. Be sure to ask patients if they have any questions regarding their treatment plans. Discuss the details of the medications chosen, including adverse effects. Give details of the hospital stay if patients are to receive inpatient treatment, such as estimated length of stay, visiting hours, and other aspects. Inform patients that even though the interviewer is the treating physician, their input and concerns are valuable and necessary in order to fulfill treatment goals.
Every patient interview affords the health care professional an invaluable opportunity to provide patient education. While different illnesses may require specialized attention, this time can be used to discuss such patient issues as medication compliance, nutrition, the importance of follow-up appointments with primary care physicians and other specialists (eg, obstetricians, gynecologists), the urgency of seeking emergency medical help at the emergency department when necessary, the prevalence of psychiatric disorders, and general education concerning the patient's illness. Never overlook providing needed education to patients.
The process of conducting an accurate history and MSE takes practice and patience, but it is very important in order to evaluate and treat patients effectively. This part of psychiatry is so important that it comprises part II of the Board Certification Test. The history and MSE are crucial first steps in the assessment and are the only diagnostic tools psychiatrists have to select treatment for each patient and, therefore, ultimately are the deciding factor for initial treatments. This fact alone should make the interviewer cognizant of the essential role the history and MSE play each time a patient is evaluated.
Once the history and MSE are complete, documenting this event accurately and efficiently is important.
Patient History



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