Key Components and Tools of Mental Status Examination (MSE)
The Mental Status Examination (MSE) is a structured approach to gathering a patient's behavioral and cognitive information, analogous to the physical exam, providing a systematic template to collect clinical data about psychiatric and cognitive functioning. 1
Core Components of MSE
The American Psychiatric Association recommends 2 that the MSE should include assessment of:
- Mood, level of anxiety, thought content and process, perception and cognition
- Hopelessness
- Current suicidal ideas, plans, and attempts
- Current aggressive or psychotic ideas
A comprehensive MSE follows the ABC-STAMPS structure 1:
Appearance and Behavior
- General appearance and nutritional status
- Coordination and gait
- Involuntary movements or abnormalities of motor tone
- Skin, including stigmata of trauma, self-injury, or drug use
Cooperation
- Patient's engagement with the examination
- Level of consciousness
Speech
- Fluency and articulation
- Rate, volume, prosody
- Spontaneous speech
Thought Process and Content
- Organization of thoughts (logical, tangential, circumstantial)
- Presence of delusions, obsessions, phobias
- Suicidal ideation assessment:
- Patient's intended course of action if symptoms worsen
- Access to suicide methods including firearms
- Possible motivations for suicide
- Reasons for living
- Quality of therapeutic alliance
Affect and Mood
- Observed emotional expression
- Subjective emotional state
- Range, appropriateness, and stability
Perceptions
- Presence of hallucinations or illusions
- Misinterpretations of sensory input
Sensorium and Cognition
- Orientation to time, place, and person
- Memory (immediate, recent, remote)
- Attention and concentration
- Abstract thinking
- Insight and judgment
Standardized Assessment Tools
Several validated tools can be used to structure and quantify the MSE 2, 3:
| Tool | Time (min) | Best Use | Considerations |
|---|---|---|---|
| Mini-Mental State Exam (MMSE) | 7-10 | Dementia detection | Less sensitive for MCI; proprietary; not free for clinical use [2] |
| Montreal Cognitive Assessment (MoCA) | 10-15 | MCI detection | Tracks progression through mild to moderate dementia; freely available; requires training/certification [2] |
| Mini-Cog | 2-4 | Rapid dementia screening | Combines three-word recall with clock drawing; less sensitive for MCI [2] |
| SLUMS Examination | 7-10 | VA population | Suited for MCI and dementia detection [2] |
| GPCOG | 2-5 (patient), 1-3 (informant) | Primary care | Includes clock drawing; informant component [2] |
| Memory Impairment Screen (MIS) | 4-5 | Memory assessment | Four-item delayed free and cued recall test [2] |
Implementation in Clinical Practice
The MSE should be incorporated when 4:
- The physician senses something is "not quite right" with a patient
- Evaluating for psychiatric disorders
- Assessing cognitive impairment
- Following up on behavioral changes
Practical Considerations
- Most emergency physicians take less than five minutes to evaluate mental status 5
- Focus on key components based on clinical presentation
- Record findings using descriptive psychopathology with phenomenological orientation 6
- Use standardized tools to complement the clinical examination
Common Pitfalls to Avoid
Overreliance on screening tools: The MMSE was not designed to diagnose dementia or measure cognitive deterioration in neurologic patients 2
Ignoring educational and cultural factors: Interpret results with caution in individuals with low education or different cultural backgrounds 2
Missing subtle cognitive changes: Brief screening tools may miss subtle deficits, particularly in highly educated patients 2
Neglecting informant reports: Collateral information is crucial, especially for behavioral symptoms 3
Failing to document thoroughly: Document an estimate of the patient's suicide risk and factors influencing risk 2
The MSE is a core competency in medical education and essential for distinguishing between mood disorders, thought disorders, and cognitive impairment. When performed systematically, it guides appropriate diagnostic testing and referral to mental health professionals when necessary 4.