From the Guidelines
A comprehensive mental state examination (MSE) for a psychiatry registrar should include a thorough assessment of the patient's psychiatric history, appearance and behavior, speech, mood and affect, thought process and content, perception, cognition, and insight and judgment, as recommended by the American Psychiatric Association 1. When conducting an MSE, it is essential to begin by observing the patient's general appearance, noting their level of grooming, dress, posture, eye contact, and any abnormal movements or behaviors.
- Assess speech for rate, volume, tone, and fluency, noting any abnormalities such as pressured speech, poverty of speech, or dysarthria.
- Evaluate mood (the patient's subjective emotional state) and affect (the observed emotional expression), documenting quality, range, appropriateness, and stability.
- Examine thought process for coherence, logic, and flow, while thought content assessment should identify any delusions, obsessions, phobias, or suicidal/homicidal ideation, as outlined in the American Psychiatric Association practice guidelines for the psychiatric evaluation of adults 1.
- Assess perceptions for hallucinations across all sensory modalities or other perceptual disturbances.
- Cognitive assessment should include orientation to person, place, time, and situation; attention and concentration; memory (immediate, recent, and remote); abstract thinking; and general intelligence.
- Finally, evaluate the patient's insight into their condition and judgment regarding everyday decisions, taking into account their treatment-related preferences and collaboration with the clinician in decision-making, as suggested by the American Psychiatric Association 1. It is also crucial to consider the patient's psychiatric history, including past and current psychiatric diagnoses, prior psychotic or aggressive ideas, and prior suicidal ideas, suicide plans, and suicide attempts, as recommended by the American Psychiatric Association 1. Additionally, the MSE should include an assessment of the patient's risk of aggressive behavior, including factors influencing risk, and documentation of the rationale for clinical tests, as suggested by the American Psychiatric Association 1. In cases of acute mental status changes, new onset delirium, or new onset psychosis, it is essential to consider the underlying causes, such as medical conditions, drug/alcohol use, or withdrawal, and to employ validated assessment scales, such as the Richmond Agitation Sedation Scale and Glasgow Coma Scale, to objectively quantify the severity of symptoms, as outlined in the ACR Appropriateness Criteria for acute mental status change, delirium, and new onset psychosis 1.
From the Research
Mental State Examination
The mental state examination is a crucial component of psychiatric assessment, including general observations and specific testing based on patient and physician needs 2. This examination evaluates multiple cognitive functions, such as:
- Attention
- Executive functioning
- Gnosia
- Language
- Memory
- Orientation
- Praxis
- Prosody
- Thought content
- Thought processes
- Visuospatial proficiency
Tools for Mental State Examination
Various proprietary and open-source clinical examination tools are available, including:
- Mini-Mental State Examination
- Mini-Cog These tools have varying sensitivity and specificity for neurologic and psychiatric disorders but are not diagnostic for any mental status disorder, requiring interpretation in the context of physician observation 2.
Applications of Mental State Examination
The mental state examination is useful in differentiating between systemic conditions, neurologic disorders, and psychiatric disorders, including:
- Delirium
- Dementia
- Bipolar disorder
- Schizophrenia However, there are no guidelines for further testing in the setting of an abnormal mental status examination, making clinical judgment essential 2.
Psychiatric Disorders and Treatment
In the context of psychiatric disorders, studies have investigated the efficacy of various treatments, such as:
- Selective serotonin reuptake inhibitors (SSRIs) for major depression 3, 4
- Risperidone combined with lithium or valproate for mania in bipolar disorder 5
- Antidepressant-associated mania and psychosis resulting in psychiatric admissions 6
Key Findings
Key findings from these studies include:
- The lower range of licensed doses for SSRIs achieves an optimal balance between efficacy, tolerability, and acceptability in the acute treatment of major depression 3
- Concomitant cognitive behavioral therapy (CBT) may enhance the prophylactic efficacy of SSRIs in major depressive disorder 4
- Risperidone can be safely combined with either lithium or valproate, with similar efficacy regardless of the mood stabilizer used 5
- Antidepressant-associated adverse behavioral effects, such as mania and psychosis, can result in significant psychiatric admissions 6