From the Guidelines
A comprehensive mental state examination (MSE) for a psychiatry registrar should include assessment of appearance and behavior, speech, mood and affect, thought process and content, perception, cognition, and insight and judgment, as recommended by the most recent guidelines 1.
Key Components of the MSE
The following components should be included in the MSE:
- Appearance and behavior: observing the patient's general appearance, noting their level of grooming, dress, posture, eye contact, and any abnormal movements or behaviors.
- Speech: assessing speech for rate, volume, tone, and fluency, noting any abnormalities such as pressured speech, poverty of speech, or dysarthria.
- Mood and affect: evaluating mood (the patient's subjective emotional state) and affect (the observed emotional expression), documenting whether affect is appropriate, restricted, blunted, flat, or labile.
- Thought process and content: examining thought process for coherence, logic, and flow, while thought content assessment should identify any delusions, obsessions, phobias, or suicidal/homicidal ideation.
- Perception: assessing perceptions for hallucinations across all sensory modalities.
- Cognition: including orientation to person, place, time, and situation; attention and concentration (using tests like digit span or serial sevens); memory (immediate, recent, and remote); abstract thinking; and general intelligence.
- Insight and judgment: evaluating the patient's insight into their condition and judgment regarding everyday decisions.
Additional Considerations
The MSE should also include a review of the patient's psychiatric history, including past and current psychiatric diagnoses, prior psychotic or aggressive ideas, and prior suicidal ideas or attempts, as recommended by the American Psychiatric Association 1. The clinician should perform a mental status examination that assesses cognition, mood, and behavior, and a dementia-focused neurologic examination, using validated tools whenever feasible 1. The MSE should be comprehensive and systematic, providing crucial information for diagnosis, treatment planning, and monitoring clinical progress in psychiatric patients.
Documentation
All findings should be documented objectively using specific examples of patient statements or behaviors rather than interpretations. This systematic approach ensures comprehensive evaluation of mental status, providing crucial information for diagnosis, treatment planning, and monitoring clinical progress in psychiatric patients, as supported by the most recent guidelines 1.
From the Research
Mental State Examination
A mental state examination is an essential tool for psychiatry registrars to evaluate patients and make psychiatric diagnoses 2. The examination includes:
- Historic report from the patient
- Observational data gathered by the physician throughout the patient encounter The mental state examination can help distinguish between mood disorders, thought disorders, and cognitive impairment, and guide appropriate diagnostic testing and referral to a psychiatrist or other mental health professional 2.
Components of the Mental State Examination
The components of the mental state examination include:
- Appearance and general behavior
- Motor activity
- Speech
- Mood and affect
- Thought process
- Thought content
- Perceptual disturbances
- Sensorium and cognition
- Insight
- Judgment These components can help identify features of various psychiatric illnesses 2, 3.
Cognitive Functions
Multiple cognitive functions may be tested during the mental state examination, including:
- Attention
- Executive functioning
- Gnosia
- Language
- Memory
- Orientation
- Praxis
- Prosody
- Thought content
- Thought processes
- Visuospatial proficiency Proprietary and open-source clinical examination tools, such as the Mini-Mental State Examination and the Mini-Cog, can be used to assess these cognitive functions 3.
Clinical Judgment
Physician judgment is necessary in selecting the most appropriate tool for an individual patient and interpreting the results in the context of physician observation 3. The mental state examination is useful in helping differentiate between a variety of systemic conditions, as well as neurologic and psychiatric disorders ranging from delirium and dementia to bipolar disorder and schizophrenia 3.
Treatment of Bipolar Depression
For the pharmacological treatment of bipolar depression, several guidelines exist, and combinations of psychotropic drugs are frequently used 4. Lithium and valproate are commonly used mood stabilizers, and their efficacy can be maximized when used to prevent both manic and depressive episodes 5. The choice of treatment should be guided by clinical and preclinical factors, such as family history, previous affective episodes, and comorbidities 5.