What is the typical Mental Status Examination (MSE) format for a patient presenting with moderate depression?

Mental Status Examination Format for Psychiatric Consultations

The Mental Status Examination should follow a structured nine-domain format: Appearance, Behavior, Speech, Mood and Affect, Thought Process, Thought Content, Perceptual Disturbances, Cognition/Sensorium, and Insight/Judgment. 1, 2

Core MSE Domains

1. Appearance

• Document grooming, hygiene, dress appropriateness, and physical presentation 1, 3
• Note any signs of self-neglect or unusual attire that may indicate psychiatric disturbance 1

2. Behavior and Motor Activity

• Observe general demeanor, eye contact, cooperation level, and psychomotor activity 1, 4
• Document agitation, retardation, abnormal movements, or catatonic features 1, 3

3. Speech

• Assess rate, volume, tone, fluency, and spontaneity 1, 4
• Note pressured speech, poverty of speech, or other abnormalities 3

4. Mood and Affect

• Mood is the patient's subjective emotional state (ask directly: "How is your mood?") 1, 3
• Affect is your objective observation of emotional expression, including range, appropriateness, and congruence with mood 1, 3

5. Thought Process

• Evaluate the organization and flow of thoughts 1, 3
• Document tangentiality, circumstantiality, flight of ideas, loose associations, or thought blocking 1, 2

6. Thought Content

• Always assess for suicidal ideation, homicidal ideation, and self-harm thoughts—this must never be omitted regardless of presentation 5, 6
• Document delusions, obsessions, preoccupations, or paranoia 1, 3
• For moderate depression specifically, suicidal thoughts are not rare and require frequency and specificity assessment 5

7. Perceptual Disturbances

• Screen for hallucinations (auditory, visual, tactile, olfactory, gustatory) 1, 3
• Assess for illusions or depersonalization/derealization 3, 2

8. Cognition and Sensorium

• Orientation: person, place, time, situation 1, 3
• Attention and concentration: serial 7s or spelling "WORLD" backwards 3
• Memory: immediate recall, short-term (5-minute recall), and long-term 1, 3
• Executive function: abstraction, judgment in hypothetical scenarios 3
• Consider formal screening tools like Mini-Mental State Examination or Mini-Cog when cognitive impairment is suspected 5, 3

9. Insight and Judgment

• Assess patient's awareness of their illness and need for treatment 1, 3
• Evaluate decision-making capacity and understanding of consequences 1, 2

Critical Considerations for Moderate Depression

Immediate Safety Assessment

• If any risk of self-harm or harm to others is identified, immediately refer for emergency psychiatric evaluation, facilitate a safe environment, implement one-to-one observation, and initiate risk reduction interventions 5
• The presence of psychosis, severe agitation, or confusion (delirium) also warrants emergency evaluation 5

Rule Out Medical Causes First

• Before attributing symptoms to depression, exclude uncontrolled pain, fatigue, delirium from infection or electrolyte imbalance, thyroid disorders, and medication side effects 7, 8, 6
• Perform careful evaluation for altered mental status or unexplained vital sign abnormalities 5

Functional Impairment Documentation

• Document how symptoms interfere with work, relationships, self-care, and daily activities 5, 7
• For moderate depression (PHQ-9 score 8-14), expect mild to moderate functional impairment 5

Practical Implementation

Interview Strategy

• Interview patient and collateral sources (family, caregivers) both together and separately 5
• Patients frequently minimize symptom severity, making collateral information essential 5
• For adolescents, discuss confidentiality limits before interviewing alone 5

Documentation Structure

• Use a standardized format to ensure comprehensive coverage of all domains 9
• Structured MSE forms significantly improve report quality and comprehensiveness 9
• The ABC-STAMPS mnemonic (Appearance, Behavior, Cooperation; Speech, Thought process and content, Affect, Mood, Perceptions, Suicidality) provides a systematic framework 4

Common Pitfalls to Avoid

• Never omit the suicidal ideation assessment—doing so artificially lowers risk detection and misses critical safety information 5, 6
• Do not rely solely on symptom counts; assess functional impairment and duration 5
• Avoid using PHQ-9 in patients with cognitive impairment, as it loses accuracy in this population 6
• Do not confuse mood (subjective) with affect (objective observation) 1, 3