Teifion Davies and Tom Craig
OVERVIEW
Mental health problems affect about a third of the adult population at any time, and all clinicians should be familiar with their recognition and initial assessment
Mental health or psychiatric assessment follows a similar pattern to assessment in other clinical specialities: history of the presenting complaint, formal examination, investigation and diagnosis
A full picture of the patient's problems may be built up over several interviews, and broadened to include collateral history from family and friends
An initial interview with a distressed patient has important therapeutic value
Psychiatry in healthcare
Symptoms of mental disorder are common: at any time, about a third of the adult population reports suffering from distressing symptoms such as worry, sleep disturbance or irritability. According to the World Health Organization, mental disorders comprise five of the top 10 causes of years lived with disability, accounting for about 22% of the total disability worldwide. All healthcare professionals will encounter people experiencing mental health problems, so all clinicians require basic mental health skills (Box 1.1).
Psychiatry is the branch of medicine that deals with disorders in which mental (emotional or cognitive) or behavioural features are most prominent. The cause, presentation and course of such disorders are influenced by diverse factors; their symptoms can be bewildering to patients and their relatives; and their management may require social and psychological as well as medical interventions. It is not surprising that this complex situation can lead to misunderstandings regarding the role of psychiatrists (who are neither social workers nor gaolers) and myths about the practice of psychiatry.
The bulk of mild mental disorders has always been managed by family doctors. Patients referred to psychiatrists are increasingly likely to be managed at home by community mental health services or, if admitted to an acute psychiatric ward, to be discharged after a short stay. Many former long-stay patients have been discharged to the community with varying degrees of support and supervision. This book will deal with the principles and practice of managing mental health problems.
Psychiatric assessment
There is a myth that psychiatric assessment differs from that in other medical specialties: it does not, it follows the familiar sequence of history, examination (both mental state and physical) and investigation, leading to differential diagnosis. Another myth holds that management cannot proceed without obtaining an extensive history that delves into all aspects of a patient's life. Diagnosis can take only a few minutes, but time must be spent fleshing out the initial impressions, assessing immediate risks and collecting information about personal and social circumstances that modify symptoms or affect management and long-term prognosis.
Accuracy is achieved by close attention to the pattern of evolution of presenting symptoms and examination of a patient's mental state. A complete psychiatric assessment requires a detailed personal history, which, if the doctor is not familiar with the patient, may be built up over a series of interviews. The important point is that such detail comes into play only once the basic problem has been ascertained clearly.
Good interview technique
Interview technique is important in all branches of medicine. A good psychiatric interview comprises a series of 'nested' processes of gathering information in which gathering of general information is followed by specific questions to clarify ambiguities and confirm or refute initial impressions (Boxes 1.2 and 1.3).
Open questions
The interview begins with open questions concerning the nature of the present problem, followed by more focused questions to clarify chronological sequences and the evolution of key symptoms. Open questions encourage patients to talk about matters of immediate concern to them and help to establish a rapport.
Closed questions
Specific closed questions (equivalent to the systematic inquiry of general medicine) should follow only when a clear outline of the underlying disorder has emerged. These questions form a checklist of symptoms often found in variants of the likely disorder but not mentioned spontaneously by the patient (such as diurnal variation of mood in severe depression).
Choice questions
Sometimes patients are not accustomed to answering open questions. This is often so with adolescents and children, who are more used to being told how they feel by adults. In these cases, a choice question may be more useful. This suggests a range of possible answers to the patient but always allows for replies outside the suggested range: 'Do you feel like ..., or ..., or something else?'
On each topic the interview should move smoothly from open questions to more closed, focused questions
Initial assessment
The first and most important stage entails getting a clear account of current problems (presenting complaint and mental state), social circumstances and an estimate of concurrent physical illness (including substance misuse) that might influence the presentation.
Once the current situation is clear and rapport has been established, closed questions should be used to elicit specific items of history. Topics covered at this stage include patient's prior psychiatric and medical problems (and their treatment), use of alcohol and prescribed and illicit drugs, and level of functioning at home and at work. Initial suspicions of risk to the patient or others should be clarified gently but thoroughly.
Risk assessment
It is a myth that asking about suicidal ideas may lead patients to consider suicide for the first time. Fleeting thoughts of suicide are common in people with mental health problems. Importantly, intensely suicidal thoughts can be frightening, and sufferers are often relieved to find someone to whom they can be revealed.
Persecutory beliefs, especially those focusing on specific people, should be elicited clearly as they are associated with dangerousness. Patients who ask for complete confidentiality - 'Promise you won't tell anyone' - should be reassured sympathetically but firmly that the duty to respect their confidence can be overridden only by the duty to protect their own or others' safety.
Assessment of capacity
All patients must be assumed to have the capacity to make decisions for themselves about their care and treatment. Where there is doubt about this capacity, it must be assessed formally according to the Mental Capacity Act: this will be covered in more detail in Chapter 21.
Mental state examination
Whereas the history relates to events and experiences up to the present time, the mental state examination focuses on current symptoms and signs using closed questions. This bears direct analogy to the physical examination and is an attempt to elicit, in an objective way, the signs of mental disorder. The emphasis is now on the form as well as the content of the responses to well-defined questions covering a range of mental phenomena. For example, the form of a patient's thought may be delusional, and the content of the delusions may concern abnormal beliefs about family or neighbours (Box 1.4).
Physical examination and investigation
Relevant physical examination is an important part of the assessment and should follow as soon as is practicable. Usually, this will require only simple cardiovascular (pulse, blood pressure) and neurological (muscle tone and reflexes, cranial nerves) examination. Similarly, laboratory investigations (Box 1.5) should be performed as indicated, considering a patient's past health and intended treatment. The choice may be influenced by
Patient's age
Known or suspected concurrent physical disease
Alcohol or substance misuse
Intended drug treatment (e.g. antidepressants, antipsychotics or lithium). An electrocardiogram should be considered before starting drugs with known cardiac effects, and body mass index (BMI) calculated before starting treatment with drugs that affect metabolism
Concurrent medication (several drugs potentiate the cardiac effects of antidepressants and antipsychotics).
Further inquiry
The second broad phase of assessment involves gathering information to place the present complaint in the context of a patient's psychosocial development, premorbid personality and current circumstances. This phase also follows the scheme of open and then closed questioning, but, because of the breadth of the issues to be covered, it is often the longest component of a psychiatric assessment. Whenever possible, a collateral history should be obtained from those who know the patient (family, friends or carers).
For a disturbed patient who is bewildered by his or her bizarre experiences, the interview may be a critical period and the doctor should not waste it
Much of this information may not be available initially, or may take too long to collect in a busy surgery or accident and emergency department. There is no reason to delay urgent management while this information is sought. Similarly, sensitive issues such as a patient's psychosexual history should not be avoided but can be elicited more easily when the patient's trust has been gained.
Therapeutic importance of the psychiatric interview
The interview is more than an information gathering process: it is the first stage of active management. This may be the first opportunity for a patient to tell his or her full story or to be taken seriously, and the experience should be beneficial in itself. The length of the interview should allow time for intense emotions to calm and for the first steps to be taken towards a trusting therapeutic relationship. The balance between information gathering and therapeutic aspects of the interview is easily lost if, say, a doctor works relentlessly through a pre-set questionnaire or checklist of symptoms.
Making sense of psychiatric symptoms
Although psychiatric symptoms can be clearly bizarre, many are recognisable as part of normal experience. The situation is identical to the assessment of pain: a doctor cannot experience a patient's pain nor measure it objectively but is still able to assess its significance. A pattern can be built up by comparing the patient's reported pain - its intensity, quality and localisation - with observation of the patient's behaviour and any disability associated with it. Similarly, patients' complaints of 'feeling depressed' may be linked to specific events in their life, to a pervasive sense of low self-esteem, or to somatic features such as disturbed sleep and diurnal variation in mood.
Another myth is that the vagueness of psychiatric features makes diagnosis impossible (Box 1.6). In fact, psychiatric diagnoses based on current classification systems are highly reliable. It is true that there are no pathognomonic signs in psychiatry - that is, most psychiatric signs in isolation have low predictive validity, as similar features may occur in several different disorders. It is the pattern of symptoms and signs that is paramount.
In practice, sense may be made of the relation between features and disorders by envisaging a hierarchy in which the organic disorders are at the top, the psychoses and neuroses in the middle, and personality traits at the bottom (Figure 1.1). A disorder is likely to show the features of any of those below it in the hierarchy at some time during its course but is unlikely to show features of a disorder above it. Thus, a diagnosis of schizophrenia depends on the presence of specific delusions and hallucinations and will often include symptoms of anxiety, depressed mood or obsessional ideas; it is much less likely if consciousness is impaired (characteristic of delirium, which is higher in the hierarchy). Conversely, personality factors will influence the presentation of all mental (and physical) disorders as they are at the foot of the hierarchy.
Summarising the findings
A bare diagnosis rarely does justice to the complexity of a presentation, nor does it provide an adequate guide to management. The formulation is a succinct summary of a patient's history, current circumstances and main problems: it aims to set the diagnosis in context. It is particularly useful in conveying essential information, as when making a referral to specialist psychiatric services (Box 1.7). An adequate referral to such services should include
Description of the presenting complaint, its intensity and duration
Relevant current and past medical history and medication
Findings of mental state examination
Physical health and any drug treatment
Estimate of degree of urgency in terms of risk to the patient and others
Indication of referrer's expectations (assessment, advice, admission)
Very urgent requests may be brief but should be reinforced by telephone.
Consequences of mental disorder
Patients with mental disorders often suffer stigma - the experience of being discriminated against and rejected by others, and a consequent feeling of shame and disgrace. There may also be other serious consequences.
Mortality rates
Psychiatric disorders are associated with increased risk of death from all causes, and the all-cause standardised mortality ratio (SMR) among community psychiatric patients is about 1.6 (that is, about 1.6 times the rate in the general population). Mortality rates are highest among people suffering schizophrenia (SMR 1.76), men (SMR 2.24), and younger patients (SMR 8.82 for ages 14 to 24 years). So-called avoidable deaths are four times higher in patients with psychiatric diagnoses than in the general population. Some of this excess is due to suicide and violence, some to higher rates of respiratory, cardiac, and other diseases, and some to lack of appropriate healthcare. In some surveys, over 50% of patients smoked more than 15 cigarettes per day.
Disability rates
The World Health Organization estimates mental disorders to have a disproportionate effect on disability worldwide: mood disorders, schizophrenia and alcohol misuse cause about 20% of the days lived with disability. Depression alone contributes almost 5% of the global burden of disease, is worse in women and in developing countries, and reduces recovery from a range of physical illnesses.
Fitness to drive
A driver with a mental disorder has a slightly increased risk of being involved in a road traffic accident, with personality disorders, alcohol intoxication, and side effects of drug treatment accounting for most of the increase. Some disorders (such as schizophrenia, bipolar affective disorder) affect a driver's entitlement to hold a driving licence, at least during the acute illness and for 6-12 months afterwards. For other disorders, the period of withdrawal of the licence will depend on the severity of the condition, and may be permanent in some cases (such as severe dementia). Patients have a duty to inform the licensing authority of any such disorder, and the doctor should do this where a patient is unable or unwilling to do so. Care should be taken to warn patients of potential side effects of drug treatment that might affect their driving.
Other aspects
Suffering from mental disorder might affect life insurance premiums, while being detained under the Mental Health Act may restrict a patient's voting rights. Local guidance should be sought in cases of doubt.
Role of voluntary organisations
Several local and national voluntary organisations are concerned with mental health. They may provide telephone advice or support, counselling, day centres, and volunteers or befriending services. Many patients benefit from the counselling or mutual support offered by such organisations, self-help groups and charities. These include patients with severe or protracted mental disorders and their carers, and many others who are distressed by unpleasant circumstances but are not suffering from a mental disorder and so do not require a referral to specialist mental health services.
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Excerpted from ABC of Mental Health Copyright © 2009 by Blackwell Publishing. Excerpted by permission.
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