[HD 202] E01-T10-Mental Health Assessment

• Mental health is crucial for decision-making, building relationships, and shaping the world, beyond just the absence of mental disorders.

Introduction: Mental Health

• Psychosocial well-being includes emotional, psychological, social, and collective aspects.
• Quality of life encompasses emotional, social, and physical components, often studied in healthcare research to understand the impact of medical conditions.
• Conceptualizations of mental health include:
  • "Above normal" mental state and Freud's capacity to work and love.
  • Maturity from a healthy adult development perspective.
  • Positive emotions like love, hope, joy, forgiveness, compassion, faith, and awe.
  • Socioemotional intelligence and successful object relations.
  • Subjective well-being experienced as happiness and contentment.
  • Resilience as the ability to adapt and maintain homeostasis.
• According to the WHO, mental health is a state of well-being that enables individuals to:
  • Cope with life's stresses.
  • Realize their abilities.
  • Learn and work effectively.
  • Contribute to their community.
• Mental health is a basic human right and exists on a complex continuum with varying degrees of distress and different social/clinical outcomes.
• Mental health conditions include mental disorders, psychosocial disabilities, and states of distress, impairment, or risk of self-harm.

Mental Health Assessment

• Mental health assessments use interviews and questionnaires to determine the presence, severity, frequency, and duration of psychiatric symptoms.
• Healthcare providers such as primary care physicians, specialists, psychologists, social workers, therapists, nurses, trainees, and psychiatrists can conduct these assessments.
• It is a learnable skill, and pop psychology is not a substitute for expertise.
• Factors that impede a General Practitioner's identification of mental disorders at outpatient departments include:
  • Lack of confidence and skills in psychiatric evaluation.
  • Shortage of strategies and insufficient practice.
  • Misunderstandings about diagnosis and unclear qualifications.
  • Deficiencies in psychiatric evaluation, mental state examination, communication, and assessment skills.
• Developing countries encounter difficulties in GPs becoming competent in diagnosing and systematically evaluating mental disorders without external help.
• The medical curriculum is being adjusted in the Philippines to enable GPs to diagnose and treat mental health conditions.

Psychiatric Interview

• The psychiatric interview aims to:
  • Obtain a historical perspective of the patient's life.
  • Establish rapport and a therapeutic alliance.
  • Develop mutual trust and confidence.
  • Understand present functioning.
  • Make a diagnosis.
  • Establish a treatment plan.
  • Agreement as toProcess: Introduce yourself, explain the interview's purpose, obtain consent, and state the duration.
  • Address voluntariness and inform them consent to proceed with the interview, state how long the interview will take.
  • Privacy and confidentiality is essential, with the exception being potential harm to self or others.
  • Patients must be treated with respect and consideration.
  • Rapport involves harmonious responsiveness between the physician and the patient.
  • The patient-physician relationship is reinforced by non-judgmental attitudes, understanding, and genuineness.
• Majority of the mental activity remains outside of conscious awareness
• Conduct a person-centered interview, focusing on strengths and assets.
• Assess safety issues and ensure patient comfort, with initial interviews lasting 45-90 minutes.

Process of the Interview

• Before the interview:
  • Identify the patient's needs and refer to emergency services if urgent.
  • Review medical records for crucial information.
  • Ask the reasons for consult and referral.
  • Make sure the Waiting Room environment is not overwhelming and minimizes distractions.
  • Ask patients to fill in forms, questionnaires, lists of medications, and healthcare providers, which may include screening tools as part of their process.
• The interview room must be soundproof, pleasant, and free of distractions.
• During the initiation, greet the patient with a friendly face, and use open-ended questions to encourage storytelling.

Elements of Psychiatric Interview

• Elements of a psychiatric interview include: Patient History, Mental Status Examination
• Patient history is based on subjective reports from the patient and collaterals (such as family members and other healthcare providers).
• Mental status examination is an objective tool used by the interviewer.

Parts of Initial Psychiatric Interview

• Parts of the initial psychiatric interview include: Identifying Data, Chief Complaint, History of Present Illness, Past Psychiatric History, Other Diagnoses, Substance Use History, Past Medical History, Family History, Development and Social History (Anamnesis)
• Identifying data includes name, age, sex, and gender.
• Assess source and reliability from the patient and other collateral informants.
• Other additional identifying data may include military service indicators.
• The chief complaint is a brief statement in the patient's own words explaining their reason for the consultation.
• History of present illness includes the development of symptoms from onset to present, relationship to events and stressors, substance use, changes in functioning, and previous hospitalizations.
• Past psychiatric/medical illness details extent, treatment, outcome, hospitalizations, and adherence.
• A substance use history involves a careful review of substance use, addictions, and abuse, starting with innocuous questions in a non-judgmental style.
• Family history includes age of parents and occupations, cause of death if deceased, separation status, number of siblings, birth order, relationships, and psychiatric/medical history.
• Developmental and social history includes birth, infancy, childhood, adolescence and Adulthood

Mental Status Examination

• Mental status examination should include: General Survey, Mood and Affect, Thought Process and Content, Perceptual Disturbances, Sensorium Cognition, Judgment and Insight
• In a general survey assess appearance and behavior and make Apparent physical examination findings
• Common disorders in thought process include circumstantiality, flight of ideas, tangentiality, looseness of associations and thought blocking
• Common disorders in thought content include: delusions, preoccupations and obsessions
• In hallucinations, there are false perceptual experiences that arise from no external stimuli
• Illusions are perceptions of existing stimuli
• Make a determination as to wakefulness of the patient
• Cognition Mental: Processes in a person's mind include Orientation, Memory, Concentration and Abstract Reasoning
• Test the patient for their Capacity to make good decisions and act on them
• Patients' awareness of having a mental disorder/condition and requiring help if they do

Formulation

• Formulation discusses biological, psychological, social, and spiritual factors, elicited from history including patient's relationship to transcendence.
• Neurotransmitter derangement, Intra-psychic event and social difficulties can have a Precipitating impact.
• Assess the patient's Neurologic development, ego integrity and family to determine the Predisposing factors
• Identify Intact ego functions determine the protective factors

Assessment tools

• The World Health Organization Disability Assessment Scale (WHODAS 2.0) is and example tool for evaluating a disability assessment
• Hamilton Rating Scale for Depression (HAM-D) is an example tool for evaluating mood disorders

Treatment Planning

• Treatment planning should include: treatment relationship, medication recommendation, clinical treatment recommendation, Safety planning and contact information
• When giving treatment, the position needs to ask if the patient has any concerns and queries

Answering Question and Answers

• Delusions indicate a need for intervention, and may require referral to a specialist and should assess patient safety.
• Diagnosis is provisional and can be crystalized and lead to a proper diagnosis with more and more contact with the patient
• Controlled substances are the ones that need a special license, and it falls upon your professional judgment to determine the medication.
• Use local guidelines by the Philippine Psychiatric Association or guidelines from other countries, and implement a treatment plan.
• In practice, request the patient to return at least three times to arrive at a diagnosis.
• For a patient that refuses to proceed with the interview then that reporting informs your diagnosis and point to problems with personality or mental status at that time
• For a patient that may have done an answer toll online, have a collaborative approach
• Most important thing from the lecture: When you do the mental health assessment, try to be empathetic, open, non-judgmental in your stance
• With regards to the mental health law, there is an obligation to protect confidentiality with some exceptions
• Duty to protect confidentiality EXCEPT for: the patient themselves who consent to the disclosure, a life-threatening emergency exists, patient being treated is a minor