Mental Health Assessment In
The Ambulatory Setting
Thomas E. Franklin, D.O.
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Introduction
• Psychologically impaired individuals frequently
consult primary care physician with somatic
complaints.
• Minor and major events may cause impaired
mental health in previously healthy individuals.
• Primary care physicians need system to identify
mental health issues for treatment
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Objectives
•
•
•
•
Take pt., social & developmental history
Perform mental status examination
Recognize coping responses, co-morbidities
Determine competence, decision-making
capacity and need for commitment.
• Formulate plan to address mental
impairment
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Information Gathering
• Information from many sources
(patient,family, police, EMS, other health
care facilities, employer) all valuable
• Current medications, illicit drugs, alcohol
– May cause depression, psychosis,
delirium, etc.
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Social & Developmental History
• Profile patient’s current life situation
– Marital status, family, education, job
– Family history invaluable
– Conflicts, losses, self view, etc.
• Recent changes in patient’s life
• Patterns & events shaping development
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Social & Developmental History
• Substance abuse and/or domestic violence
• Social factors related to psychological symptoms:
– Loss: personal due to death or desertion
– Conflict: interpersonal within family, work
– Change: adolescence, menopause, senescence
– Maladjustment: home, work
– Stress: unexpected event or chronic problem
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Social & Developmental History
• Isolation: not due to any recent loss, change
• Failure or frustrated expectations: patient’s
life’s goals not realized (e.g. failure at
school, loss of job, non promotion).
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Mental Status
• Appearance: Grooming, attention to dress,
motor activity (quiet versus agitated).
• General level of consciousness: Alert,
sleepy, stuporous, obtunded.
• Orientation: Person, place, time, purpose
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Mental Status
• Speech: Ability to use customary syntax. Note
slurring, inability to find the right word, pressured
speech, flight of ideas, looseness of association,
muteness.
• Memory: Recent memory-knows recent events,
capacity to remember names of current treating
physicians. Remote memory-ability to give past
medical history.
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Mental Status
• Attention and concentration: Ability to
understand and follow questions or instructions.
• Intelligence: Can be estimated from level of
schooling achieved, vocational history, use of
language.
• Mood: Pervasive,sustained emotion described by
patient (anger, anxiety, etc.).
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Mental Status
• Affect: An observable and immediately expressed
emotion (anger, anxiety, sadness, fear, humor,
etc.). Is affect consistent with content of speech,
thoughts, and behavior?
• Suicidal thoughts: Statements or actions that
indicate the patient wishes to harm or kill himself.
• Homicidal or violent thoughts: harm or kill others
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Mental Status
• Perceptions: Presence of hallucinations
(visual, auditory, or somatic perceptions
occurring without external stimuli),
delusions (fixed beliefs which are false),
paranoid ideas, or persistent phobias (fears
directed toward specific objects or
situations).
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Mental Status
• Judgment: Capacity to understand one’s
current situation and/or to demonstrate
appropriate compliance with instructions for
care.
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Coping Responses
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•
•
•
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Denial
Rationalization
Regression
Projection
Displacement
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Recognizing Family Co-morbidity
• Assume co-morbidity with chronic
problems:
– Alcoholism
– Affective disorders
– Anxiety disorders
– Somatoform disorders
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Determining Competence
• Competence and incompetence
– Legal terms, restricted to formal judicial
determinations
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Determining Competence
• Decision-Making Capacity
– Capacity to comprehend information
relevant to decision
– Capacity to choose re: personal values and
goals
– Capacity to communicate (verbally or
nonverbally) with caregivers
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Determining Competence
• Commitment Laws
– Most states require physician examination
to determine whether the patient is of
danger to self or others
– not necessarily psychiatrist
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Formulation of Mental Impairment
• Five-Axis Approach (APA)
– Axis I:
• Psychosocial syndrome(s)
• Conditions not attributable to a formal
mental disorder e.g. malingering,
uncomplicated bereavement, noncompliance
with medical treatment, academic or
occupational problems, etc
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Formulation of Mental Impairment
• Axis II: Personality disorders or styles and
specific developmental disorders.
• Axis III: General medical conditions
• Axis IV: Psychological and environmental
problems.
• Axis V: Global Assessment of Functioning;
current level and highest level for at least a few
months during past year.
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Summary
• Systematic approach is needed
– History
• Developmental
• PMH, medications, alcohol / substance abuse
• Marital, family, job history
• Recent events, changes, losses
– Mental status examination
• FP’s can care for many psychiatric problems
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References:
• American Psychiatric Association: Diagnostic
and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV). Wash DC, American
Psychiatric Association, 1994.
• Cadoret RJ: In: Cadoret RJ, King LJ (eds):
Psychiatry in Primary Care. St. Louis, CV Mosby,
1983. Chap 2.
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