Psychiatric evaluation

A psychiatric assessment is a process of gathering information about a from a person within a mental health service, with the purpose of making a diagnosis. The assesment is usually the first stage of a treatment process, but psychiatric assessments may also be used for various legal purposes. The assessment includes social and biographical information, direct observations, and data from specific psychological tests. It is typically carried out by a psychiatrist but may be a mult-discipinary process involving nurses, psychologists, occupational therapists and social workers.

Clinical assessment
A psychiatric assessment is most commonly carried out for clinical and therapeutic purposes, to establish a diagnosis and formulation of the individual's problems and to plan the individual's care and treatment. This may be done in a hospital (or in-patient) setting, in an ambulatory (or out-patient) setting, or in a community setting (as a home-based assessment). Clinical assessment is the main focus of this article.

Forensic assessment
A forensic psychiatric assessment may have a number of purposes. A forensic assessment may be required of an individual who has been charged with a crime (usually a violent crime), to establish whether the person has the capacity (in legal terms) to stand trial. If a person with a mental illness is convicted of an offence, a forensic report may be required to inform the Court's sentencing decision, as a mental illness at the time of the offence may be a mitigating factor. A forensic assessment may also take the form of a risk assessment, to comment on the relationship between the person's mental illness and the risk of further violent offences.

Medico-legal assessment
A medico-legal psychiatric assessment is required when a psychiatric report is used as evidence in civil litigation, for example in relation to compensation for work-related stress or after a traumatic event such as an accident. The psychiatric assessment may be requested in order to establish a link between the the trauma and the victim's psychological condition, or to determine the extent of pscyhological harm and the amount of compensation to be awarded to the victim.

Medico-legal psychiatric assessments are also utilized in the context of child safety and child protection services. A child psychiatrist's assessment can provide information on the psychological impact of abuse or neglect on a child. A child psychiatrist can carry out an assessment of parenting capacity, taking into consideration the mental state of both the child and the parents, and this may be used by child protective services to decide whether a child should be placed in an alternative care arrangement such as foster care.

The History
A standard part of any psychiatric assessment is the obtaining of a body of social, demographic and biographical data known as the history. The standard psychiatric history consists of biographical data (name, age, marital and family contact details, occupation and first language), the presenting complaint (an account of the onset, nature and development of the individual's current difficulties) and personal history (including birth complications, childhood development, parental care in childhood, educational and employment history, relationship and marital history, and criminal background). The history also includes an enquiry about the individual's current social circumstances, family relationships, current and past use of alcohol and illicit drugs, and the individual's past treatment history (current and past diagnoses, and use of prescribed medication).

The psychiatric history includes an exploration of the individual's culture and ethnicity, as cultural values can influence the way a person (and their family) communicates psychological distress and responds to a diagnosis of mental illness. Certain behaviours and beliefs may be misinterpreted as features of mental illness by a clinician who is from a diiferent cultural background than the individual being assessed.

The assessment often includes gathering collateral information from other sources such as family members or (with children) teachers at school.

Mental status examination
The mental status examination (or mental state examination in the UK and Australia) abbreviated MSE, is another core part of any psychiatric assessment. The MSE is a structured way of describing a patient's current state of mind, under the domains of appearance, attitude, behavior, speech, mood and affect, thought process, thought content, perception, cognition (including for example orientation, memory and concentration), insight and judgement. The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient's mental state. The data are collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information, focused questions about current symptoms, and formalised psychological tests. As with the psychiatric history, the MSE is prone to errors if cultural differences between the examiner and the patient are not taken into account, as different cultural backgrounds may be associated with different norms of interpersonal behaviour and emotional expression. The MSE is not to be confused with the mini-mental state examination (MMSE) which is a brief neuro-psychological screening test for dementia.

Physical examination
A thorough physical examination is regarded as an integral part of a comprehensive psychiatric assessment. This is because physical illnesses are more common in people with mental disorders, because neurological and other medical conditions may be associated with psychiatric symptoms, and to identify side effects of psychiatric medication. The physical examination would include measurement of body mass index, vital signs such as pulse, blood pressure, temperature and respiratory rate, observation for pallor and nutritional deficiencies, palpation for lymph nodes, palpation of the abdomen for organ enlargement, and examination of the cardiovascular, respiratory and neurological systems.

Physical investigations
Although there are no physiological tests that confirm any mental illness, medical tests may be employed to exclude any co-occurring medical conditions that may present with psychiatric symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism, basic electrolytes, serum calcium and liver enzymes to rule out a metabolic disturbance, and a full blood count to rule out a systemic infection or chronic disease. The investigation of dementia could include measurement of serum vitamin B-12 levels, serology to exclude syphilis or HIV infection, EEG, and a CT scan or MRI scan. People receiving antipsychotic medication require measurement of plasma glucose and lipid levels to detect a medication-induced metabolic syndrome, and an electrocardiogram to detect iatrogenic cardiac arrhythmias.

Assessment tools
Clinical assessment can be supplemented by the use of symptom scales for specific disorders, for example the Beck Depression Inventory for depression or the Brief Psychiatric Rating Scale for psychotic disorders. Scales such as HoNOS or the Global Assessment of Functioning are used to measure global level of functioning and to monitor response to treatment.

Multidisciplinary assessment
Psychiatric assessment in a hospital settings is typically a multidisciplinary process, with contributions from psychiatric nurses, occupational therapists, psychologists and social workers. A psychiatrist takes a history and carries out a mental state examination and physical examination as described above. A nursing assessment includes risk assessment (risk of suicide, aggression, absconding from hospital, self harm, sexual safety in hospital and medication compliance), physical health screening, and obtaining background personal and health information from the person being admitted and their carers. The immediate purpose of the nursing assessment is to determine the required level of care and supervision, and to have a plan to manage disturbed behavior. Assessment could include a visit to the person's home, for direct observation of the social and living environment. The role of a psychologist includes the use of psychological tests: structured diagnostic instruments such as the Millon Clinical Multiaxial Inventory or psychometric tests such as the WISC or WAIS, to assist with diagnosis and formulation of the person's problems. A psychologist might contribute to the team's assessment by carrying out a behavioral analysis, which is an analysis, through systematic observation, of the factors which trigger or perpetuate problematic behaviours.

Other perspectives
This article describes the assessment process within a medical model, with the collection of supposedly objective data, identification of problems, formulation of a diagnosis leading to a specific treatment, but there are other approaches to the assessment of people with social and emotional difficulties. A family therapy or systemic therapy approach is not concerned with diagnoses but seeks to understand the problem in terms of relationships and communication patterns. The systemic tradition is suspicious of the objectivity of medical assessment, sees the individual's account as a subjective narrative, and sees diagnosis as a socially constructed phenomenon. From a solution focused perspective, the assessment deliberately avoids indentification of problems, and seeks to elicit strengths and solutions.