In the consultation, a GP has to make an initial assessment of the nature and severity of the problem, the risk to the individual and other people and then to formulate an initial management plan. The patient's concerns need to be taken seriously. Respect and empathy will help to build trust.
For many people presenting with mild psychiatric problems in primary care, it will not be necessary to explore every detail of the full psychiatric assessment outlined below. Often the initial priority is to develop a rapport and demonstrate a caring, supportive approach which can be further developed in future consultations.
The more experience GPs develop in dealing with patients with mental health problems, the easier it will become to pick up on non-verbal clues. As soon as they enter the consulting room, observe the patient's degree of personal grooming and hygiene and whether they make eye contact on greeting. Are they appropriately dressed for the time of year? Are they accompanied (indicating possible social support) or have they come alone?
In more severe presentations of psychiatric illness, the priority is to assess quickly and minimise risk and to ensure appropriate access to mental health care resources as quickly as is necessary and appropriate.
- Add notes to any clinical page and create a reflective diary
- Automatically track and log every page you have viewed
- Print and export a summary to use in your appraisal
- Identity, including marital status, education, occupation, cultural and spiritual identity.
- Presenting complaint: elucidate the patient's priorities. Use open-ended questions but quickly narrow down on the diagnosis and look for supporting evidence. Find out:
- What is the nature of the problem?
- The date of onset and was the onset slow or sudden?
- Why and precisely how has the person presented at this time?
- What precipitated the problem?
- The severity and its course and effect on work and relationships, as well as physical effects on appetite, sleep and sexual drive.
- Previous episodes, including dates, treatments and outcomes of similar episodes.
- The description of the problem will also enable an assessment of the patient's insight into their situation. Some patients may deny the existence of a problem and it may be necessary to obtain a history of the illness from a family member or close friend.
- Personal history: should cover many aspects of the individual's life, from early childhood. It should include:
- Work history: jobs held, reasons for changing jobs, level of satisfaction with employment and ambitions. Assess what effect the illness will have on their job.
- Marital history and also relationship history with others (intimate or sexual relationships). Is there anyone they currently feel able to confide in?
- Family history: close family, including names, ages and their past and present mental and physical health.
- Illegal activities/violence: criminal record and any previous episodes of violence or other acts of aggression.
- Present social situation: what support do they currently have at home?
- Premorbid personality: how does the individual describe his or her personality before becoming unwell? Overall mood or temperament - ie anxious, obsessional, solitary or social? If necessary, include detail on:
- Character traits.
- Religious and moral beliefs.
- Ambitions and aspirations.
- Social relationships with family, friends, workmates.
- Alcohol and illicit drug misuse (past and present).
- Full current drug history (prescribed medications, self-prescribed, or recreational).
Mental state assessment
- See separate article Mini Mental State Examination (MMSE) and the related articles Screening for Cognitive Impairment and Screening for Depression in Primary Care.
- Appearance and behaviour: appearance, motor behaviour, attitude to situation and examiner.
- Speech: rate, volume, quantity of information; disturbance in language or meaning.
- Mood and affect: mood (eg depressed, euphoric, suspicious); affect (eg restricted, flattened, inappropriate).
- Content of thought: delusions, suicidal thoughts, amount of thought and rate of production, continuity of ideas.
- Perception: hallucinations, other perceptual disturbances (derealisation; depersonalisation; heightened/dulled perception).
- Cognition: level of consciousness, memory (immediate, recent, remote), orientation (time, place, person), concentration: serial 7s, abstract thinking.
- Insight: extent of the individual's awareness of the problem.
Assessing suicidal intent
See separate article Suicide Risk Assessment and Threats of Suicide.
- The risk of self-harm is increased if the patient is pessimistic or feels hopeless, if there is a previous history of self-harm or no social support.
- Are things so bad at the moment that they have thought about ending their life; do they think there is a real chance that they would attempt this?
- Have they made any preparations and plans? Have they decided how they would end their life?
- What has stopped them from killing themself up to now?
Physical examination and investigations
- To exclude physical (organic) causes for current mental problems.
- Investigations, eg blood tests for anaemia, B12 deficiency, TFTs or syphilis serology, may be required depending on the presentation.
Further reading & references
- Guide to Mental and Neurological Health in Primary Care, World Health Organization, 2004
- Brannon GE; History and Mental Status Examination, Medscape, Feb 2011
- Vergare M et al; Psychiatric Evaluation of Adults, Second Edition, 2009
|Original Author: Dr Colin Tidy||Current Version: Dr Laurence Knott|
|Last Checked: 22/06/2011||Document ID: 2860 Version: 22||© EMIS|
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.