Another excellent podcast from Rob over at ERCAST – current issues in emergency medicine, reviews, opinion and curbside consults
When you examine a patient who presents with a mental health complaint, let’s say they are depressed and psychotic, how do you do it? Do you listen to their lungs and heart, check for pitting edema? You might, if the history dictates. We are also responsible for a medical screening exam, but regarding the focused mental health part of the exam, what do you look for and how do you document it? There are all sorts of different ways to go about it, but one I find particularly useful is the mental status exam. Not alert and oriented times 3 or GCS 15 mental status exam, but the one that goes by the title Mental Status Exam.
It’s an exam that is carried out by your powers of observation. There is no stethoscope, no palpation involved. You are just watching and listening. What we’re going to go through is my adaptation of the full Mental Status Exam. It’s been tweaked, added, subtracted, and modified over the years and I’ve found it helps to break down the aspects of a patient’s appearance and behavior in a way that makes sense (at least to me). As I was putting this podcast together, I thought about some of the dogma that goes into any structured evaluation, meaning: these are the core elements of the exam and that’s all there is to it; it’s always been done this way and this is the best way. But there really is no evidence that performing a mental status exam in one particular way versus another improves outcome. The same could be said for many parts of the physical exam. Much like the suicide risk assessment template I use, I see this as a way to make sense of what is often an incredibly complex emergency department presentation.
ED Mental Status Exam
The constituent elements are: Mood, affect, eye contact, attending to internal stimuli, thought process and content, speech pattern, grooming, and presence or absence of suicidal ideation. Let’s break that down piece by piece.
Mood and affect. These terms are confusing because they are synonyms and don’t they kind of mean the same thing? Think of it this way: mood is how the patient tells you they’re feeling and affect is what you observe. For example, mood: I am anxious, I am depressed, I am crawling out of my skin, etc. Affect: what do you observe about their emotional state. Do they appear anxious, depressed, flattened, blunted, restricted, is their affect exaggerated? Is it congruent with their mood and the current situation?
Eye contact. Do they look you in the eye, are they engaged in the conversation? Are they withdrawn and looking down/away?
Attending to internal stimuli. This is something we usually equate with a psychotic state: auditory and/or visual hallucinations. It’s being generated by their mind as opposed to an external force. Sometimes it’s pretty clear. They’re intently looking around in an empty room or carrying on a conversation when there’s no one there. Sometimes it can be more subtle and only manifested as inattentiveness with latency in answering a question or following an instruction (although that latency can have many other causes).
Thought process and content. Is their thought pattern organized or disorganized? Are there delusions or obsessions?
Speech. Is it normal content and cadence? Pressured? Super loud or super soft? Is it tangential? Tangential speech is often categorized as a thought process because it is a variant of disorganized thought, but I put it here because it’s such a distinct speech pattern.
Grooming: Well kempt? Disheveled? Clothing encrusted with urine and feces?
Suicidal ideation: Present, absent, passive, active with a plan?
There are many other parts of the full Mental Status Exam, but those are the high yield aspects that I use, or at least start with. Some things like ‘insight’ I put in the suicide risk assessment, because that takes an involved conversation with more direct engagement to tease out, rather than easily observe.
Putting it all together.
A person who is having no issues at all, completely normal exam.
Mood, baseline and neutral per patient. Affect, neutral and congruent with mood. Eye contact good. He does not appear to be attending to internal stimuli. Thought process and content normal. Answers all questions appropriately. Speech is normal content and not tangential. Grooming well kempt. Suicidal ideation denies.
Or a psychotic patient may have an exam that looks something like this.
Mood is depressed. Affect flattened. Poor eye contact. He appears to be attending to internal stimuli and is looking about the room during our conversation. He periodically turns his head to the side and yells obscenities. Thought process is disorganized and there are several seconds of latency in answering questions. There is a delusion of persecution where the patient reports being followed by the government. Speech is slowed cadence, tangential, and he gives answers that are not always relevant to the question. Grooming disheveled. Suicidal ideation: Patient does not answer questions regarding this, but presents after attempting to jump of an overpass.
This evaluation will be different for every patient and the findings aren’t always easy to describe, but I find that having a standard framework makes assessment consistent, exponentially easier, and more thorough.