Mental state assessment

Bias, Stigma and Discrimination

People with mental illness experience discrimination and difficulties accessing necessary treatment. An interviewer needs to be aware of their own values and beliefs and how this may influence a mental state assessment. If a health professional notices their decision-making is affected by a negative attitude toward the patient, they should seek assistance from a senior colleague. ( Box 20.1.1 ).

ABCs of the mental state examination

At the point of triage, initial risk assessment should be conducted to identify any imminent and/or life-threatening risks to the patient or staff. The triage nurse and treating doctor should obtain a brief collateral history from emergency services and/or significant others and devise an initial treatment plan in order to ensure the safety of the patient, staff and others in the ED. Regardless of risk or patient behaviour, all assessments and interventions should balance the safety of patient and staff with respect and dignity.

The ABC of Mental Health Assessment is based on :

• A ppearance, affect and mood

• B ehaviour

• C ommunication, conversation and cognition

If the situation is relatively controlled, the formal mental health assessment should then take place. Further information is gathered from community-based resources such as a general practitioner. A provisional assessment and management plan is developed in conjunction with the mental health team and appropriate disposition is arranged ( Fig. 20.1.1 ).

Triage

The Mental Health Triage Scale ( Table 20.1.1 ) has been developed and modified to be included in the Australian Triage Scale (ATS). It provides symptom and behavioural descriptors for the triage nurse to determine the level of risk or urgency required to manage risks such as suicide and self-harm, violence and absconding. It is also important for the triage nurse to determine whether the patient is intoxicated, as this is a significant contributing risk factor. From this, the triage nurse determines the ATS category, urgency of initial treatment and most appropriate clinical area for the patient to receive further treatment. Having timely access to the patient’s clinical file with reference to previous psychiatric history, risk and past behaviours is also helpful. The local mental health service may be able to provide further information or tell you whether the patient is known to them.

Many hospital EDs have developed a triage risk-assessment form or screening tool. For ease of use, many of these have included ‘tick box’ areas designed to identify risk factors for dangerous behaviour. A compilation of multiple assessment tools used throughout Australia is shown in Boxes 20.1.2 to 20.1.4 .

It is recommended that any patient who presents as a high or imminent risk be seen in a timely manner. Some EDs have teams specifically assigned to respond to high-risk behavioural disturbance in a co-ordinated and standardized manner. These teams may include a mental health clinician, security or police, depending on the resources available to the hospital. As a last resort, the use of sedation or restraint may be required and used according to legislation and local policy. A collaborative approach to assessment and treatment by ED and mental health clinicians will help to ensure a streamlined and safe pathway of care through an often chaotic and congested department.

Introduction

The central components to a psychiatric assessment are the patient history and the mental state examination (MSE).

Taking a patient’s history requires gathering all the relevant details pertaining to the patient’s current presentation to the ED and doing this succinctly. Obtaining a history enables the clinician to identify what the problem is; the nature, duration and severity of any symptoms; and what has precipitated the presentation to the ED at this time. While taking a history, it is imperative to observe and listen, demonstrating empathy, establishing rapport and endeavouring to develop a collaborative approach to treatment. Using skills of observation, listening and enquiry, the clinician can construct an MSE in order to identify possible diagnoses and risks. By identifying the main problem or problems and themes in the first few minutes of the interview, the ED clinician can identify the possible diagnosis and then focus the questioning on exploring this further.

The environment in which the MSE is conducted is an important consideration. Behaviourally disturbed people are often fearful and overwhelmed; they may find the highly stimulating environment of an ED to be threatening. The interview space should be quiet and private, making the patient feel safe, and the interviewer should avoid interruptions as much as possible. These prerequisites are difficult to attain in an increasingly busy ED. Wherever appropriate, the interviewer should sit at the same level as the patient, although depending on the context or level of risk, standing may be reasonable. The interviewer must demonstrate respect, genuineness and empathy. His or her voice should be quiet and calming, especially when seeking to calm the hyper-aroused patient. The interviewer should use non-judgmental language and open-ended questions. It is important that the interviewer also feel safe and secure. If any risk is felt, the interviewer should have security or police present in the room or just outside. The interviewer may ask to have the patient searched for items of potential risk, according to legislation and hospital policy; this may include weapons or medications that the patient is at risk of ingesting. The interviewer should also note the nearest duress alarm and may choose to wear a personal alarm if available. The interviewer should sit within easy access of an exit and should never be boxed into a corner. If the interviewer begins to feel uncomfortable, there is always the option of leaving and returning to complete the assessment at a later stage. All threats, attempts and gestures suggestive of violence should be treated seriously.