1. ----------Ambulatory Mental Health---------- Mental Health Assessment In The Ambulatory Setting Thomas E. Franklin, D.O.

2. ----------Ambulatory Mental Health---------- 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

3. ----------Ambulatory Mental Health---------- 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

4. ----------Ambulatory Mental Health---------- 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.

5. ----------Ambulatory Mental Health---------- 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

6. ----------Ambulatory Mental Health---------- 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

7. ----------Ambulatory Mental Health---------- 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).

8. ----------Ambulatory Mental Health---------- 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

9. ----------Ambulatory Mental Health---------- 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.

10. ----------Ambulatory Mental Health---------- 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.).

11. ----------Ambulatory Mental Health---------- 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

12. ----------Ambulatory Mental Health---------- 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).

13. ----------Ambulatory Mental Health---------- Mental Status Judgment: Capacity to understand one’s current situation and/or to demonstrate appropriate compliance with instructions for care.

14. ----------Ambulatory Mental Health---------- Coping Responses Coping Responses Denial Rationalization Regression Projection Displacement

15. ----------Ambulatory Mental Health---------- Recognizing Family Co-morbidity Assume co-morbidity with chronic problems: –Alcoholism –Affective disorders –Anxiety disorders –Somatoform disorders

16. ----------Ambulatory Mental Health---------- Determining Competence Competence and incompetence –Legal terms, restricted to formal judicial determinations

17. ----------Ambulatory Mental Health---------- 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

18. ----------Ambulatory Mental Health---------- Determining Competence Commitment Laws –Most states require physician examination to determine whether the patient is of danger to self or others –not necessarily psychiatrist

19. ----------Ambulatory Mental Health---------- 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

20. ----------Ambulatory Mental Health---------- 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.

21. ----------Ambulatory Mental Health---------- 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

22. ----------Ambulatory Mental Health---------- 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.