1. Mental Status Examination Always attempt to ask the patient for permission to obtain collateral information from family members, G.P., friends, roommates, or coworkers. These are all potential sources of valuable information regarding the pt’s baseline mental status and functioning. If a patient refuses to give consent and is certified, the goal is to obtain pertinent information from third parties that will help to make clinical decisions but DON'T REVEAL any information regarding the patient or details of their admission.

2. Brief introduction: Introduce yourself; educate the patient on how long and the process of the assessment. ID: Age, living situation (home, on the streets), relationship status, financial status (employed, social assistance) Chief Complaint/Reason For Referral (ROF): Elicit the patient’s understanding of the ROF. Compare it to the referring physician’s ROF. Be mindful of any discrepancies. Keep it open ended!

3. HPI: Current episode: Onset, Duration, Course, Impact on function, Baseline (When was last well?) Ask about stressors, and why presenting now (in ER) Always screen for mood disorders (both MDD and BPD, anxiety disorder, psychotic features and substance use (see below). Current treatment (medications and psychotherapy and response), Current mental health care providers Past episodes, previous diagnoses,

4. Psychiatric History: (may overlap with HPI) Diagnosis, Hx of hospitalizations, mental health care providers Previous med trials and efficacy, and side effects Current Substance use/abuse and history Family Psychiatric History: Bipolar, Depression, Suicide, Psychosis, Substance

5. Medical History/Surgical History: Traumatic Head Injury, Seizure disorder, thyroid disorders. LMP if premenopausal Medications: If on any psychiatric meds, ask about adherence and their views on taking meds. Allergies: Note reactions.

6. Personal History: **Should include if time permits, can defer in an emergency setting. Early Childhood Experiences: How would you describe your early childhood? How was your relationship with your parents? How about with your siblings? How about your peers? History of trauma or abuse: Has anybody ever done anything to you against your will? (Indirect) or Have you ever suffered any physical, verbal or sexual abuse? (Direct) Level of education and employment history: How far along in school did you go? Don’t assume people have graduated!!! What was school like for you? Any difficulties?

7. R elationship status and history of past relationships: (establish pattern): "Are you currently involved in a romantic relationship with anyone?" If they have a partner, “How would you describe the status of your relationship?” Sexual history: If relevant. E.g if taking SSRI Legal Involvement: Have you ever had problems with the law?" Any arrests, charges? On probation?

8. What are the top Don’ts when conducting a psychiatric interview? 1. Don't turn the interview into a checklist., 2. Don’t give false reassurance (“Everything is going to be okay”). 3. Don’t lead the patient. For example, don’t frame questions in the negative, For example, “You don’t have thoughts of suicide, do you? Suggest to the patient that there are right or wrong answers. 4. Don’t give premature advice. (“You smoke 2 packs/ day. You know that’s really bad for you.”) 5. Don’t be judgmental. Watch your verbal cues and nonverbal cues.

9. What are some ways to approach sensitive/threatening topics? 1. Use normalizing questions to decrease a pt’s sense of embarrassment. For example, “Many of patients who’ve told me that their anxiety causes them to drink more to help them calm down, have you found that to be beneficial? 2. Use symptom exaggeration to determine the actual frequency, How many cigarettes do you smoke a day? 3-4 packs? 3. Reduce guilt: Use familiar language when asking about behaviors. If they say “speedball”, use that term too. 4. Gentle assumptions What sort of drugs do you use when drinking?

10. What are some ways to terminate the interview? You can end with “Is there anything I’ve missed that would help me understand your concerns?” Give feedback to the pt, address pt’s concerns and answer their questions. Establish the next step (e.g. follow up with G.P, psychiatrists, contacts for psychotherapy groups etc)

11. Mental Status Exam What are the components of the Mental Status Exam? You can use the mnemonic “ASEPTIC ” to help you remember the different components (taken from TO Notes). Only include current mental status. If pt reported hallucinating before admission, do not include it here but in the HPI.

12. A: Appearance/Behavior: Examples include: well groomed vs. unkempt, tattoos, cuts, bruises, slashes on body, eye contact, agitation or psychomotor retardation, any unusual mannerisms, any evidence of EPS *** Must include the following: Accessibility (were you able to get information or was pt guarded/psychotic) Reliability (was the information accurate, e.g. compared to old chart, collateral) Rapport : Was good rapport was established.

13. S: Speech: Describes how the patient speaks, rather than the content Quantity: Logorrhea (incessant talking), poverty of speech, mute Fluency: Dysarthria, Stuttering, Stammering, Aphasic, Pressured Response latency: Latency to respond

14. E: Emotional State: Subjective mood ( in patient’s words): Sad, bored, agitated, lonely. Could rate …/10 Objective (Affect is what you observe): Changes in affect with certain topics, range (flat, restricted, blunted, reactive to labile), appropriate… P: Perception: Hallucinations (AH, VH, OH, TH, GH) Derealization (feeling reality has changed or surroundings altered, seen in psychotic, panic attacks and dissociative disorders) Depersonalization (feeling self or environment is unreal, usually under stress) Did pt appear to be responding to internal stimuli, even if they denied hallucinations?

15. T : Thought Form: Goal directed, Coherent vs. Disorganized: (Tangential, circumstantial, flight of ideas (seen in mania, loosening of associations seen in disorganized schizophrenia) Concrete vs Abstract T: Though Content: Delusions: Highlight different themes: grandiose, reference, religious, erotomanic. Idea of reference Thought broadcasting, insertion, withdrawal Obsession Magical Thoughts Paranoia

16. C:Cognition: Need to know educational level. Can assess orientation, STM, LTM, attention and concentration, calculations, basic Canadian geography MMSE and MOCA are appropriate tools, if time permits.

17. Mini-Mental Status Exam Mini-Mental Status: 5 ponts: orientation to time/place (5 pts, year, season, month, day, day of week; 5 points: country, province, city, hospital, floor), 3 points: memory (3 pts, honesty, tulip, black; 3 points: delayed recall, 5 points: attention/concentration, (serial 7s, or “WORLD” backwards), 3 points: language tests: comprehension (three point command), 1 point: reading (“close your eyes”), 1 point: writing (complete sentence), 1 point: repetition (“no ifs, ands or buts”), 2 points: naming (watch, pen), 1 point: spatial ability (intersecting pentagons).

18. Multiaxial Diagnoses Axis I Clinical Disorders (may be >1) Axis II Personality disorder, Mental retardation Axis III General Medical Condition (potentially relevant to the mental disorder) Axis IV Psychosocial & Environmental Problems (which may affect the diagnosis, treatment or prognosis of the mental disorder) Axis V Global Assessment of Functioning (GAF): Psychological, social & occupational functioning on a hypothetical continuum of mental health-illness, on a scale 0-100.

19. Most common Axis I Diagnoses 1. Mood Disorder (MDD, Dysthymic Disorder, Depressive Disorder NOS, BDI, BD II, Cyclothymic Disorder, BD NOS, Mood Disorder due to GMC, Substance-Induced Mood Disorder, Mood Disorder NOS) 2. Anxiety Disorder (Panic Disorder +/- Agoraphobia, Specific Phobia, Social Phobia, OCD, PTSD, Acute Stress Disorder, GAD, Anxiety Disorder due to a GMC, Substance-Induced Anxiety Disorder, Anxiety Disorder NOS) 3. Psychotic Disorder (Schizophrenia, Schizophreniform Disorder, Schizoaffective Disorder, Delusional Disorder, Brief Psychotic Disorder, Shared Psychotic Disorder, Psychotic Disorder due to a GMC, Substance-Induced Psychotic Disorder, Psychotic Disorder NOS, Mood or Anxiety Disorder with psychotic features)

20. Depression Mood Disorders: Depressed mood: (MSIGECAPS) Mood/Anhedonia,Sleep,Guilt,Energy,Concentration and Cognition,Appetite,Psychomotor Agitation Suicide and Homicidal Ideation Mania, Elevated mood:(GST PAID) Gradniose, Sleep, Pleasurable Activities, Irritable, Do you feel you thoughts are faster then normal/Distractable.

21. Psychosis Hallucinations: Have you been particularly sensitive to sounds or colors lately? Have you been able to pick up on noises that other people can’t hear? Have you heard any voices that other people can’t hear? Do you think that it is your imagination or real? Have you seen anything that other people can’t see? How about any odd or new smells? Delusions: Open with :Has anything unusual been happening lately? Have people been noticing you more than usual lately? how about str angers?

22. Psychosis cont-d: Have there been any special messages or signs for you - like on tv or when your reading? Paranoia: Have you had the sense that you are being watched or followed? Do you worry that someone wants to harm you? Is anyone trying to interfere in your life? E.g someone tapping your phone, opening your mail?

23. Cases... 1. First year university student, 9 weeks pregnant, considering abortion. Take a history and counsel. Findings: tearful, guilty, sleep disturbance, has not engaged social supports. 2. 48 year old woman complains of “diseased stomach.” Has had negative investigations by several other doctors. Take a history and perform a mental status examination. Q: Without looking at the patient again, describe her appearance. What is your diagnosis? 3. 60 year old woman with multiple pains investigated by several other doctors, all lab tests normal. Manage.

24. Cases... 4. 16-year old female in hospital for ASA overdose. Medically cleared. 5. 37-year old male. 1 week hyperactivity, histrionic, spending spree, bizarre behavior. Take a history. 6. 35-year old woman feels depressed. Manage. 7. 30-year old male, married with 2 children. Brought in by police for violent and dangerous behavior. Take a history. Q: Would you admit this patient? What are the criteria for a Form 1?

25. The END... QUESTIONS????