----------Ambulatory Mental Health---------- Mental Health Assessment In The Ambulatory Setting...

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Mental Health Assessment In Mental Health Assessment In The Ambulatory SettingThe Ambulatory Setting

Thomas E. Franklin, D.O.

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

IntroductionIntroduction

• 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

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

ObjectivesObjectives

• 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

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Information GatheringInformation 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.

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Social & Developmental HistorySocial & 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

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Social & Developmental HistorySocial & 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

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Social & Developmental HistorySocial & 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).

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Mental StatusMental Status

• Appearance: Grooming, attention to dress, motor activity (quiet versus agitated).

• General level of consciousness: Alert, sleepy, stuporous, obtunded.

• Orientation: Person, place, time, purpose

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Mental StatusMental 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.

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Mental StatusMental 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.).

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Mental StatusMental 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

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Mental StatusMental 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).

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Mental StatusMental Status

• Judgment: Capacity to understand one’s current situation and/or to demonstrate appropriate compliance with instructions for care.

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Coping ResponsesCoping Responses

• Denial

• Rationalization

• Regression

• Projection

• Displacement

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Recognizing Family Co-morbidityRecognizing Family Co-morbidity

• Assume co-morbidity with chronic problems:

– Alcoholism

– Affective disorders

– Anxiety disorders

– Somatoform disorders

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Determining CompetenceDetermining Competence

• Competence and incompetence

– Legal terms, restricted to formal judicial determinations

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Determining CompetenceDetermining 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

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Determining CompetenceDetermining Competence

• Commitment Laws

– Most states require physician examination to determine whether the patient is of danger to self or others

– not necessarily psychiatrist

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Formulation of Mental ImpairmentFormulation 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

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

Formulation of Mental ImpairmentFormulation 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.

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

SummarySummary

• 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

----------Ambulatory Mental Health--------------------Ambulatory Mental Health----------

References: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.