What happens during a mental health assessment?

mentally illness

If you suspect you have a mental illness, you should see a doctor who will conduct a mental health assessment, generally called a history and mental status examination. This assessment aims to document the reported problem and surrounding facts in order to make an accurate diagnosis and provide treatment options. Many patients fear that just being assessed will end in their being hospitalized, but this is rarely the case unless the patient is a danger to himself or others.

Mental Health History

After the doctor has introduced herself, and attempted to create a rapport with the patient, a patient’s history is taken. This starts with identifying data like sex, religion, and the patient’s name. The mental health history moves on to documenting the patient’s chief complaint, often documented in the patient’s own words. The history of the present illness is the next part of the mental health assessment. This is the main part of the interview. The history of the present illness includes things like medication allergies, substance abuse issues, and, of course, specific mental illness symptoms. It also aims to answer the question as to why the patient is seeking help now. This part of the assessment can be seen as the patient’s story. Then the medical and psychiatric history of the patient is taken. This is a list of all medical problems both past and present. This also includes things like a medication and surgical history. A family and social history of the patient is obtained as well. Family history can be one of the biggest red flags when diagnosing a mental illness and a social history, including details about work, school, and housing, can indicate the severity of a mental illness.

The Mental Status Examination

A mental status examination is then undertaken. Part of this examination happens from the time the patient walks into the room as it includes everything from appropriate dress, (for example, is the patient wearing 3 layers in the middle of summer?) to affect, speech, and the attitude towards the doctor. The questions asked during this part of the mental health assessment attempt to find out about things like: Insight, thought processes, judgment, impulsivity and reliability

Other Diagnostic Evaluations

In addition to these parts of the mental health assessment, there is typically a physical exam and additional tests, such as blood work and neuropsychological test. These tests are done often as a part of a differential diagnosis (in other words, used to rule out other possible diagnoses).

Mental Health Treatment Plan

The outcome of the mental health assessment is a treatment plan. This treatment plan may include additional tests, medication, therapy, referrals, education, inpatient or outpatient care, and recommendations regarding complications.

While many people are intimidated by doctors and even the idea of a history and mental status examination, really, it is a step-by-step process that should not scare the patient. People may find answering the questions asked during a mental health assessment difficult, but these answers are important in diagnosing and treating any illness. A mental health assessment includes a medical and personal history, a mental status examination, and other diagnostic evaluations.


Natasha Tracy




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