Unit 3: Assessment Skills and Screening Tools (Weeks 6 & 7)

To understand one another we must be willing to stand together and ask hard questions, and continue to stand together once the response is given.

Overview

Once we have discovered the ways that our thinking, behaviour and feelings are altered with mental illness, it is important to carefully distinguish one illness from the other to ensure that our interventions are appropriate. This involves careful attention to assessing mental status and the signs and symptoms that influence thinking, behaviour and mood. Regular assessment of mental status and potential risk of self-harm is critical. There are numerous tools that assess mental status. For the purpose of this course we will use the Mental Status Examination (MSE) to guide our assessments and we will consider some of the many tools used to screen for mental illness, monitor mental illness, and communicate assessment findings with other members of the health care team.

435 Unit 3 from CNHS AU on Vimeo.

Unit Learning Outcomes

By the end of Unit 3 you will meet or exceed the following:

familiarize yourself with common mental health assessment/screening tools;
review in depth an assessment/screening tool that is applicable to your Community Mental Health Promotion project;
understand what is meant by the various terms used in mental health assessment, such as hallucinations, delusions, and sensorium; and,
demonstrate a mental status assessment and reflect on your assessment skills.

Reminder

During Week 6 you will conduct a mental status exam with your study buddy, please see Assessment Overview and information below for details.

Mental health is often missing from public health debates even though it's critical to wellbeing. Diane Abbott

1. Mental Status Examination (Week 6)

The Mental Status Examination (MSE) is like the head to toe assessment of mental health and is the foundation of mental health practice. The information gleaned from the MSE is considered when the physician makes a diagnosis, as well as for monitoring changes and treatment efficacy.

Required Learning Activity 1 General Assessment and Mental Status Examination

Read the chapter in your text titled, The Assessment Process

Here are MSE Guidelines that you can use in your MSE Demonstration (see learning activity 3). The following links include MSE information as well as example of how to write up the results of your MSE. National Association of Social Workers, and Positive Psychology .

General Assessment will include:

Presenting problem and precipitating factors

Current living situation

Personal and social supports

Current daily routines (attending school, employment, caregiver etc.)

History of physical and mental health challenges

General functioning

ability to carry out tasks of daily living
appetite/weight loss
sleep
mood

Prescription or OTC medication, drug and alcohol use

Watch these video examples to learn how to do a MSE:

MSE demonstration with person experiencing psychosis.MSE demonstration with person experiencing psychosis.
MSE demonstration with person experiencing depression.MSE demonstration with person experiencing depression.
MSE demonstration with person experiencing mania.MSE demonstration with person experiencing mania.

You may wish to view these additional videos:

Complete the General Assessment and MSE Demonstration (part of assignment 4)

At the outset of this course your tutor paired you with another student in your class. This person is your study-buddy for this course. Connect with your study-buddy to practice conducting a MSE; pay particular attention to how you phrase your questions. There are two client case histories available here Case history. Students will decide who will take which case.

Consult with your study-buddy by course mail to determine a time during Week 6 when you can meet in real-time on a video conferencing platform. At this meeting both students take turns assuming client roles (based on the case histories), while the other person acts as the nurse at the meeting and completes a mental status exam.

Study-buddies switch roles and repeat this process. A recording will be made and sent to you to review.

For your Skills 1 testing you will:

Conduct a General assessment and a MSE with your study buddy acting the role of client.
Write up a formal MSE as though you are charting on a health record. Please use sub-headings to organize your MSE. Appropriate descriptive terminology is required.
Review recording and write a reflection noting what went well and areas for improvement.
Submit MSE documentation and reflections of yourself to the Assignment 4 Skills Demo 1 dropbox
See the Assessment Overview for additional instructions

We need to change the culture of this topic and make it OK to speak about mental health and suicide. Luke Richardson

2. Screening and Referral Tools (Week 7)

While the MSE is the foundational assessment, screening and referral tools are used in mental health nursing to assess particular mental illnesses, or problems such as addictions or domestic violence. Examples include:

mood assessment with tools such as Beck's Depression Inventory (BDI), the Hamilton Rating Scale for Depression (HAMD), the Centre for Epidemiologic Studies Depression Scale (CES-D), and the Edinburgh Post Natal Scale (EDPS);
anxiety assessment tools such as the Holmes and Rahe Social Readjustment Rating Scale (SRRS), and the Yale Brown Obsessive Compulsive Scale; and
behaviour assessment tools including the CAGE Substance Abuse Screening Tool, and intimate partner violence or family assessment.

To further your search for assessment tools consider these collections of assessment tools:

The Family Practice Notebook - Mental Health: Examination

NOTE: If you find a link broken, try typing the website name into a search engine as an alternative means to access the information and let your course instructor know so the link can be fixed.

Required Learning Activity 3 Assessment Tool Review

Recall the topic you selected for your Community Mental Health Promotion project at the beginning of this course. Search online for a tool that is currently in use for assessing this disorder. When was it first in use? Who developed it? Can nurses use it directly or is further training required? Locate at least two scholarly research studies addressing the reliability and validity of the tool. Consider any benefits or limitations of using this tool. Post your tool and your comments about the tool in the Unit 3 Assessment Tools Forum. This learning activity will be helpful content for assignment 2, your Community Mental Health Promotion project.

Points to remember

MSE and screening tools are not diagnostic; rather they are used to assess current mental state, indicate changes in illness status, and to assess risk. A physician makes mental health diagnoses.
Risk of harm to self or others is a critical aspect of assessment and will be discussed further in Unit 5.

References

American Psychological Association. (2013). Center for epidemiological studies - depression.
http://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/depression-scale.aspx

Beck, A.T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry 4, 561-571.

Campbell, J.C., & Furniss, K.K. (2002). Violence against women: Identification, screening, and managing intimate partner violence. Association of Women's Health, Obstetrics and Neonatal Nurses.

Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786. http://www.wellmother.com/articles/edinburgh.htm

Geeky Medics (2023). Psychosis (Schizophrenia): Mental state examination. OSCE Guide. [YouTube]. https://www.youtube.com/watch?v=wlftjXHdWKo&t=6s

Geeky Medics (2023). Depression: Mental state examination (MSE). OSCE Guide [YouTube]. https://www.youtube.com/watch?v=5fK3IDR-Rp8

Geeky Medics (2023). Mania (Bipolar Disorder): Mental state examination (MSE). OSCE Guide [YouTube]. https://www.youtube.com/watch?v=3Ci-Q0J_5Fg

Goodman, W., & Price, L. et al. (1989). The Yale-Brown obsessive compulsive scale. Development use and reliability. Archives General Psychiatry, 46, 1006-1011. http://www.stlocd.org/handouts/YBOC-Symptom-Checklist.pdf

Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 56-62. Retrieved from http://healthnet.umassmed.edu/mhealth/HAMD.pdf

Holmes, T., & Rahe, R. (1967). Social readjustment rating scale. Journal of Psychosomatic Research, 11, 213-219. http://www.testandcalc.com/richard/resources/Teaching_Resource_Holmes_and_Rahe_Social.pdf

Lasiuk, G., & Hegadoren, K. (2019). The assessment process. In W. Austin and M.A. Boyd (Eds.), Psychiatric & mental health nursing for Canadian practice (4th ed.) (pp. 174-180). Philadelphia, PA: Kluwer.

Mayfield, D., McLeod, G., & Hall, P. (1974). The CAGE questionnaire: Validation of a new alcoholism instrument. American Journal of Psychiatry, 131, 1121-1123.

Nelson, H., Nygren, P., McInemy, Y., & Klein, J. (2004). Screening women and elderly adults for family and intimate partner violence: A review of the evidence for the U.S. Preventative Services Task Force.

Annals of Internal Medicine, 140(5), 387-396.

Pearth Co-occurring Disorders Capacity Building Consortium (2011). Understanding the MSE Lisa. https://www.youtube.com/watch?v=83i2MWMqph8.

Pearth Co-occurring Disorders Capacity Building Consortium (2011). Understanding the MSE Barry. https://www.youtube.com/watch?v=6ss827LbbtA.

Registered Nurses Association of Ontario. (2005). Woman abuse: Screening, identification, and initial response. Toronto, ON: Registered Nurses Association of Ontario.

Last updated: February 8, 2024 Copyright 2016 Athabasca University
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