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In the consultation, a GP has to make an initial assessment of the nature and severity of the problem and the risk to the individual and other people. The GP then formulates an initial management plan. The patient's concerns need to be taken seriously. Respect and empathy will help to build trust.
For many people presenting with mild psychiatric problems in primary care, it will not be necessary to explore every detail of the full psychiatric assessment outlined below. Often the initial priority is to develop a rapport and demonstrate a caring, supportive approach which can be further developed in future consultations.
The more experience GPs develop in dealing with patients with mental health problems, the easier it will become to pick up on non-verbal clues. As soon as they enter the consulting room, observe the patient's degree of personal grooming and hygiene and whether they make eye contact on greeting. Note whether they are appropriately dressed for the time of year and whether they are accompanied (indicating possible social support) or have come alone.
In more severe presentations of psychiatric illness, the priority is to assess quickly and minimise risk and to ensure appropriate access to mental health care resources as quickly as is necessary and appropriate.
- Identity, including marital status, education, occupation, cultural and spiritual identity.
- Presenting complaint: elucidate the patient's priorities. Use open-ended questions but quickly narrow down on the diagnosis and look for supporting evidence. Find out:
- The nature of the problem.
- The date of onset and whether the onset was slow or sudden.
- Why and precisely how the person presented at this time.
- What precipitated the problem.
- The severity and its course and effect on work and relationships, as well as physical effects on appetite, sleep and sexual drive.
- Previous episodes, including dates, treatments and outcomes of similar episodes.
- The description of the problem will also enable an assessment of the patient's insight into their situation. Some patients may deny the existence of a problem and it may be necessary to obtain a history of the illness from a family member or close friend.
- Personal history: should cover many aspects of the individual's life, from early childhood. It should include:
- Work history: jobs held, reasons for changing jobs, level of satisfaction with employment and ambitions. Assess what effect the illness will have on their job.
- Marital history and also relationship history with others (intimate or sexual relationships). Establish whether there is anyone they currently feel able to confide in.
- Family history: close family, including names, ages and their past and present mental and physical health.
- Illegal activities/violence: criminal record and any previous episodes of violence or other acts of aggression.
- Present social situation: establish what support they currently have at home.
- Premorbid personality: note how the individual would describe his or her personality before becoming unwell. Establish the patient's overall mood or temperament - ie anxious, obsessional, solitary or social. If necessary, include detail on:
- Character traits.
- Religious and moral beliefs.
- Ambitions and aspirations.
- Social relationships with family, friends, workmates.
- Alcohol and illicit drug misuse (past and present)..
- Full current drug history (prescribed medications, self-prescribed, or recreational).
Mental state assessment
- See separate Mini Mental State Examination (MMSE) article and the related Screening for Cognitive Impairment and Screening for Depression in Primary Care articles.
- Appearance and behaviour: appearance, motor behaviour and attitude to situation and examiner.
- Speech: rate, volume, quantity of information; disturbance in language or meaning.
- Mood and affect: mood (eg, depressed, euphoric, suspicious); affect (eg, restricted, flattened, inappropriate).
- Content of thought: delusions, suicidal thoughts, amount of thought and rate of production, continuity of ideas.
- Perception: hallucinations, other perceptual disturbances (derealisation; depersonalisation; heightened/dulled perception).
- Cognition: level of consciousness, memory (immediate, recent, remote), orientation (time, place, person), concentration: serial 7s, abstract thinking.
- Insight: extent of the individual's awareness of the problem.
Assessing suicidal intent
See separate Suicide Risk Assessment and Threats of Suicide article.
- The risk of self-harm is increased if:
- The patient is pessimistic or feels hopeless.
- There is a previous history of self-harm or no social support.
- Ask whether things are so bad at the moment that they have thought about ending their life and whether they think there is a real chance that they would attempt this.
- Establish whether they have made any preparations and plans and whether they have decided how they would end their life.
- Ask what has stopped them from killing themself up to now.
Physical examination and investigations
- To exclude physical (organic) causes for current mental problems.
- Investigations (eg, blood tests for anaemia, B12 deficiency, TFTs or syphilis serology) may be required depending on the presentation.
Further reading and references
Guide to Mental and Neurological Health in Primary Care; World Health Organization, 2004
Mental Health; Royal College of General Practitioners