Psychiatric history and the mental state examination

• A psychiatric assessment has two parts: a psychiatric history (what the patient tells you about symptoms, development, relationships and background) and a mental state examination (what you observe and test at the time of the interview).
• The interview is a collaborative, clinician-led conversation. It starts with the reason for presentation and moves through background domains before finishing with risk; the mental state examination is recorded alongside it, not bolted on at the end.
• Risk is assessed by risk formulation (understanding the person, the circumstances and what could keep them safe), not by a score. Low, medium and high risk labels do not predict repetition or suicide.^[1]
• Collateral from family, friends and other clinicians often changes the diagnosis and always improves safety planning; in many jurisdictions information can be taken from relatives even when the patient has not consented.^[1]
• Rating scales and structured tools are adjuncts. They track change and prompt questions, but they do not on their own decide who is offered treatment or discharged.^[1]

By the end of this topic you should be able to:

1. Prepare a suitable setting, obtain consent and explain confidentiality for a psychiatric assessment.
2. Conduct a structured psychiatric interview, moving from presenting complaint through history domains to a shared formulation.
3. Perform and document a mental state examination across appearance and behaviour, speech, mood and affect, thought, perception, cognition and insight.
4. Adapt the interview and the mental state examination for risk, culture, age, cognition and low-resource settings.
5. Gather and use collateral history ethically and safely.
6. Carry out a risk formulation, list protective factors, and draft a safety plan.
7. Choose, use and correctly limit common psychiatric rating scales and structured tools.
8. Write a psychiatric assessment that another clinician could act on.

This topic teaches the core clinical skill of psychiatric assessment: taking a psychiatric history and recording a mental state examination. It is a procedure rather than a prescription, and the patient is both the subject and the partner. The psychiatrist's job is to help a distressed person describe experiences they may never have put into words, while noticing signs they cannot see in themselves.

A psychiatric interview is not a checklist read out loud. It is usually longer than other medical interviews, it often covers areas the patient has never discussed before, and it screens for conditions such as psychosis in which lack of insight can itself be part of the illness.^[3] The skill is learned by watching others, practising under supervision, and receiving feedback, but the structure is the same in every setting from a busy emergency department to an outpatient clinic.

This procedure draws on current guidance from the Royal College of Psychiatrists (curriculum and professional guidance), the American Psychiatric Association (Practice Guideline for the Psychiatric Evaluation of Adults, 2015)^[4] and the National Institute for Health and Care Excellence (NICE guideline NG225, 2022), alongside standard texts such as the Oxford Handbook of Psychiatry. Tear it into one phrase and it is this: listen first, observe continuously, assess risk explicitly, document so the next person can work from your notes.

Indications. Any new patient in psychiatric care; any presenting complaint where psychological, behavioural or cognitive factors could matter; any presentation with self-harm, suicidal thoughts, psychosis, mania, severe depression, eating disorder, substance use, cognitive change or trauma; and any medical or surgical patient where distress, capacity or risk is in question.

Contraindications and cautions. There is no disease that contraindicates talking to a patient respectfully. Defer or modify the interview if the patient is in immediate physical danger, is too drowsy, painful or acutely confused to take part, or if proceeding would place you or the patient at risk of violence. In those situations stabilise, ensure safety and security, and return as soon as it is safe. A psychiatric interview can be conducted with family in the room if that is what the patient wants, but privacy should be offered even then.

Equipment and environment. A quiet, private space; chairs (not a desk between you); a means of recording notes; a clock; information about safeguarding and referral pathways; and, where available, validated rating scales translated into the patient's language. For remote work, a reliable connection and a pre-agreed disconnection plan are required.

A psychiatric assessment should be carried out in a private, designated area where the conversation cannot be overheard.^[1] Privacy is not a luxury; patients under-report suicidal thoughts, substance use and sexual or traumatic experiences when others might listen. Arrange the chairs so you are not behind a desk, keep a clear route to the door, and let the patient sit where they feel in control. Have paper or a screen ready for notes, but do not type through the opening minutes of the interview.

In a shared ward or clinic room, ask whether the patient would rather talk somewhere quieter, and close the door and curtains as fully as the space allows. In an emergency department, this may mean finding the quietest corner, but it still matters. Noise, interruptions and the presence of anxious relatives in earshot change what is said.

Allow more time than a general medical review. The interview cannot be rushed without losing the very information that makes a diagnosis safe. If you are working in a team, agree in advance who is the interviewer and who is observing; agree how much silence is comfortable; and agree who will speak to relatives. In teaching settings, simulated interviews with supervising psychiatrists acting as patients have been shown to improve student confidence and skills scores.^[3]

Explain your role, who you are and what the assessment is for. Take consent for the interview itself, for any examination or test, and for contacting relatives or other clinicians. Before you begin, say clearly what will stay confidential and what cannot: risk of serious harm to the patient or to others, safeguarding concerns, and legal duties in your jurisdiction. Mental capacity is decision-specific, so a patient may be able to consent to a blood test and still need support to consent to admission.

Confidentiality in psychiatry is a little more conditional than in general medicine, and patients deserve to hear that at the start, not at the end. Write down consent discussions. Where a patient lacks capacity, consult the legal framework in your country and act in their best interests, documenting your reasoning.

Some people cannot participate fully at first: they may be too distressed, intoxicated by drugs or alcohol, in pain or acutely confused. Do not wait for them to be perfectly well, but do not force a full assessment before basic needs are met. Safety comes first, then comfort, then questions. If participation is not possible, record why, provide what care you can, and return as soon as you can. The NICE guideline on self-harm recommends that intoxication should not delay psychosocial assessment, and breath or blood alcohol levels should not be used to delay it.^[1]

Tell the patient what will happen: how long it will take, that you will ask about current symptoms, background, and risk, and that you will go through everything at the end so they can correct you. Invite questions. This single step reduces anxiety and usually improves the quality of the information you receive.

A psychiatric interview is best thought of in phases: an opening, a history, a mental state examination, a risk assessment, and a summary and plan. The phases overlap. You will be observing the mental state from the first hello and assessing risk from the first answer about sleep.

Start with introductions and the question "What brings you here today?" or "What has been happening?" Let the patient speak uninterrupted for as long as they need, even if it feels long. Do not write this part; gather the story. You are listening for their own words, their own order of events, and what they think is wrong. Make eye contact. Reflect back key phrases. Make a brief note of the reason for presentation only after they pause.

After the narrative, summarise in two or three sentences what you heard and ask the patient to correct you. This is the first therapeutic act as well as the first assessment step. It shows that you listened, lets the patient correct you, and often brings out a further concern they were saving.

Once the story is clear, close the gaps systematically. Ask about the present episode in detail: onset, triggers, duration, diurnal variation, associated symptoms, and what the patient has tried. Then move through the background domains in Table 1. Change the order to suit the person, but do not skip domains: the domains you skip are usually the ones that matter.

The mental state examination is recorded at the same time, but written up as a separate section. It is what you can observe and test at that moment, in contrast to the history, which is what has happened over time. A review of teaching and research notes that mental state examinations in use worldwide contain anywhere between 6 and 18 domains, depending on tradition and purpose.^[2] The variation is a reminder that the headings are a tool for clear communication, not a ritual to be recited.

Risk assessment is described in its own section below. It should be explicit, it should be documented, and it should be discussed with the patient unless doing so would create immediate danger.

End by summarising, in plain language, what you heard, what it suggests, and what you would like to do next. Name the provisional diagnosis as a working hypothesis rather than a verdict, discuss differential diagnoses, and invite corrections. Ask whether anything has been missed or whether there is anything else they wanted to discuss. Agree a plan with dates and contact numbers. If you are referring, say what you are referring for and when the person should expect to hear.

Collateral is information from relatives, friends, carers, employers, general practitioners and other services. It exists because patients may be frightened, ashamed, lacking insight, or unable to remember, and because another person's view of change is often more reliable than a self-report made while unwell.

Collateral should be sought whenever there is diagnostic uncertainty, a first presentation, a risk question, a change from baseline, or a capacity question. Sometimes one relative interview changes the whole picture, for example when a husband describes his wife's week-long lack of sleep and spending which she experienced as happiness.

Consent and confidentiality. If the person consents, speak with relatives openly and in their presence where possible. Even when consent is withheld, family members or carers can still provide information about the person, provided you do not disclose to them anything confidential in return.^[1] Be clear about this boundary from the outset and record it. Information should be gathered tactfully: ask relatives to describe behaviour and changes, not to diagnose. A reliable formulation of collateral also distinguishes what the relative observed from what they concluded.

What to ask collateral informants:

• What changed, when it started, and how it is different from the patient's usual self.
• Sleep, energy, appetite, self-care, substance use and adherence to medication.
• Contact with others, conflicts, withdrawal, spending, driving, or unusual communications.
• Any expressed thoughts of hopelessness, self-harm, violence, or plans to end life.
• How they have already tried to help, and what they think would keep the person safe.
• Whether there are children, dependents or vulnerable adults at home.

Write collateral as a distinct subsection, attributed to the source, so the reader can weigh its reliability. Cross-cultural interviewing deserves the same care: use professional interpreters rather than relatives where possible, and check idioms of distress rather than translating vocabulary word for word.

The mental state examination is a snapshot. It records what you can see and test at the time you see the patient, including how they arrived, how they looked, and how they responded to your questions. It is the part of the assessment most often copied into the next clinician's notes, so record it in clear, neutral language and avoid jargon such as "cooperative" or "appropriate" without saying what was actually seen.

The headings used worldwide vary, and no single structure has been agreed by international consensus.^[2] The conventional English-language teaching structure, widely reproduced in textbooks and derived from the British Medical Association tradition, covers appearance and behaviour, speech, mood and affect, thought, perception, cognition and insight.^[2] A cross-cutting modern addition, argued for in recent psychiatric education literature, is to capture eating behaviour, nutritional status and body image within these existing domains rather than as a separate heading; the authors estimate this takes no more than one to two minutes when no such features are present.^[2]

Record general appearance, dress, grooming, hygiene, posture, eye contact, gait, notable physical signs, and any neurological or sensory features. Note whether appearance is consistent with age and circumstances, or whether it signals weight change, self-neglect, injury, or a deliberate attempt to hide the body. Observe psychomotor activity: restless, retarded, agitated, or normal. Note how they relate to you and to anyone else present.

Record rate, volume, rhythm and fluency, and abnormalities such as pressure of speech, poverty of speech, or speech without obvious word-finding difficulties. Distinguish speech (how the words come out) from thought (what the words are about). Slurred, rushed or very quiet speech may reflect intoxication, mania, depression, or neurological impairment.

Mood is what the patient says they feel; affect is what you see. Ask directly about mood, and ask the patient to rate it on a scale, for example 0 to 10, if that helps. Observe range, reactivity, congruence with content, and stability. Note irritability, anxiety, elation and emotional blunting. A patient who says they are fine while crying, or who does not react to bad news, tells you something either about concealment or about the condition itself.

Form is the stream of thought: whether ideas connect logically, whether they jump between topics, whether they race or slow, whether they stop suddenly, or whether the patient goes round and round the same concerns. Content is what the thoughts are about: preoccupations, obsessions, delusions, overvalued ideas, and worries. Record delusions by type (persecutory, grandiose, referential, religious, somatic, jealous, nihilistic), and note whether they are held with complete conviction. Do not accept "paranoid" as a diagnosis; write what was said.

Ask about and observe hallucinations in every modality: auditory, visual, olfactory, gustatory and somatic. Ask the patient to describe the experience in their own words, and ask whether the experience felt external and real. Ask about derealisation and depersonalisation. Elaborate hallucinations are more likely to be pathological; hypnagogic and hypnopompic phenomena in someone who is otherwise well are common. Command hallucinations that instruct the patient to harm themselves or others need an immediate risk assessment.

Screen attention and orientation first, because they colour everything else. Test orientation to person, place and time, then attention (serial sevens, months backwards, digit span), then memory (immediate, recent and remote), language, visuospatial function, executive function and reasoning. Use standard screening tools such as the Mini-Mental State Examination, Montreal Cognitive Assessment or Addenbrooke's Cognitive Examination, but remember that these are screens, not diagnoses, and are influenced by education, language, culture and sensory impairment.

Insight is not a single yes or no. Record the patient's understanding of their condition, their acceptance that treatment may help, and their willingness to accept help. Note whether any lack of insight seems to be primary (a symptom of the illness) or secondary (a consequence of stigma, denial or lack of information). Judgement refers to practical decisions the patient makes during the assessment.

The mental state examination always includes a risk focus: observed aggression, self-injury scars, scars from injection or self-harm, weight and nutritional status, behaviour in the interview, and the patient's response to questions about hopelessness. Risk is also embedded in what you hear about perception and thought content. Do not leave risk to the end as if it were a separate questionnaire; it is part of the same picture.

Risk assessment in psychiatry means understanding and managing the possibility of harm to the patient (suicide, self-harm, severe self-neglect), harm to other people, and harm from other people (exploitation, abuse). It is not a score or a label; it is a clinical formulation produced by identifying what increases risk, what reduces it, and what can be changed.

NICE is explicit that risk assessment tools and scales should not be used to predict future suicide or repetition of self-harm, and should not be used to decide who is and is not offered treatment or who is discharged.^[1] Global stratification into low, medium or high risk should not be used for those purposes either.^[1] Instead, the assessment should focus on the person's needs and on how to support their immediate and long-term psychological and physical safety, and mental health professionals should undertake a risk formulation as part of every psychosocial assessment.^[1]

• Static factors: long-standing features that cannot change (age, gender in statistical terms, past suicide attempts, family history of suicide, early adversity, permanent brain injury).
• Dynamic factors: current states that can change and that can be treated (depression, psychosis, panic, anger, intoxication, insomnia, recent loss, acute stress, access to means).
• Protective factors: reasons to live, relationships, religious or cultural beliefs, hope, care for dependents, engagement with services, and coping skills.
• Context: the situation the person is in right now, including housing, finances, legal proceedings, isolation, andcontagion (recent suicide in their family or social network).
• Plan and means: whether there is a plan, whether means are available, whether the plan is specific and feasible, and whether the person intends to act.

Ask directly and compassionately. Asking about suicide does not plant the idea. Start broad ("Have you had thoughts that life is not worth living?") and then increase specificity ("Have you thought about ending your life? Have you made a plan? Have you ever tried? When? What stopped you? Do you have the means now?"). Ask about timing and triggers, about what protective factors exist now, and about the last time they felt this way and what helped. Record the exact words where possible.

Ask about anger, resentment, jealousy, grievance, and fantasies of harm. Ask about specific people, weapons, stalking, threats, and changes in behaviour that relatives have noticed. Include risk of neglect or exploitation of dependents, not only deliberate violence. Most patients are not violent, and most violence in society is not committed by people with mental illness; your job is to identify the small subgroup in whom mental state, history and context combine to raise risk.

NICE recommends developing a safety plan together with the person. A safety plan establishes the means of self-harm and seeks to remove or restrict them, recognises the triggers and warning signs of increased distress or a suicidal crisis, identifies individualised coping strategies, identifies social contacts and settings as distractions, identifies family or friends for support, includes service and out-of-hours contact numbers, and works with the person to keep the environment safe by reducing access to lethal means.^[1] The plan should be written with and agreed by the patient, held by them, shared only with people they choose, and accessible at times of crisis.^[1]

Finish with a short written formulation in your own words, for example: "A 22-year-old student presents with a first episode of depression after bereavement, with insomnia and passive suicidal thoughts. Risk is increased by recent loss, alcohol misuse and reduced contact with friends, and reduced by a wish to finish her degree, a supportive mother and an absence of intent or plan. Plan:..." This is far more useful to the next clinician than "suicide risk: low".

Scales help; they do not decide. They are most useful for screening suspected conditions, measuring severity, and tracking change over time. A single score should never determine whether someone is admitted, treated or discharged.^[1]

When you use a scale, note the edition, the date, the scorer and the language or version, and record the score as one piece of evidence among many. Discuss results with the patient, who may understand their meaning differently from you. Be aware that scales developed in one language or culture often lose meaning when translated without local validation, and that internet or arbitrary cut-offs should not be treated as thresholds for individual decisions.

Children require age-appropriate questions, observation of play, and information from parents and teachers. Pay attention to developmental level, school, peer relationships, social media, and safeguarding concerns. NICE emphasises that children and adolescents who have self-harmed are assessed by a mental health professional experienced with this age group, with attention to their social, peer, educational and home situations.^[1]

Older adults have higher rates of physical illness, cognitive impairment, isolation and suicide after self-harm than younger adults. Pay particular attention to depression, cognitive impairment, physical health and frailty, to their social and home situation (including any caring role), to loneliness, and to the possibility that a recent physical illness is the trigger.^[1]

Adapt pace, language and method. Use accessible environments, visual supports and trusted supporters. Behavioural changes may be the main sign of distress. Where self-harm has occurred, a mental health professional experienced in assessing people with a learning disability should carry out the assessment.^[1]

Do not delay assessment solely because of intoxication, but prioritise safety. Assess physical needs first and revisit risk when the patient is clearer. People who are intoxicated may be more impulsive and less able to plan, but risk is not absent.

Use professional interpreters, brief them before the interview, and do not use relatives, especially children. Cultural norms shape how distress is expressed, how symptoms are named, and how families expect to be involved. Ask about idioms of distress ("nerves", "thinking too much") rather than literal equivalents of Western symptom names, and record what the patient actually said. Your own assumptions about culture are as important to examine as the patient's.

Remote assessment can work well, especially for follow-up and for people who cannot travel, but it restricts observation of behaviour, gait and affect. Confirm privacy at both ends, check that the patient is alone if they want to be, have a plan for disconnection, and be more explicit in summarising and checking understanding. For high-risk assessments, a remote interview is usually a supplement to, not a replacement for, a face-to-face review.

Establish who you are working for, what will be reported, and how confidentiality is limited. Record objective observation as carefully as subjective report, and coordinate with the responsible team and safeguarding leads.

Aim for notes that a tired colleague could act on at 2 am. A useful structure:

• reason for presentation and one-line summary
• psychiatric history by domain, with the patient's own words
• medical history and medication
• substance use
• forensic, personal, family and social history
• mental state examination by domain
• risk formulation, safety plan and protective factors
• collateral, attributed to source
• provisional diagnosis and differential, with reasons
• plan, including medication, psychological and social interventions, risk management, care plan, and review date

After self-harm with ongoing safety concerns, NICE recommends that the mental health team, general practitioner or responsible team provide initial aftercare within 48 hours of the psychosocial assessment.^[1] For people with frequent episodes, a multidisciplinary review should agree a joint plan, identify a coordinator and develop detailed care and safety plans.^[1] Share the plan with the patient and, with consent, with their supporters, and give them contact numbers for out-of-hours help.

• imminent suicide intent or a lethal plan with means and opportunity
• command hallucinations to harm self or others
• rapid onset of confusion, fever, withdrawal, or postnatal disturbance
• suspected neuroleptic malignant syndrome or serotonin syndrome
• severe self-neglect, refusal of essential treatment, or a dependant at risk
• psychosis in pregnancy or in the postpartum period
• anyone expressing thoughts of harming a named individual
• a carer or relative who reports a marked change from baseline that the patient denies

In any of these situations, seek senior advice, ensure close observation as arranged locally, and document decisions and the reasoning, including your uncertainty.

• Missed risk because direct questions were avoided, or because collateral was not sought. Ask directly and document what was not possible to clarify.
• Diagnostic error from accepting a label ("paranoid", "manipulative") instead of recording observations and the patient's own words.
• Over-diagnosis by interpreting cultural or religious experience, sleep deprivation or intoxication as psychosis.
• Breach of confidentiality through unthinking disclosure to relatives, carers or in open wards.
• Collusion with the patient's account against relatives, or with relatives against the patient, rather than holding both views.
• Papering over the limitations of a remote, rushed or noisy assessment.

Where interview rooms, staff or interpreters are scarce, the principles remain the same:

• find the quietest private space you can; even a curtained corner is better than a corridor
• prioritise identifying the reason for presentation, suicidal thoughts and protective factors
• use a relative or friend as an informant, but only with the limits described above
• use mobile phones for follow-up where travel is impossible
• keep a written or photographed copy of the safety plan with the patient
• use locally validated or translated tools, and avoid imported cut-offs
• know your local referral pathway and who carries the duty at night and weekends
• train all staff who meet distressed patients, not only psychiatrists, because they see people first

• A psychiatric assessment combines a history (what has happened over time) with a mental state examination (what is observed and tested now).
• The interview is collaborative and structured: opening, history, mental state examination, risk, formulation and plan.
• Cover every history domain each time; the skipped domain is usually the important one.
• The mental state examination is a snapshot and should be written in neutral, specific language.
• Global low, medium and high risk labels do not predict suicide or repetition and should not decide treatment or discharge.^[1]
• Risk assessment is a formulation of static factors, dynamic factors, protective factors, context and plan.
• Collateral can be taken from relatives even without the patient's consent, provided no confidential information is disclosed in return.^[1]
• Rating scales are adjuncts: they screen, measure and track; they do not decide.
• Psychiatric assessment should occur in a private designated space, with consent and a clear explanation of confidentiality.^[1]
• After self-harm with ongoing safety concerns, initial aftercare should be provided within 48 hours of the psychosocial assessment.^[1]
• Ask every patient about suicidal thoughts directly; asking does not create risk.
• Adapt the assessment for age, cognition, culture, language, disability and resource level.

Alcohol use disorder; anorexia nervosa; attention deficit hyperactivity disorder; autism and developmental conditions; bipolar disorder; capacity and consent; cognitive impairment and dementia; common psychiatric disorders of older adults; deliberate self-harm and suicide prevention; delirium; depressive disorders; forensic psychiatry; generalised anxiety disorder; obsessive compulsive disorder; personality disorders; post-traumatic stress disorder; psychopharmacology and monitoring; schizophrenia and related psychoses; substance use disorders.

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