The Importance of Assessment

Across clinical and research domains, mental health assessment and diagnosis are carried out using interviews and questionnaires that determine the presence, severity, frequency, and duration of a broad range of psychiatric symptoms. The question content of these assessment tools is often based on classification systems that we have previously discussed, notably the DSM-5 and/or ICD, where pre-defined patterns of symptom criteria have been grouped together and designated as specific mental health disorders. Their design ranges from more open-ended, clinician-led interviews typically used to make a formal psychiatric diagnosis (e.g., The Structured Clinical Interview for DSM Disorders (SCID), to more quantitatively designed auxiliary questionnaires (e.g., The Patient Health Questionnaire  (PHQ-9) that provide multidimensional assessments of symptom experience and severity to support diagnosis and treatment evaluation in clinical practice. These interviews are used to investigate underlying etiologies and treatment effectiveness in clinical trials and academic research studies.^[1]

Figure 1. Patients may be asked various questions about their mental health to help reach a diagnosis.

When an individual begins therapy, collateral information is also collected about personal, occupational, or medical history, such as from records or from interviews with parents, spouses, teachers, or previous therapists or physicians. Many psychologists do some level of assessment when providing services to clients or patients, and may use for example, simple checklists to assess some traits or symptoms, but psychological assessment is a more complex, detailed, in-depth process. Typical types of focus for psychological assessment are to provide a diagnosis; to assess a particular area of functioning or disability, often for school settings; to help select a type of treatment or to assess treatment outcomes; to help courts decide issues such as child custody or competency to stand trial; to help assess job applicants or employees; or to provide career development counseling or training.

A top -perspective of this landscape of mental health assessment reveals a huge range of interviews and questionnaires available for use. This diversity of choice means there is no shortage of options when searching for assessment tools for clinical use or to suit the needs of a clinical research study. However, this diversity can also make it a real challenge to decide which questionnaire(s) or interview(s) to select for clinical diagnosis or evaluation. For example, there have been more than 280 different questionnaires developed over the last century to assess symptoms of depression that differ in terms of which iteration of the DSM they align to; the degree to which they consider co-morbid symptoms; whether they are computer-based or paper-based; and whether they are self-rated, parent-rated or clinician-led. Knowing which questionnaire to choose to obtain a suitable assessment of an individual’s mental health is therefore not always a straightforward exercise for even the most experienced researcher or clinician.

The Clinical Interview

The clinical interview is the most widely used means of assessment. A clinical interview is a face-to-face encounter between a mental health professional and a patient in which the professional observes the patient and gathers data about the person’s behavior, attitudes, current situation, personality, and life history. The interview may be unstructured, in which open-ended questions are asked; structured, in which a specific set of questions according to an interview schedule are asked; or semi-structured, in which there is a pre-set list of questions but clinicians are able to follow up on specific issues that catch their attention.

Unstructured Interview

An unstructured interview or non-directive interview is an interview in which questions are not pre-arranged. These non-directive interviews are considered to be the opposite of a structured interview that offers a set amount of standardized questions. They tend to be more informal and free flowing than a structured interview, much like an everyday conversation. The chief feature of the unstructured interview is the idea of using probing questions aimed at determining the client’s reason for being in treatment, symptoms, health status, family background, and life history that are designed to be as open as possible. Open-ended questions that have no prepared response choices enable and empower the client to shift the direction of the interview and to bring in unanticipated information. It can require a skillful clinician to bring a talkative respondent back on topic, or to help a client end an awkward silence. However, these open-ended questions give the ability for the respondent to reply about a topic that neither the interviewee nor the interviewer may have thought about before. Some evidence shows that using open-ended questions in interviews results in greater reporting of sensitive subjects, such as domestic violence, or socially disapproved behavior than when closed-ended questions on a self-reporting questionnaire are used. A typical clinical interview will cover the following:

• age and sex
• reason for referral
• education and work history
• current social situation
• physical and mental health history
• drug/alcohol use and current medication
• family history
• behavioral observations

Structured Interview

A structured interview (also known as a standardized interview) can provide a diagnosis or classify the client’s symptoms into a DSM-5 disorder. The aim of this approach is to ensure that each interview is presented with exactly the same questions in the same order. This aim ensures that answers can be reliably aggregated. The Structured Clinical Interview for DSM-5 Disorders (SCID-5) is one of the most widely used clinical interviews. It is a diagnostic exam and covers the diagnoses most commonly seen in clinical settings.

Both of these methods (unstructured and structured) have their pros and cons. A highly unstructured interview and informal observations provide key findings about the patient that are both efficient and effective. A potential issue with an unstructured, informal approach is that  the clinician may overlook certain areas of functioning or not notice them at all. Or they might focus too much on presenting complaints. The highly structured interview, although very precise, can cause the clinician to make the mistake of focusing a specific answer to a specific question without considering the response in terms of a broader scope or life context. They may fail to recognize how the patient’s answers all fit together.

As mentioned above, a semi-structured interview is another option. In this situation, the clinician follows a general outline of questions designed to gather essential information, but is free to ask the questions in any particular order and to branch off into other directions to follow up on relevant information.

There are many ways that the issues associated with the interview process can be mitigated. The benefits to more formal standardized evaluation types such as batteries and tests are many. First, they measure a large number of characteristics simultaneously. These include personality, cognitive, or neuropsychological characteristics. Second, these tests provide empirically quantified information. The obvious benefit to this is that we can more precisely measure patient characteristics as compared to any kind of structured or unstructured interview. Third, all these tests have a standardized way of being scored and being administered. Each patient is presented with a standardized stimulus that serves as a benchmark that can be used to determine their characteristics. These types of tests eliminate any possibility of bias and produce results that could be harmful to the patient and cause legal and ethical issues. Fourth, tests are normed. This means that patients can be assessed not only based on their comparison to a “normal” individual ,but how they compare to the rest of their peers who may have the same psychological issues that they face. Normed tests allow the clinician to make a more individualized assessment of the patient. Fifth, standardized tests that we commonly use today are both valid and reliable. We know what specific scores mean, how reliable they are, and how the results will affect the patient.

Most clinicians agree that a balanced battery of tests is the most effective way of helping patients. Clinicians should not become victims of blind adherence to any one particular method. A balanced battery of tests allows there to be a mix of formal testing processes that allow the clinician to start making their assessment while conducting more informal, unstructured interviews with the same patient may help the clinician to make more individualized evaluations and help piece together what could potentially be a very complex, unique-to-the-individual kind of issue or problem.

Mental Status Examination (MSE)

Mental status examination, or MSE, is a medical process where a clinician working in the field of mental health (usually a psychotherapist, social worker, psychiatrist, psychiatric nurse, or psychologist) systematically examines a patient’s mind and the way they look, think, feel, and behave. It is an important part of the clinical assessment process. It is a structured way of observing and describing a patient’s psychological functioning at a given point in time under the domains of appearance, attitude, behavior, and mood and affect speech, thought process, thought content, perception, cognition, insight, and judgment. There are some minor variations in the subdivision of the MSE and the sequence and names of MSE domains.

The purpose of the MSE is to obtain a comprehensive, cross-sectional description of the patient’s mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis and formulation, which are required for coherent treatment planning. The data are collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information, focused questions about current symptoms, and formalized psychological tests.

The MSE is a core skill of qualified (mental) health personnel. It is a key part of the initial psychiatric assessment in an outpatient or psychiatric hospital setting. It is a systematic collection of data based on observation of the patient’s behavior while the patient is in the clinician’s view during the interview. The purpose is to obtain evidence of symptoms and signs of mental disorders, including danger to self and others, that are present at the time of the interview. Further, information on the patient’s insight, judgment, and capacity for abstract reasoning is used to inform decisions about treatment strategy and the choice of an appropriate treatment setting. It is carried out in the manner of an informal inquiry, using a combination of open and closed questions, supplemented by structured tests to assess cognition. The MSE can also be considered part of the comprehensive physical examination performed by physicians and nurses, although it may be performed in a cursory and abbreviated way in non–mental-health settings. Information is usually recorded as free-form text using the standard headings, but brief MSE checklists are available for use in emergency situations, for example by paramedics or emergency department staff. The information obtained in the MSE is used, together with the biographical and social information of the psychiatric history, to generate a diagnosis, a psychiatric formulation, and a treatment plan.

The MSE accesses behavioral and cognitive functioning. Behavioral components include appearance and general behavior, level of consciousness and attentiveness, motor and speech activity, mood and affect, thought and perception, attitude and insight, and the reaction evoked by the examiner. Cognitive components include alertness, language, memory, constructional ability, and abstract reasoning. There are many versions of MSE that differ around the world, but there is a broad commonality and goal in constructing an overall picture of a patient’s mental health.