What to Expect: A Guide to Understanding a Mental Health Assessment

Every provider has different ways of assessing and evaluating their clients. The following are the elements of the things covered in an initial psychiatric evaluation with Carrie Hill, CARN-AP, PMHNP-BC.

Prior to your first appointment there are clinical forms to be completed. The basic forms that every patient completes are 3 consent forms, 7 screening tools, and 1 clinical history assessment. Let’s review each of these. 

3 CONSENT FORMS:

1) Medical Informed Consent

A medical consent form serves a crucial legal and ethical purpose in healthcare. Essentially, it documents a patient's informed agreement to receive a specific medical treatment, procedure, or for the release of their medical information. The core principle is "informed consent." This means the patient has been provided with comprehensive information about:

     * The nature of the proposed treatment or procedure.

     * The potential benefits and risks involved.

     * Alternative treatment options.

     * The right to refuse or withdraw consent at any time.

The form serves as evidence that this information has been communicated and understood.

2)      Notice of Privacy Practices

Medical privacy notices, often referred to as Notices of Privacy Practices (NPPs), are documents required under the HIPAA Privacy Rule. They inform individuals about how their personal health information may be used and shared by health care providers and health plans. These notices also outline patients' rights regarding their health information, such as the right to access their records, request corrections, and understand how their data is protected.

3)      Late Cancellation/No-Show Policy 

A late cancellation/no-show policy is a set of rules that businesses and service providers implement to address situations where patients:

 * Late Cancellation: Cancel an appointment with insufficient notice (less than 24 hours).

 * No-Show: Fail to show up for a scheduled appointment without any prior notification.

A late cancellation/no-show policy is a way for businesses to protect their time and resources, while also setting clear expectations for their patients.

7 SCREENING TOOLS:

1. Adverse Childhood Experiences (ACEs)

The ACE screening tool is used to assess an individual's exposure to Adverse Childhood Experiences (ACEs).

   * These are potentially traumatic events that occur in childhood (0-17 years).

   * They can include various forms of abuse (physical, emotional, sexual), neglect (physical, emotional), and household challenges (such as parental divorce, substance abuse, or violence).

The primary goal is to identify individuals who have experienced ACEs.

This identification allows healthcare providers and other professionals to understand the potential impact of these experiences on a person's health and well-being.

   * Knowing ACE scores can help in providing more informed and sensitive care.

Research has shown a strong link between ACEs and increased risk for numerous health problems, including:

      Mental health disorders (depression, anxiety, PTSD)      Substance use

      Chronic diseases (heart disease, diabetes)                      Social problems

In essence, the ACE screening tool is a valuable instrument for recognizing and addressing the long-term consequences of childhood trauma.

2.      Trauma Questionnaire

A trauma questionnaire is a tool designed to assess an individual's history of traumatic experiences and/or the symptoms they may be experiencing as a result of those experiences.

   * To help mental health professionals diagnose conditions like post-traumatic stress disorder (PTSD) or complex PTSD (CPTSD).

   * To guide treatment planning and monitor progress.

Types of Information Collected:

   * Exposure to traumatic events: asks about experiences such as physical or sexual abuse, accidents, natural disasters, or witnessing violence.

3.      Patient Health Questionnaire-9 (PHQ-9)

The PHQ-9 is a widely used tool for screening and monitoring depression.

Purpose: a brief, self-administered questionnaire designed to measure the severity of depression symptoms.

What it Measures: The frequency of nine key depression symptoms over the past two weeks, based on the criteria for major depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

The PHQ-9 is a valuable tool for primary care physicians, mental health professionals, and researchers.

It provides a standardized way to assess depression symptoms and helps guide treatment decisions.

The PHQ-9 is a simple yet effective tool that plays a significant role in the identification and management of depression.

4.      Generalized Anxiety Disorder-7 (GAD-7)

The GAD-7, or Generalized Anxiety Disorder 7-item scale, is a widely used self-report questionnaire designed to screen for and measure the severity of generalized anxiety disorder (GAD).

Purpose: It's a tool used by healthcare professionals to identify individuals who may be experiencing GAD. It also helps to assess the severity of anxiety symptoms.

It is a useful tool for monitoring the progression of anxiety symptoms, and the effectiveness of treatment.

In summary, the GAD-7 is a brief and effective tool for screening and measuring the severity of generalized anxiety disorder.

5.      The Mood Disorder Questionnaire (MDQ)

The Mood Disorder Questionnaire (MDQ) is specifically designed to assess symptoms related to mania and hypomania, which are key indicators of bipolar disorder. More specifically, it looks at: Manic and Hypomanic Symptoms.

 The questionnaire contains a series of questions that explore whether an individual has experienced periods of time when they felt unusually "high," irritable, or had significant changes in their energy, sleep, thinking, and behavior.

Symptom Co-occurrence: It also assesses whether these symptoms tend to occur together.

Functional Impairment: It inquires about whether these symptoms have caused problems in the person's life, such as difficulties at work, in relationships, or with other daily activities.

Essentially, the MDQ aims to identify individuals who may be experiencing or have experienced a cluster of symptoms consistent with bipolar disorder. It's crucial to remember that the MDQ is a screening tool, and a positive result necessitates a thorough evaluation by a mental health professional for an accurate diagnosis.

6.      ADHD Self-Report Scale (ASRS)

The ASRS v1.1 refers to the Adult ADHD Self-Report Scale, version 1.1.

Purpose: It's a self-report questionnaire designed to screen for symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) in adults.

It helps to identify individuals who may require further evaluation for ADHD.

The ASRS v1.1 consists of 18 questions that assess symptoms related to inattention and hyperactivity/impulsivity.

The ASRS v1.1 is a valuable tool for quickly assessing the likelihood of adult ADHD, prompting further professional evaluation when necessary.

7.      The Columbia-Suicide Severity Rating Scale (C-SSRS)

The Columbia-Suicide Severity Rating Scale (C-SSRS) is a crucial tool used to assess suicide risk.

Purpose: It's designed to evaluate suicidal ideation (thoughts) and behavior.

It helps determine the severity and immediacy of suicide risk.

It aids in identifying the level of support an individual requires.

It uses straightforward, plain-language questions, making it accessible for various users.

It differentiates between suicidal ideation and suicidal behavior.

It allows for the assessment of the intensity of ideation, from "wish to be dead" to "active suicidal ideation with specific plan and intent."

It helps to identify if someone has taken any actions to prepare to end their life.

The C-SSRS is a vital instrument for identifying and addressing suicide risk, ultimately aiming to save lives.

1 CLINICAL HISTORY FORM:

A thorough history that covers life stressors, an overview of physical systems and symptoms, substance use history and treatment, history of self-harm or violence, past medical and psychiatric history, allergies, family background, developmental history, educational background, social history, current and past medication trials, and other treatments attempted.

In conclusion, a mental health assessment consists of multiple steps to gain a thorough understanding of your mental health. Prior to your initial appointment, you are required to fill out three consent forms, seven screening tools, and one clinical history evaluation. These documents and tools assist your provider in gaining a better understanding of your circumstances, allowing them to create a detailed and tailored treatment plan to support your mental well-being.

Assessment