Mental state examination

The mental state examination is a tool that can be used to gain an understanding of a person’s experiences in relation to their mental health status at a particular moment in time. It is considered as part of a holistic approach when supporting individuals with their health and wellbeing. The tool offers parameters for clinicians to understand mental health disorders and can be used as part of a comprehensive, person-centred assessment. It considers both the subjective narrative of the individual being assessed and the objective observations made by the clinician (Evans et al, 2019). The tool can be used as part of the initial assessment, and can then form the content of pre-assessment information at subsequent applications throughout a persons’ recovery journey (Assadi, 2020).

Findings should be considered alongside information gained from observations and assessments made outside of the mental state examination, so that there is a thorough understanding and evaluation of the signs and symptoms of a mental health disorder or crisis. This must include cultural and intercultural context (Crawford et al, 2017), as well as family and carer reflections, considering

Before conducting a mental state examination, the clinician should understand what the tool entails. The mental state examination consists of nine main domains that guide the clinician in ascertaining the presence of a mental health disorder or decline in mental health status. The nine domains are:

1. appearance
2. behaviour
3. speech
4. mood and affect
5. thought (form and content)
6. perception
7. cognition
8. insight
9. judgement

When considering the use of the mental state examination, the clinical must reflect on the following key points:

• Does the assessing clinician have a basic knowledge of the current symptomatic and diagnostic criteria of mental health disorders and referral routes to secondary care?
• What impact will the environment have on the mental state examination? Is there a quiet and private space available to gather personal, subjective views? What considerations are needed if the environment is less than ideal?
• Does the assessing clinician have the skills to manage potential risk? Is

The clinician should prioritise the development of therapeutic rapport by beginning with introductions and gaining consent. Effort should be made to create a partnership approach (Davis and Day, 2010), so the assessment should be conducted as part of a conversation to develop trust and understand the individual’s views of their experiences from a subjective perspective (Assadi, 2020).

Effective communication is paramount to the application of the mental state examination. Skilful application of a variety of communication techniques is required, such as using:

• open questions
• affirmations
• reflections and summaries
• semi-structured interviews
• adaptability in the use of verbal and non-verbal communication (Miller and Rollnick, 2013; Norman and Ryrie, 2017)

The mental state examination can be used when working with individuals across their lifespan, necessitating adaptations in how the clinician communicates. Ultimately, the clinician should be guided by the individual and their communication preferences or ability (Kwame and Petrucka, 2021).

The assessing clinician

When considering the use of the mental state examination, the clinician must have a basic understanding of mental health diagnosis. Without this, clinicians may struggle in the synthesis and evaluation of information, leading to omissions or misidentification of the need to escalate or consult with a mental health clinician (Burton et al 2010; Assadi, 2020).

The assessing clinician is analysing information about an individual, and when a therapeutic rapport has been established, the individual may be sharing complex personal information that may increase the risk level. The assessing clinician should be aware of this before commencing a mental state examination to ensure the environment in which the assessment is taking place is adequate. Where appropriate, support from other clinicians should be sought.

Additionally, in the literature and clinical practice, the way in which the mental state examination is organised or applied may differ (Evans, 2019; Assadi, 2020).

Before assessing the mental state of an individual, observing and reading about the use of mental state examination by other experienced practitioners is important when it comes to understanding mental health disorders and the application of mental state examination in your clinical area. This will enable clinicians to make an evidence-based decision to use the mental state examination as part of the assessment process. There may be variations to the structure of the examination, such as presenting the assessment in a checklist format (Whittard, 2020), via the use of a mnemonic (Mansel and Bradley-Adams, 2017; Evans et al, 2019), as part of a wider assessment process guided by best practice (National Institute for Health and Care Excellence, 2011), or specific clinical or local policies and procedures.

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 1: Procedures for assessing people’s needs for person-centred care

1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages:

1.1 mental health and wellbeing status
1.1.2 signs of mental and emotional distress or vulnerability

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Burton N, Stockman T, Chopdar C, Nair A, Pillinger T. The mental state examination. International Journal of Clinical Skills. 2010;4(1):9–13

Crawford T, Candlin S, Roger P. New perspectives on understanding cultural diversity in nurse–patient communication. Collegian. 2017;24(1):63-69. https://doi.org/10.1016/j.colegn.2015.09.001 

Davis H, Day C. Working in partnership: the family partnership model. 2nd edn. London: Pearson Education; 2010

Evans K, Nizette D, O’Brien A, Johnson C. Psychiatric and mental health nursing in the UK. London: Elsevier; 2019

Kwame A, Petrucka PM. A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward. BMC Nurs. 2021;20:158. https://doi.org/10.1186/s12912-021-00684-2 

Mansel B, Bradley-Adams K. ‘I AM A STAR’: a mnemonic for undertaking a mental state examination. Mental Health Practice. 2017;21(1):21-26. http://doi.org/10.7748/mhp.2017.e1214 

Miller WR, Rollnick S. Motivational interviewing: helping people change. New York: Guilford Publications; 2013

National Institute for Health and Care Excellence (NICE). Common mental health problems: identification and pathways to care. 2011.