An overview of the importance of mental health assessment, the different types of assessments used, and the key principles guiding the assessment process.
Introduction to Mental Health Assessment
Designed as a quick‑reference guide for students, clinicians, and anyone interested in the basics of mental‑health evaluation.
| Aspect | Description |
|---|---|
| Definition | A systematic process of gathering information to understand a person’s emotional, cognitive, and behavioral functioning. |
| Purpose | • Identify psychiatric diagnoses • Determine severity & functional impact • Guide treatment planning • Monitor progress over time |
| Setting | Outpatient clinic, primary‑care office, emergency department, community agency, tele‑health, or inpatient unit. |
| Key Principles | • Confidentiality – HIPAA/local privacy laws • Cultural competence – respect language, beliefs, and values • Trauma‑informed – assume safety, choice, collaboration • Strength‑based – focus on resilience and resources |
| Component | What It Covers | Typical Tools / Methods |
|---|---|---|
| 1. Identifying Information | Demographics, contact details, legal status, emergency contacts. | Intake forms, electronic health record (EHR). |
| 2. Presenting Problem | Chief complaint, duration, triggers, impact on daily life. | Open‑ended interview, symptom checklist. |
| 3. Psychiatric History | Past diagnoses, hospitalizations, treatments, medication trials, suicide attempts. | Structured interview (e.g., SCID‑5), timeline graphic. |
| 4. Medical & Developmental History | Chronic illnesses, surgeries, birth history, developmental milestones. | Medical record review, patient/family interview. |
| 5. Substance Use | Alcohol, nicotine, illicit drugs, prescription misuse. | AUDIT, DAST‑10, CAGE questionnaire. |
| 6. Family & Social History | Family psychiatric history, relationships, support network, housing, employment, education. | Genogram, social history questionnaire. |
| 7. Mental Status Examination (MSE) | Appearance, behavior, speech, mood/affect, thought process, thought content, perception, cognition, insight/judgment. | Observation + brief cognitive tests (MMSE, MoCA). |
| 8. Risk Assessment | Suicide, homicide, self‑harm, aggression, neglect, mania, psychosis. | Columbia‑Suicide Severity Rating Scale (C‑SSRS), HCR‑20. |
| 9. Functional Assessment | Daily living skills, work/school performance, social roles. | WHODAS 2.0, GAF, SDS. |
| 10. Strengths & Resources | Coping skills, spiritual beliefs, community ties, previous successes. | Narrative interview, resilience scales. |
| 11. Diagnostic Formulation | Synthesis of data into DSM‑5/ICD‑11 diagnoses and differential list. | Clinical judgment, structured diagnostic tools. |
| 12. Treatment Planning | Goals, interventions, referrals, follow‑up schedule. | SMART goals, care coordination checklist. |
| Tool | Target Population | Primary Use |
|---|---|---|
| SCID‑5 | Adults | Gold‑standard DSM‑5 diagnostic interview |
| MINI | Adults & adolescents | Brief, structured diagnostic screen |
| C‑SSRS | All ages | Suicide risk severity |
| PHQ‑9 | Adults | Depression severity |
| GAD‑7 | Adults | Anxiety severity |
| AUDIT | Adults |