The Psychiatric History and Mental State Examination

Psychiatry is unique among medical specialties in that the primary diagnostic instrument is the clinical interview. Unlike cardiology or respiratory medicine, there is no single laboratory test or imaging modality that confirms most psychiatric diagnoses. The systematic collection of a psychiatric history and the performance of a Mental State Examination (MSE) form the bedrock of psychiatric assessment, diagnosis, treatment planning, and risk management.

In Australian general practice and emergency medicine, mental health presentations are among the most common and most time-consuming consultations. General practitioners manage the majority of mental health conditions in Australia, with approximately 12.5% of all GP encounters involving a mental health-related diagnosis.

Australian Epidemiology

According to the Australian Bureau of Statistics (ABS) National Study of Mental Health and Wellbeing (2020–2022):

• 43% of Australians aged 16–85 years have experienced a mental disorder at some point in their lifetime.
• 22% of Australians had a 12-month mental disorder, with anxiety disorders (17%) being the most prevalent class, followed by affective disorders (8%) and substance use disorders (3.3%).
• Suicide was the leading cause of death for Australians aged 15–44 years in 2022, with 3,249 deaths registered — a rate of 12.5 per 100,000 population.
• Aboriginal and Torres Strait Islander Australians die by suicide at approximately twice the rate of non-Indigenous Australians.
• Mental health conditions cost the Australian economy an estimated 0–220 billion annually (Productivity Commission, 2020).

A thorough psychiatric history follows a systematic structure. The interview should ideally be conducted in a quiet, private environment with adequate time allocated (45–60 minutes for a comprehensive initial assessment). Begin with open-ended questions and progress to more specific enquiries as the clinical picture emerges.

Presenting Complaint

Document the presenting complaint in the patient's own words. Explore the history of presenting complaint using a biopsychosocial framework:

• Onset: Acute vs. insidious; date of onset; precipitating factors
• Course: Episodic, continuous, or progressive; any previous episodes
• Duration: How long have symptoms been present?
• Severity: Impact on daily functioning, work, relationships, and self-care
• Treatment to date: Previous and current treatments, response, and adherence

Mood Assessment

Systematically screen for depressive and manic symptoms:

• Depression screen: Low mood, anhedonia, hopelessness, guilt, worthlessness, suicidal ideation, sleep disturbance (early morning wakening), appetite/weight change, reduced energy, poor concentration, psychomotor retardation or agitation
• Mania/hypomania screen: Elevated or irritable mood, decreased need for sleep, grandiosity, pressured speech, racing thoughts, increased goal-directed activity, reckless behaviour (spending, sexual disinhibition), flight of ideas
• Validated tools: Patient Health Questionnaire-9 (PHQ-9), Mood Disorder Questionnaire (MDQ) for bipolar screening

Anxiety Assessment

Screen across the anxiety spectrum:

• Generalised anxiety: Excessive worry, restlessness, fatigue, muscle tension, irritability, sleep disturbance, difficulty concentrating
• Panic attacks: Sudden onset of intense fear with palpitations, sweating, trembling, dyspnoea, chest pain, dizziness, derealisation, fear of dying or losing control
• Specific phobias: Excessive fear of specific objects or situations (heights, needles, flying, animals)
• Social anxiety: Fear of scrutiny or embarrassment in social situations
• Agoraphobia: Avoidance of situations where escape might be difficult
• Validated tools: Generalized Anxiety Disorder 7-item scale (GAD-7), Kessler Psychological Distress Scale (K10)

Psychotic Symptoms

Enquire directly about positive and negative psychotic symptoms:

• Positive symptoms: Auditory hallucinations (voices), visual hallucinations, paranoid or grandiose delusions, thought insertion, thought broadcasting, thought withdrawal, passivity phenomena
• Negative symptoms: Alogia, avolition, affective flattening, social withdrawal, anhedonia
• Disorganisation: Tangential or incoherent speech, bizarre behaviour, disorganised thought
• Always distinguish between hallucinations (perceptions without external stimulus) and delusions (fixed false beliefs not amenable to contrary evidence)

Substance Use History

Systematic substance use assessment should cover all major substance classes:

Personal and Social History

A comprehensive personal and social history provides the biographical context essential for understanding the patient's presentation:

• Developmental history: Birth complications, developmental milestones, childhood behavioural problems, learning difficulties
• Educational history: Level of education, academic performance, school exclusions or truancy
• Relationship history: Marital/relationship status, domestic violence, sexual history
• Occupational history: Current employment, occupational functioning, history of job losses
• Forensic history: Criminal charges, incarceration, violence history
• Family psychiatric history: Mental illness in first-degree relatives (especially mood disorders, psychotic disorders, suicide)
• Abuse and trauma history: Childhood abuse (physical, sexual, emotional), neglect, adult trauma, PTSD screening
• Social supports: Living situation, social network, cultural and spiritual supports
• Current medications: Psychiatric and non-psychiatric, including over-the-counter and complementary medicines
• Allergies: Medication allergies and previous adverse drug reactions

The following overview covers the major psychiatric disorder categories encountered in Australian clinical practice. Diagnosis is based on DSM-5-TR (American Psychiatric Association, 2022) or ICD-11 (World Health Organization, 2019) criteria, applied within the context of a thorough psychiatric history and mental state examination.

Mood Disorders

Major Depressive Disorder (MDD)

Characterised by discrete episodes of depressed mood and/or loss of interest or pleasure, lasting at least two weeks, with associated neurovegetative symptoms (sleep, appetite, energy, concentration, psychomotor changes) and functional impairment. Prevalence in Australia: approximately 8–10% lifetime risk.

• Diagnostic criteria (DSM-5): ≥5 of 9 symptoms for ≥2 weeks, including at least depressed mood or anhedonia
• Severity: Mild (5–6 symptoms, minimal impairment), Moderate (symptoms and functional impact between mild and severe), Severe (most symptoms, marked impairment, possible psychotic features)
• Key differentials: Bipolar disorder (screen for prior mania/hypomania), hypothyroidism, medication-induced (beta-blockers, corticosteroids, interferon), adjustment disorder

Bipolar Disorder

Characterised by episodes of mania (Bipolar I) or hypomania (Bipolar II) alternating with depressive episodes. Lifetime prevalence approximately 1–2% in Australia. Misdiagnosis as unipolar depression is common — always screen for prior manic or hypomanic episodes.

• Mania: ≥7 days of elevated/irritable mood with ≥3 associated symptoms (grandiosity, decreased sleep, pressured speech, flight of ideas, distractibility, increased goal-directed activity, excessive involvement in risky activities); may require hospitalisation
• Hypomania: ≥4 days, same symptoms but less severe, no hospitalisation required, no psychosis, no marked functional impairment

Anxiety Disorders

Anxiety disorders are the most prevalent class of mental illness in Australia (12-month prevalence ~15–17%). The anxiety disorders include:

Psychotic Disorders

Psychotic disorders are characterised by disruptions to thinking and perception that impair the individual's sense of reality. The lifetime prevalence of psychotic disorders in Australia is approximately 3%.

• Schizophrenia: ≥6 months of characteristic symptoms (delusions, hallucinations, disorganised speech, negative symptoms, grossly disorganised/catatonic behaviour); significant functional decline. Peak onset: males 18–25, females 25–35.
• Schizoaffective disorder: Concurrent mood episodes and schizophrenic symptoms; both present for majority of illness duration
• Brief psychotic disorder: Psychotic symptoms lasting 1 day to 1 month with full return to premorbid functioning
• Delusional disorder: Non-bizarre delusions for ≥1 month without other prominent psychotic symptoms
• First-episode psychosis: A psychiatric emergency in Australia — early intervention services (e.g., EPPIC in Victoria) aim for assessment within 72 hours of referral

Somatic Symptom and Related Disorders

Previously termed "somatoform disorders," these conditions are characterised by prominent somatic symptoms associated with disproportionate thoughts, feelings, and behaviours:

• Somatic symptom disorder: One or more distressing somatic symptoms with excessive health-related anxiety, disproportionate time/energy devoted to symptoms, persisting for >6 months
• Conversion disorder (functional neurological symptom disorder): Neurological symptoms (weakness, tremor, gait disturbance, seizures, sensory loss) not explained by neurological disease
• Illness anxiety disorder: Preoccupation with having or acquiring a serious illness; minimal somatic symptoms; excessive health-related behaviours
• Factitious disorder: Intentional production of symptoms motivated by assumption of the sick role

Organic Brain Disorders

Organic (secondary) psychiatric conditions arise from identifiable medical or substance-related aetiologies and must always be excluded:

Substance Misuse Disorders

Substance use disorders are defined by DSM-5-TR as a pattern of use leading to clinically significant impairment or distress, manifested by at least 2 of 11 criteria within a 12-month period. Severity is classified as mild (2–3 criteria), moderate (4–5), or severe (≥6).

• Dual diagnosis: The co-occurrence of a substance use disorder and another psychiatric disorder is the norm rather than the exception. Approximately 60–80% of individuals with a substance use disorder have a comorbid mental health condition, and vice versa.
• Assessment: Use validated screening tools — AUDIT (alcohol), DAST-10 (drugs), ASSIST (WHO Assist — all substances)
• Treatment: Integrated treatment of both conditions simultaneously is the gold standard in Australia, as outlined by the RANZCP and the Australian Government's National Drug Strategy

The Mental State Examination (MSE) is the systematic observation and documentation of the patient's current psychiatric state at the time of assessment. It is the psychiatric equivalent of the physical examination. The MSE should be recorded using standardised terminology that is understood by all mental health professionals in Australia.

Appearance

Document the patient's general appearance upon first meeting. Key descriptors include:

• Physical: Apparent age vs. chronological age, height, weight (BMI), nutritional status, signs of self-harm (scars, burns), signs of substance use (track marks, nasal septum perforation, dental erosion)
• Dress and grooming: Appropriateness for context, cleanliness, grooming, cosmetics, unusual or eccentric clothing
• Psychomotor activity: Retardation (depression, parkinsonism), agitation (anxiety, akathisia, mania, psychosis), catatonia (immobility, posturing, waxy flexibility, mutism, stereotypies, echolalia/echopraxia)

Behaviour

Behaviour is observed throughout the interview. Key observations include:

• Rapport: Quality of therapeutic relationship; cooperative, guarded, hostile, evasive, overly familiar
• Eye contact: Normal, reduced (depression, anxiety, autism), intense (mania, paranoia)
• Non-verbal communication: Gestures, facial expressions, body language, mirroring
• Response to examination: Compliance, resistance, suspiciousness

Speech

Speech is assessed both through content and form:

• Rate: Slow (depression, sedation, parkinsonism), normal, rapid/pressured (mania, anxiety, stimulant use)
• Volume: Quiet/whispered (depression, auditory hallucinations), normal, loud (mania, hearing impairment)
• Spontaneity and latency: Spontaneous, responsive, minimal spontaneous speech; increased response latency (depression, cognitive impairment)
• Rhythm and prosody: Monotone (depression, negative symptoms of schizophrenia, autism), dysprosodic (Parkinson's disease, right hemisphere lesions)

Mood and Affect

This is one of the most commonly confused domains of the MSE:

Thought Form and Content

Thought Form (the "how" of thinking)

Disturbances in the form of thought include:

• Flight of ideas: Rapidly shifting between topics with loose connections — mania, anxiety
• Tangentiality: Responses diverge from the question and never return
• Circumstantiality: Responses include excessive unnecessary detail but eventually return to the point
• Loose associations: Shifts between unrelated topics without logical connection — schizophrenia
• Neologisms: Made-up words with personal meaning — schizophrenia, aphasia
• Thought blocking: Sudden cessation of speech mid-sentence — schizophrenia
• Perseveration: Repetition of words or ideas — organic brain disorders, severe depression
• Word salad: Incoherent, jumbled speech with no discernible meaning — severe schizophrenia

Thought Content (the "what" of thinking)

• Delusions: Fixed, false beliefs not amenable to contrary evidence. Types: persecutory, grandiose, referential, erotomanic, somatic, nihilistic, jealous, control/passivity
• Overvalued ideas: Unreasonable beliefs held with less intensity than delusions, but influencing behaviour (e.g., anorexia nervosa, body dysmorphic disorder)
• Obsessions: Intrusive, repetitive, ego-dystonic thoughts (e.g., contamination, harm, symmetry)
• Suicidal and homicidal ideation: Must be assessed directly in every MSE (see Suicide Risk Assessment below)
• Preoccupations: Recurrent themes of concern (health, finances, relationships)

Perception

Disturbances of perception are divided into:

• Hallucinations: Perceptions without an external stimulus. Categorised by modality:
  • Auditory — most common in schizophrenia; voices commenting, conversing, commanding; may be ego-syntonic or ego-dystonic
  • Visual — more common in organic states, delirium, substance use, Lewy body dementia
  • Tactile — formication (insects crawling under skin — "cocaine bugs"), somatic sensations
  • Olfactory/Gustatory — temporal lobe epilepsy, organic states
• Illusions: Misinterpretations of real external stimuli (e.g., shadows perceived as figures)
• Depersonalisation: Feeling of detachment from one's self or body
• Derealisation: Feeling that the external environment is unreal or dreamlike

Cognition

Cognitive assessment is covered in detail in the section below. At minimum, document:

• Orientation: Time (date, day, month, year, season), place (building, city, state, country), person (own name, names of others)
• Attention and concentration: Serial 7s, WORLD backwards, digit span
• Memory: Immediate recall (3 words), short-term (5 minutes), long-term (remote events)
• General knowledge: Current and past prime ministers, state capital

Insight and Judgement

Insight is a multidimensional concept. Assess on a spectrum:

Judgement refers to the patient's ability to make reasonable decisions about their behaviour and wellbeing. It is closely related to insight and is assessed by exploring the patient's understanding of the consequences of their actions and their ability to make safe, informed decisions. Impaired judgement may indicate the need for assessment of capacity under relevant state and territory mental health legislation (e.g., Mental Health Act 2014 in Victoria, Mental Health Act 2007 in NSW).

Cognitive Assessment

Cognitive assessment is a critical component of psychiatric evaluation, particularly when organic brain disorders (delirium, dementia) are suspected. Bedside cognitive testing should be performed whenever there is clinical concern about cognitive function. The following tools are widely used in Australian clinical practice:

Mini-Mental State Examination (MMSE)

The MMSE (Folstein, Folstein & McHugh, 1975) is the most widely used bedside cognitive screening tool globally. It assesses five cognitive domains and yields a score out of 30:

Frontal Lobe Assessment

The MMSE has limited sensitivity for frontal lobe/executive dysfunction. Supplementary bedside tests include:

Suicide Risk Assessment

The assessment of suicide risk should be systematic, thorough, and documented. Use a structured approach while maintaining a compassionate, non-judgemental clinical stance.

Systematic Risk Assessment Framework

Risk Factors for Suicide

SAD PERSONS Scale

The SAD PERSONS scale is a mnemonic screening tool used in Australian emergency and primary care settings. Each factor scores 1 point:

Safety Planning

A safety plan (Stanley & Brown model) should be collaboratively developed with every patient identified as at risk. The plan includes:

1. Warning signs that a crisis may be developing
2. Internal coping strategies (things the patient can do on their own)
3. Social contacts and settings that provide distraction
4. People to contact for help (family, friends, supports)
5. Professionals and agencies to contact in a crisis (Lifeline 13 11 14, Beyond Blue 1300 22 4636, Suicide Call Back Service 1300 659 467, 000 for emergency)
6. Making the environment safe (means restriction)

Mandatory Reporting and Duty of Care

Under Australian common law and state/territory mental health legislation, clinicians have a duty of care to act on identified suicide risk. This includes:

• Assessing and documenting risk at every contact
• Implementing least restrictive interventions consistent with safety
• Communicating risk to the treating team and relevant stakeholders
• Considering involuntary assessment or admission under state/territory Mental Health Act when indicated
• Notifying relevant authorities as required by mandatory reporting obligations (e.g., child protection, elder abuse)

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