Discussion Main Post Week 2

Abnormal involuntary Movement Scale (AIMS) 

Three important components of the psychiatric interview: Are to build rapport/trust with the patient, which is important because without that trust, treating a psychiatric patient can feel almost impossible… with we need to know people care to listen to their psychiatric advice. The second is to ask questions with empathy, but to be bold and blunt. This is important because patients need to know that the uncomfortable questions are not uncomfortable for us to ask as providers. The third component that is so important in the interview, is seeking the patient’s collaboration, after the trust is built, because if they are not taking ownership of their own decision making, their choices once they leave the office or telepsychiatry appointment, will be in question (Lenouvel et al., 2022).

As I was thinking about my experiences in behavioral health nursing, the Abnormal Involuntary Movement Scale (AIMS) was one scale I used to fill out in our charting with very little to report unless it was mild to moderate tremors as a side effect from taking an antipsychotic, until I ran into a patient who had a case of full blown tardive dyskinesia, and then the scale took on a whole different meaning for me. My patient was ambulating towards me with jerky, very intense full body movements that looked to me like something out of my imagination and truly scared me because of how the patient’s body moved and how much pain she seemed to be in. These movements are explained as having “no rhythm and like a repetitive dance” (Chakrabarty et al., 2023). I am not making fun or trying to characterize this is in a negative light at the patient’s expense. It absolutely broke my heart how abnormally this patients body moved, the pain they were experiencing that they told me they were used to, and that they had had this issue for years. It was embarrassing for her, but she said she had gotten used to it. This is multiple bell curves on the abnormal plus three side of things, with the other end being no abnormal movements at all.

The psychometric properties of the AIMS scale are used to decipher whether the patient’s movements are in fact a physical issue, like poorly fitting dentures, or if the abnormal movements are due to the side effects of antipsychotics. While many of the questions are appropriate to be asked as assessment questions, this may make some patients uncomfortable, however it is necessary to make sure that involuntary movements caused by medications do not become exacerbated leading to tardive dyskinesia. These involuntary movements are caused by dopamine D2 hypersensitivity (Takeuchi et al., 2022).

References

Chakrabarty, A. C., Bennett, J. I., Baloch, T. J., Shah, R. P., Hawk, C., & Natof, T. (2023). Increasing Abnormal Involuntary Movement Scale (AIMS) Screening for Tardive Dyskinesia in an Outpatient Psychiatry Clinic: A Resident-Led Outpatient Lean Six Sigma Initiative. Cureus, 15(5), e39486. https://doi.org/10.7759/cureus.39486Links to an external site.

Lenouvel, E., Chivu, C., Mattson, J., Young, J. Q., Klöppel, S., & Pinilla, S. (2022). Instructional Design Strategies for Teaching the Mental Status Examination and Psychiatric Interview: a Scoping Review. Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, 46(6), 750–758. https://doi.org/10.1007/s40596-022-01617-0Links to an external site.

Takeuchi, H., Mori, Y., & Tsutsumi, Y. (2022). Pathophysiology, prognosis and treatment of tardive dyskinesia. Therapeutic advances in psychopharmacology, 12, 20451253221117313. https://doi.org/10.1177/20451253221117313Links to an external site.

Andrew Moore Main Discussion Response

Good afternoon, Professor and class!

Boland et al. (2022) report that the psychiatric interview is the most crucial element when evaluating persons with mental illness. The essence of a psychiatric interview is to assess, identify, and diagnose specific disorders for which individuals may present. Without conducting a proper psychiatric interview, an improper diagnosis may be made, thus commencing improper treatment. While every component of the psychiatric interview is essential, there are three overarching components which must be met, including; rapport building, clinical history/ history of presenting illness, and mental status examination. Butt (2021) define rapport as the harmonious relationship relating to collaboration and parity between patient and physician. Further, the authors reported that when healthy rapport is established, it has been shown to improve compliance with treatment, clinical outcomes, and patient satisfaction. Additionally, the authors report that rapport is not just what is said, but also what is shown nonverbally, as 93% of communication occurs through non-verbal cues, including; body language and tone of voice. Without developing rapport, patients may feel uncomfortable sharing personal details about their life including sexual abuse history, trauma, and any embarrassing behaviors they may engage in.

Ascertaining clinical history and history of presenting symptoms are essential to aid in assessment and diagnosis. According to Savander et al. (2021), a clinician’s question is designed to elicit a specific symptom, however, there times when a patients’ self-disclosure provides greater insight into their subjective experience. Further, the authors report that shifting focus toward an individual’s subjective experience, often provides greater detail than merely answering the question. For instance, when a patient presents with mood lability, and a clinician investigates recent fluctuations in mood, an open-ended response can suggest their ability to have insight and understanding into their mental illness. In contrast, when a patient rebuffs such questioning, this can suggest lack of insight and awareness into their mental health. Gleaning this level of insight into a patient’s comprehension or lack thereof, will help a clinician tailor their treatment plan. When a clinician fails to identify presenting symptoms, they are in essence relying solely on their observation, ultimately, narrowing their ability to conduct a thorough assessment.

The mental state examination is as equally important during the psychiatric interview. Rocha Neto et al. (2019) report that the mental state examination (MSE) is akin to the physical examination assessment for medical evaluations, as it is described as a reliable method for gathering objective data. For medical evaluations, there are widely available biomarkers to identify disease, however, for many disorders in mental health, there are none. This emphasizes the importance of the MSE, as it aids in diagnosis by observing specific symptoms. The MSE comprises several distinguishing features including appearance, speech, mood and observed affect, thought process and thought content, cognition, and insight. Through careful consideration of each of these items, a clinician can help ascertain a patient’s appearance as being appropriate or disheveled, speech as being normal in rate and volume or pressured, mood as being euthymic or dysthymic, affect as being congruent or incongruent, thought process as linear and goal directed, or loosely connected, cognition as being alert and oriented or not, and possessing or lacking insight and awareness of their mental health. By identifying any deviations in these elements, a clinician can be more successful in achieving accurate diagnosis, and establishing a relevant and appropriate treatment plan.

Quality of Life Scale: Young Mania Rating Scale (YMRS) Young et al. (1978)

According to Hosnea (2019) the Young Mania Rating Scale (YMRS) is a universal clinical instrument used to measure symptom severity of mania. Further, the author reports this 11-item tool was introduced in 1978 by Young et al., often being regarded as the “gold standard” of symptom severity screening tools. Rabinowitz et al. (2022) report that the YMRS is an 11-item observer rated instrument with a score being determined by a brief interview. Further, the authors report the range of scoring is from 0-60 with the higher score indicating greater abnormality and presence of adverse signs and symptoms. Further, the authors report that each of the 11 items have anchor points, seven of the 11 items are scored 0-4 and in the remaining four they are scored from 0-8. The 11 items are as follows; elevated mood, increased motor activity energy, sexual interest, sleep, irritability, speech, language-thought disorder, content, disruptive-aggressive behavior, appearance, and insight. According to Rabinowitz et al. (2022), scoring of each item is broken down as follows:

• Elevated mood:
  1. 0 – absent
  2. 1- mildly or possibly increased
  3. 2 – definite subjective elevation including optimism, self-assuredness, cheerfulness, and appropriate to content
  4. 3 – elevated; inappropriate to content, and humorous
  5. 4 – euphoric; inappropriate laughter, and singing.
• Increased motor activity energy:
  1. 0 – absent
  2. 1 – subjectively increased
  3. 2 – animated with increased gestures
  4. 3 – excessive energy with periods of hyperactivity and restlessness that can be calmed
  5. 4 – motor excitement; continuous hyperactivity that cannot be calmed
• Sexual interest:
  1. 0 – normal and not increased
  2. 1 – mildly or possibly increased
  3. 2 – definite subjective increase on questioning
  4. 3 – spontaneous sexual content, frequently elaborating on sexual matters and is said to be hypersexual by self-report
  5. 4 – overt sexual acts observed toward other patients, staff, and/or interviewer
• Sleep:
  1. 0 – reports no decrease in sleep
  2. 1 – sleeping less than normal amount by up to one hour
  3. 2 – sleeping less than normal by more than one hour
  4. 3 – reports decreased need for sleep
  5. 4 – denies the need for sleep
• Irritability:
  1. 0 – absent
  2. 2 – subjectively increased
  3. 4 – irritable at times during interview with a history of recent episodes of anger or annoyance observed on inpatient ward
  4. 6 – frequently irritable during interview, often being described as “short” and “curt” throughout the interview
  5. 8 – hostile, uncooperative, thus often making the interview impossible
• Speech:
  1. 0 – no increase noted
  2. 2 – feels talkative
  3. 4- increased rate or amount at times, can be described as “verbose”
  4. 6 – push, noted to be consistently increased in rate and amount, making it difficult for interview to interrupt
  5. 8 – pressured, uninterruptible with continuous speech observed
• Language-thought disorder:
  1. 0 – absent
  2. 1 – circumstantial; mild distractibility with quick thoughts
  3. 2 – distractible, often losing goal of thought and is noted to change topics frequently, presence of racing thoughts
  4. 3 – flight of ideas and tangentiality noted, often difficult to follow, can have rhyming, and echolalia
  5. 4 – incoherent; often making communication impossible
• Content:
  1. 0 – normal
  2. 2 – questionable plans with new interests reported
  3. 4 – special projects and can be hyper-religious
  4. 6 – grandiose and paranoid ideas present, can have ideas of reference
  5. 8 – delusions and hallucinations present
• Disruptive-aggressive behavior:
  1. 0 – absent, cooperative
  2. 2 – sarcastic; loud at times, at times guarded
  3. 4 – demanding; threats can occur while on the inpatient unit
  4. 6 – threatens interviewer; shouting; interview is often difficult to complete
  5. 8 – assaultive and destructive, and the interview is often impossible to complete
• Appearance:
  1. 0 – appropriate dress and grooming
  2. 1 – minimally unkempt
  3. 2 – poorly groomed; moderately disheveled, can be overdressed
  4. 3 – disheveled; partly clothed, can have garish make-up
  5. 4 – completely unkempt; can be decorated in bizarre garb
• Insight:
  1. 0 – present; can admit illness, agreeable to the need for treatment
  2. 1 – possibly ill
  3. 2 – admits behavior change but unable to recognize illness
  4. 3 – admits possible change in behavior but continues to denies illness
  5. 4 – denies any behavior change

The YMRS is a very useful tool for clinicians to use when mood disorders are suspected. However, they may not be pragmatic for all visits, and thus, should be reserved only when mood disorders are suspected. Rabinowitz et al. (2022) report that patients amenable to taking the YMRS often demonstrate good insight into their mental illness, thus indicating better adherence to treatment. For those lacking insight, quantifying symptoms may aid a patient in seeing symptoms in a more tangible way, thus expanding their understanding and willingness to engage in treatment.

References

Boland, R. & Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

Butt, M.F. (2021). Approaches to building rapport with patients. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC8806294/

Hosnea, A. (2019). Psychometric properties of bangla young mania rating scale. NRNP 6635 The Psychiatric Evaluation and Evidence-Based Rating Scales

The Malaysian Journal of Psychiatry. https://www.academia.edu/104745466/Psychometric_Properties_of_Bangla_YoungMania_Rating_ScaleLinks to an external site.

Rabinowitz, J., Williams, J., Hefting, N., Anderson, A., Brown, B., Fu, D., Kadriu, B., Kott, A., Mahableshwarkar, A., Sedway, J., Williamson, D., Yavorsky, C., & Schooler, N. R. (2022). Consistency checks to improve measurement with the Hamilton rating scale for anxiety (HAM-A). SSRN Electronic Journal. https://doi.org/10.2139/ssrn.4176802Links to an external site.

Rocha Neto, H. G., Estellita-Lins, C. E., Lessa, J. L., & Cavalcanti, M. T. (2019). Mental state examination and its procedures—Narrative review of Brazilian descriptive psychopathology. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00077Links to an external site.

Savander, E., Hintikka, J., Wuolio, M., & Peräkylä, A. (2021). The patients’ practices disclosing subjective experiences in the psychiatric intake interview. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC8141629/

The Important Components of Psychiatric Interview

A psychiatric interview, as described by Savander et al. (2021), is a systematic dialogue between a mental health professional and a patient aimed at collecting comprehensive information regarding the patient’s mental health, encompassing symptoms, personal history, and current circumstances, to formulate a diagnosis and devise a treatment approach; it is same as the process of medical history taking in general practice, though with a concentrated emphasis on psychological dimensions and mental status evaluation.

Psychiatric interview encompasses three essential components such as establishing rapport, obtaining a comprehensive history, and conducting a mental status examination. Establishing rapport is foundational, as it fosters trust and creates a secure environment for patients to share their thoughts and emotions openly. Without this therapeutic alliance, patients may withhold critical information, complicating the understanding of their concerns. Gathering a detailed history, including medical, personal, familial, and social dimensions, provides crucial context for identifying potential contributors to the patient’s mental health challenges. This process aids in recognizing patterns, triggers, and life events that may influence their condition. The mental status examination assesses the patient’s current emotional and cognitive functioning, including mood, speech, memory, and thought processes (Lenouvel et al., 2022). This evaluation is essential for identifying specific symptoms that inform diagnosis and guide treatment planning. Collectively, these components form a comprehensive framework for understanding the patient’s mental health, enabling the delivery of individualized and effective care.

Psychometric Properties of Yale-Brown Obsessive-Compulsive Scale (Y-BOCS).

Obsessive-compulsive disorder (OCD) involves persistent, unwanted thoughts (obsessions) and repeated actions (compulsions) that a person may or may not be able to resist. These behaviors often cause significant distress and discomfort for the individual (Kundu et al., 2024). The Yale-Brown Obsessive-Compulsive Scale is a popular instrument for determining the severity of obsessive-compulsive disorder (OCD). It is regarded as a gold-standard for measuring obsessive compulsion. It is thought to have excellent psychometric properties, which means that it is a valid and reliable way to measure the severity of obsessive-compulsive disorder symptoms (Cox et al., 2023). It is a reliable tool in clinical and research contexts due to its psychometric qualities. The Y-BOCS’s primary psychometric characteristics are as follows:

Reliability

• Internal Consistency: The Y-BOCS has shown high internal consistency, meaning the individual items on the scale are closely related and collectively measure the same core aspect—OCD severity.
• Inter-rater Reliability: This ensures that the results are consistent regardless of who is conducting the evaluation because the scale demonstrates a high level of agreement between the various raters who are administering the test.
• Test-retest Reliability: When no notable symptom changes have taken place, scores on the Y-BOCS stay consistent, demonstrating its long-term reliability (Castro-Rodrigues et al., 2018).

Validity

• Content Validity: The Y-BOCS is extremely relevant to OCD since it was specifically created to measure its primary symptoms, such as compulsions and obsessions.
• Construct Validity: The scale has a strong correlation with other measures of OCD severity, indicating that it accurately captures the features of the disorder.
• Criterion Validity: Its ability to measure the disorder accurately is demonstrated by the Y-BOCS scores’ good alignment with clinical diagnoses and changes in symptoms over time (Castro-Rodrigues et al., 2018).

Sensitivity to Change

• The Y-BOCS is helpful for monitoring treatment progress because it is sensitive to changes in symptom severity. This characteristic is especially crucial for assessing how well treatments like medication or cognitive-behavioral therapy (CBT) work.

Scoring and Range

• The Y-BOCS includes 10 items, evenly divided between symptoms related to compulsion and obsession, which make up the Y-BOCS. A total score that ranges from 0 to 40 is determined by assigning a 5-point rating to each item and the severity is indicated by higher scores. Additionally, there is a symptom checklist that enables thorough recording of compulsions and obsessions (Kundu et al., 2024).

Utility

• It is applicable across different age groups, including children and adolescents (with modifications). The scale can be used in various settings, including outpatient clinics, hospitals, and research studies.

When use of Y-BOCS is appropriate and its usefulness to Nurse Practitioner’s Assessment

The Yale–Brown Obsessive-Compulsive Scale (Y-BOCS) is best used during a psychiatric interview when a person shows signs of obsessive-compulsive disorder (OCD). This might include reporting persistent, intrusive thoughts (obsessions) or repetitive behaviors they feel driven to perform (compulsions). The scale is appropriate when a detailed understanding of the severity of these symptoms is needed, such as when diagnosing OCD, developing a treatment plan, or monitoring progress during therapy or medication adjustments (Vogt et al., 2022).

For nurse practitioners, the Y-BOCS is incredibly helpful because it gives a structured way to assess how much OCD symptoms are affecting the person’s life. It doesn’t just ask about the presence of obsessions and compulsions, it also measures how much time they take up, how distressing they are, and how much they interfere with daily activities. This detailed information helps identify the areas that need the most attention and ensures that the treatment plan is tailored to the individual patient’s needs (Vogt et al., 2022).

Conclusively, the Y-BOCS is a gold standard instrument for evaluating OCD due to its high validity, reliability, and sensitivity to change. The Y-BOCS is an essential resource for nurse practitioners when diagnosing and managing OCD. Its ability to measure symptom severity and track changes over time ensures that care is both accurate and personalized, ultimately supporting better outcomes for patients. Its thoroughness guarantees that it captures the intensity as well as the subtle aspects of OCD symptoms, which helps with diagnosis and treatment planning (Vogt et al., 2022).

References

Cox, R. C., Knowles, K. A., Jessup, S. C., Adamis, A. M., & Olatunji, B. O. (2023). Psychometric properties of a daily obsessive-compulsive symptom scale for ecological momentary assessment. Journal of Obsessive-compulsive and Related Disorders, 39, 100840. https://doi.org/10.1016/j.jocrd.2023.100840

Kundu, P. S., Halder, A., Pal, A. K., Ray, S., & Mondal, S. (2024). Psychometric attributes of the Dimensional Yale-Brown Obsessive-Compulsive Scale adapted in Bengali: A validation study in the Bengali-speaking population. Indian Journal of Psychiatry, 66(8), 729–735. https://doi.org/10.4103/indianjpsychiatry.indianjpsychiatry_381_24

Lenouvel, E., Chivu, C., Mattson, J., Young, J. Q., Klöppel, S., & Pinilla, S. (2022). Instructional Design Strategies for Teaching the Mental Status Examination and Psychiatric Interview: a Scoping Review. Academic Psychiatry: The Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, 46(6), 750–758. https://doi.org/10.1007/s40596-022-01617-0

Savander, E. È., Hintikka, J., Wuolio, M., & Peräkylä, A. (2021). The Patients’ Practices Disclosing Subjective Experiences in the Psychiatric Intake Interview. Frontiers in Psychiatry, 12, 605760. https://doi.org/10.3389/fpsyt.2021.605760

Vogt, G. S., Avendaño-Ortega, M., Schneider, S. C., Goodman, W. K., & Storch, E. A. (2022). Optimizing Obsessive-Compulsive Symptom Measurement with the Yale-Brown Obsessive-Compulsive Scales-Second Edition. Journal of Psychiatric Practice, 28(4), 294–309. https://doi.org/10.1097/PRA.0000000000000640

Initial Post

The psychiatric interview is an essential element of psychiatric assessment, consisting of multiple important components that guide diagnosis and treatment planning. One key component is establishing rapport, which involves building a trusting relationship with the patient to facilitate open and honest communication (Carlat, 2024). Trust is fundamental to ensuring that the patient feels comfortable sharing sensitive information, which ultimately aids in making an accurate diagnosis. The second important element is the Mental Status Examination (MSE), which provides a structured assessment of the patient’s cognitive function, mood, behavior, and thought processes. The MSE is crucial for forming a comprehensive clinical picture and helps guide diagnostic decisions (Sadock et al., 2020). Lastly, negotiating a treatment plan and communicating it to the patient is critical for shared decision-making and fostering treatment adherence. When patients understand and actively participate in their care, it enhances engagement and the likelihood of positive outcomes (Carlat, 2024; APA, 2022).

In addition to the interview components, screening tools like the Patient Health Questionnaire-9 (PHQ-9) are invaluable in psychiatric assessments. The PHQ-9, developed by Kroenke, Spitzer, and Williams in 2001, is a validated tool for assessing depression severity and monitoring treatment outcomes (American Psychological Association, 2020). It has been shown to be very consistent and reliable across different uses, with reliability ratings indicating that the questions work well together to measure depression. It is also highly effective at identifying depression, with an accuracy rate of 88% for detecting major depressive disorder when a certain score is reached (American Psychological Association, 2020). These strong properties make the PHQ-9 a dependable tool for both initial and follow-up assessments. Furthermore, its brief and structured format aligns well with DSM criteria, making it appropriate for clinical settings to quantify symptom severity and track changes over time.

For Psychiatric-Mental Health Nurse Practitioners (PMHNPs), the PHQ-9 serves as a valuable adjunct to clinical judgment. Its use during psychiatric interviews helps quantify the severity of depressive symptoms, allowing practitioners to objectively monitor treatment progress and adjust therapeutic strategies accordingly. The standardized format also facilitates effective communication among healthcare providers and supports evidence-based practice in patient care (Ford et al., 2020)

References

American Psychiatric Association. (2022). Dsm-5-tr.

American Psychological Association. (2020). Patient health questionnaire (phq-9 & phq-2). https://www.apa.org. https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/Patient-health

Boland, R., Verduin, M., & Md, P. R. (2021). Kaplan & sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

Carlat, D. (2024). The psychiatric interview (5th ed.). Wolters Kluwer.

Ford, J., Thomas, F., Byng, R., & McCabe, R. (2020). Use of the patient health questionnaire (phq-9) in practice: Interactions between patients and physicians. Qualitative Health Research, 30(13), 2146–2159. https://doi.org/10.1177/1049732320924625

Week 2 Initial Post: Cage Assessment Tool

Cage questionnaire is a tool used to assess and determine someone’s dependence on alcohol. It’s one of the leading alcohol screening tools.  Developed in 1984 by John Ewing, MD (Ashley Olivine, 2024).

The cage questionnaire consists of four questions, have you ever felt like Cutting down? Have you ever felt Annoyance by criticism? Have you ever felt Guilty feeling about drinking?  Have you ever gotten an Eye opener or drink in the morning to calm your nerves? Thus, acronym CAGE. Each of these questions can be answered by yes or no answer. No answer is given a score of zero and an yes answer given a score of one, a score of two or more is considered clinically significant (staff, 2024).

In clinical settings, cage questionnaires are valued for its efficiency in use in primary care and mental health setting. Research shows cage scores have 75%-95% sensitivity, and 80%-95% specificity. Cage questionnaire has also the advantage of simplicity making it quick and accessible tool for screening alcohol dependency in both clinical and self-assessment contexts (M.D., 2024).

The cage score has some downside in that it does not discriminate well between inactive and active drinkers. The cage score also has some constrained specific questions, and formats that hinder the counsellor from further assessing the client in other areas (Brown, 2020). Also cage score has the possibility of some false positive results where clients who are without an alcohol disorder answer affirmatively to one or more questions, suggesting problems where none exists (M.D., 2024).

Cage screening tools have been shown to have some validity and applicable culturally. Questions are well understood and endorsed by respondents. Thus, cage screening tool seems to be a close approximation ideal “universal” or “culture free” screening questionnaire for alcoholism (Debasish Basu, 2024).

In conclusion, the cage screening tool is easy to use for the clinician to the patient and does not complicate patient’s answers as the answers are direct, short, and easy.

References

Ashley Olivine, P. M. (2024). CAGE Assessment Questions to Determine Alcohol Misuse. Very Well Health.

Brown, R. a. (2020). CAGE and CAGE-AID Introduction and Scoring. Wisconsin Medical Journal.

Debasish Basu, A. M. (2024). CAGE questionnaire allows doctors to avoid focusing on specifics of drinking. British Journal of Medicine.

M.D., D. R. (2024). CAGE Questionnaire: Definition, Description, Scoring, Usage, Advantages and Limitations. White Light Behavioural Health.

staff, E. (2024). CAGE Questionnaire (4 Questions to Screen for Alcoholism). American Addiction Centers.

Main Discussion

The psychiatric interview is a crucial aspect of the assessment process, and three key components include the presenting problem and history of present illness (HPI), the mental status examination (MSE), and the review of past psychiatric and medical history. The presenting problem and HPI allow the practitioner to understand the patient’s current concerns, the symptoms they are experiencing, and the context of these symptoms, such as onset, duration, and any precipitating factors. Frequently, clinicians want to focus on recent events contributing to a patient’s current presentation. With that said many psychiatric illnesses require a longitudinal perspective, which requires obtaining a thorough history and appreciating the course it has taken to get to the current state. It would be ideal to obtain both. However, this may be limited in certain disease states (such as dementia or psychosis)(Toffel et al., 2023). This helps guide the diagnosis and treatment plan. The MSE is essential for evaluating the patient’s cognitive and emotional functioning, including appearance, speech, mood, thought processes, and cognitive abilities. This assessment helps identify abnormalities such as disorganized thinking or mood disturbances, which are vital for diagnosis. Finally, reviewing past psychiatric and medical history provides insight into prior conditions, treatments, hospitalizations, and family history, which can influence the current presentation and treatment options. It is essential to see how and when they were diagnosed, the circumstances surrounding their previous diagnoses, a timeline of treatment trials, prior doses of medications, and the duration of hospitalizations(Toffel et al., 2023).

The Quality of Life in Depression Scale (QLDS) is a psychometric tool designed to assess the impact of depression on various aspects of a patient’s life. The theoretical basis for the instrument is that life gains its quality from the ability and capacity of the individual to satisfy his or her needs. The items included in the QLDS were derived from 30 qualitative interviews with depressed or recently recovered patients(Hunt & McKenna, 1992). The scale focuses on domains such as emotional well-being, social functioning, physical health, and role functioning, all of which are typically impaired in individuals with depression. It is reliable, meaning it consistently measures the same across different instances, and it is valid as it accurately reflects the patient’s subjective experience of quality of life-related to their depression. The QLDS was shown to be responsive to change in an open study with fluoxetine in 540 patients with major depression. The scale has broad applicability and is user-friendly for respondents and administrators. The theoretical basis for the instrument is that life gains its quality from the ability and capacity of the individual to satisfy his or her needs(Tuynman-Qua et al., 1997).

The Quality of Life in Depression Scale is particularly appropriate during the psychiatric interview when a nurse practitioner needs to assess the broader effects of depression on a patient’s life. This scale is handy when monitoring the effectiveness of treatment, as it allows the clinician to evaluate how well the patient’s emotional, social, and physical functioning improves or worsens over time. It can also be used to assess the severity of depression by highlighting areas of life that are most impacted, guiding the treatment plan. For example, if a patient scores low on social functioning or physical health, the nurse practitioner might consider integrating social support or physical health interventions into the treatment plan. By using the QLDS, a nurse practitioner can gain a comprehensive understanding of how depression is affecting a patient’s overall well-being and adjust treatment strategies accordingly. This holistic approach helps ensure that treatment not only targets the symptoms of depression but also addresses the broader impact on the patient’s quality of life.

References:

Hunt, S. M., & McKenna, S. P. (1992). The QLDS: A scale for the measurement of quality of life in depression. Health Policy, 22(3), 307–319. https://doi.org/10.1016/0168-8510(92)90004-ULinks to an external site.

Toffel, S., Rodriguez-Roman, L., & Holbert, R. C. (2023, January 1). The Psychiatric Diagnostic Interview and the DSM5. ScienceDirect; Elsevier. https://www.sciencedirect.com/science/article/abs/pii/B9780323957021000154

Tuynman-Qua, H., de Jonghe, F., & McKenna, S. P. (1997). Quality of life in depression scale (QLDS). Development, reliability, validity, responsiveness and application. European Psychiatry, 12(4), 199–202. https://doi.org/10.1016/s0924-9338(97)89105-5Links to an external site.

Great Afternoon, Dr. Thoren and Colleagues,

According to the National Center for PTSD, a program of the U.S. Department of Veterans Affairs, about six out of every 100 people will experience PTSD at some point in their lives (NIMH, 2024). Though research shows evidence of the magnitude of people living with possibly untreated PTSD, to properly diagnose a patient, practitioners must conduct a psychiatric interview consisting of an appropriate diagnostic tool known as the PCL-5 and meeting criteria within the DSM-5-TR. PCL-5 test scores have demonstrated strong internal consistency (α = .94 to .96), test-retest reliability (rs = .74 to .85), and convergent and discriminant validity (Blevins et al., 2015; Bovin et al., 2016). This 20-item questionnaire can be conducted by the patient within five to ten minutes while in the waiting area and can be reviewed with the practitioner in a private setting.

PCL-5 can be utilized prior, during and after treatment to measure the efficacy of the patient’s treatment and serve as a reliable guide to change treatment along the way depending on the repeated self-reported rating scale. During a psychiatric interview, practitioners can use this rating scale prior to the interview as mentioned above, during the interview when the patient expresses exposure to a traumatic event or shows signs and symptoms that meet PTSD criteria. As PMHNP, knowing when to use this rating scale is detrimental to properly diagnosing and treating a patient. For example, my current workplace always gives patients other rating scales (GAD-7 & PHQ-9) at every visit and practitioners may add the PCL-5 during the visit if these other rating scales scores are severely high. This practice helps captures early signs and symptoms of an stressors, life changes and past or recent traumas, and gives patients the opportunity to discuss any additional concerns they may not have otherwise mentioned due to time constraints at a doctor visit that may have originally been for a cold.

The PCL-5 scale is helpful to a nurse practitioner’s psychiatric assessment as it measures change with current treatment. According to the National Center for PTSD (2024), evidence for the PCL for DSM-V suggests that a 5–10-point change represents reliable change (i.e., change not due to chance) and a 10–20-point change represents clinically significant change, and it was recommended to use 5 points as a minimum threshold for determining whether an individual has responded to treatment and 10 points as a minimum threshold for determining whether the improvement is clinically meaningful using the PCL for DSM-V. Furthermore, if the points increase, which indicates treatment decline, nurse practitioners can add additional treatment options for the patient, such as starting patient on an SSRI, increasing medication dosages or combining treatment with therapy such as cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), or prolonged exposure.

Reference

Blevins, C., Weathers, F., Davis, M., Witte, T., and Domino, J. (2015). The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28, 489-498. doi:10.1002/jts.22059Links to an external site.

Bovin, M., Marx, B., Weathers, F., Gallagher, M., Rodriguez, P., Schnurr, P., and Keane, T. (2016). Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) in veterans. Psychological assessment, 28(11), 1379–1391. https://doi.org/10.1037/pas0000254Links to an external site.

National Center for PTSD (2024). PTSD Checklist for DSM-5 (PCL-5). Available from: https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp#:~:text=The%20PCL%2D5%20has%20a,Making%20a%20provisional%20PTSD%20diagnosis NRNP 6635 The Psychiatric Evaluation and Evidence-Based Rating Scales