Discussion: The Psychiatric Evaluation and Evidence-Based Rating Scales

The Psychiatric Evaluation and Evidence-Based Rating Scale

According to Saddock, Saddock, and Ruiz (2015), the psychiatric interview is the most important element in the evaluation and care of persons with mental illness.  It is how we obtain information that will drive the criteria-based diagnosis and ultimately, the plan of care.  From the beginning, the interview will establish the client-provider relationship which, can have a profound influence on the outcome of treatment.  Three important elements of the psychiatric interview include past psychiatric illness, mental status exam, and formulation.

Past Psychiatric Illness

The past psychiatric history should include all psychiatric illnesses, symptoms, and treatment over the patient’s lifespan.  The symptoms should include, when they occurred, how long they lasted, and the frequency and severity of episodes (Saddock, Saddock, & Ruiz, 2015).  Special considerations, such as, suicidal or homicidal ideations, and episodes of self-injury should be assessed.  Treatment episodes should include outpatient, inpatient, day, and voluntary/involuntary treatment.  The practitioner should collect and review information about medication use and other modalities such as electroconvulsive therapy (ECT) that have been used and the response experienced by the patient.  Did the patient experience side effects or any other negative effects from the treatment?  Finally, was a diagnosis made in previous episodes that should be considered now.

Mental Status Exam

The mental status exam (MSE) is intended to explore all areas of mental functioning and denotes evidence of signs and symptoms of mental illness (Saddock et al, 2015).  The practitioner will begin the MSE upon initiation of the interview through observation, direct questioning, and the cognitive screening.  According to Sadock et al (2015), components of the screening include appearance, behavior, motor, speech, mood, affect, cognition, abstract reasoning, and thought process.  If suicidal ideations are present, intention, methods, motivation, reason for living, and the patient’s therapeutic alliance should also be assessed (American Psychiatric Association, 2016).

Formulation

Formulation consists of the culmination of all the data collected, the diagnosis, recommendations, and treatment planning.  The formulation should include a brief summary of the patient’s history, presentation, and current status (Saddock et al, 2015).  Combined, these elements should lead to the differential diagnosis of the patient’s illness as well as the provisional diagnosis.  The formulation should include a summary of the safety assessment, an estimate of the patient’s suicide risk, rationale for treatment selection, and treatment related preferences (American Psychiatric Association, 2016).  All should be explained and collaborated with the patient; differential diagnosis, risks of untreated illness, treatment options, and benefits and risks of treatment (American Psychiatric Association, 2016).

Psychometric Properties of the Geriatric Depression Scale

The Geriatric Depression Scale has been tested and used extensively with the older population. The GDS is a self-report measure of depression in older adults.  The response is a yes/no format and was formulated because of their high correlation with depressive symptoms in previous validation studies (American Psychiatric Association, 2020).  Of the 15 items on the assessment, 10 indicate the presence of depression when answered positively while the other 5 are indicative of depression when answered negatively (short form).

American Psychiatric Association (2020).  Geriatric Depression Scale (GDS).  Retrieved from https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/geriatric-depression

American Psychiatric Association. (2016). Practice guidelines for the psychiatric evaluation of adults (3rd ed.). https//psychiatriconline.org/doi/pdf/10.1176/appi.books..9780890426760

Greenberg, Sherry A. (2020).  The Geriatric Depression Scale (GDS). Hartford Institute for Geriatric Nursing. Retrieved from https://hign.org/consultgeri/try-this-series/geriatric-depression-scale-gds

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

 

Discussion: The Psychiatric Evaluation and Evidence-Based Rating Scales

Assessment tools have two primary purposes: 1) to measure illness and diagnose clients, and 2) to measure a client’s response to treatment. Often, you will find that multiple assessment tools are designed to measure the same condition or response. Not all tools, however, are appropriate for use in all clinical situations. You must consider the strengths and weaknesses of each tool to select the appropriate assessment tool for your client. For this Discussion, as you examine the assessment tool assigned to you by the Course Instructor, consider its use in psychotherapy.

Photo Credit: [shironosov]/[iStock / Getty Images Plus]/Getty Images

To Prepare:

  • Review this week’s Learning Resources and reflect on the insights they provide regarding psychiatric assessment and diagnosis.
  • Consider the elements of the psychiatric interview, history, and examination.
  • Consider the assessment tool assigned to you by the Course Instructor.
By Day 3 of Week 2

Post a brief explanation of three important components of the psychiatric interview and why you consider these elements important. Explain the psychometric properties of the rating scale you were assigned. Explain when it is appropriate to use this rating scale with clients during the psychiatric interview and how the scale is helpful to a nurse practitioner’s psychiatric assessment. Support your approach with evidence-based literature.

Read
 a selection of your colleagues’ responses.

By Day 6 of Week 2

Respond to at least two of your colleagues on 2 different days by comparing your assessment tool to theirs.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Main Discussion Post

 Examining, assessing, and diagnosing the client are all important aspects of being a psychiatric mental health nurse practitioner. Becoming skilled and confident in these areas helps providers to develop appropriate and effective treatment plans. One thing that has been emphasized in our reading this week and last week is the client-provider relationship. The initial assessment is where the provider lays the groundwork for a positive rapport to be developed. Sadock et al. (2015) stated one of the crucial aspects of the examination is showing empathy while retaining objectivity. Providing privacy, confidentiality, respect, and comfort are all significant factors of the assessment process as well. American Academy of Child and Adolescent Psychiatry (1995) recommended providers approach the interview with three things in mind: to obtain a diagnosis, determine if treatment will be indicated, and develop a treatment plan that will keep the client engaged. One of the objectives for this class is to feel confident with assessment tools and deciding which ones are appropriate for which clients. This post will discuss three important components of the psychiatric interview. I will also be discussing the Positive and Negative Symptom Scale (PANSS) and how the provider uses it to determine appropriate diagnoses and treatment.

 The psychiatric interview, also referred to as an examination or assessment, is complex and time-consuming. With a cooperative client, the process can still take around an hour to complete. Three crucial components of the interview include the social history, family history, and past medical history. The social history gives the provider vital information about how the client functions and what kinds of coping skills they currently employ. This part of the interview also allows the provider to assess the client’s use and history with illicit drugs and alcohol. Sadock et al. (2017) recommended approaching this section of the interview carefully, as the provider will need honest information to get a clear picture of the client’s situation. Asking questions about substance use and abuse should be done without judgment. This tactic includes tone of voice, inflection, and body language. This information is critical in determining which symptoms could be related to substance abuse and what treatment would be most appropriate for each individual client. An example would be a client who presents with attention deficit disorder and reveals that they have a history of meth use. In this case, the provider would probably want to steer away from effective medications such as Adderall due to the possibility of abuse. 

 Many psychiatric disorders have a genetic component that can be assessed during the interview’s familial history portion. The provider can use this information to determine an accurate diagnosis and treatment. For example, if a client came in complaining of symptoms that seemed to align with anxiety and then stated her mom, sister, aunt, and grandmother all had been diagnosed with anxiety, it is very likely the client has a genetic predisposition for that particular disorder. Because genetics can also affect how successful treatment is, it could be useful to know how the client’s family responded to treatment. Another significant part of the family history is the history of suicide attempts and aggressive behaviors. American Psychiatric Association (2016) found that a family history of suicidal ideation and aggression puts the client at higher risk for the same behaviors. As a provider, I would use this information to focus a few more questions in these areas for a clearer picture of my client’s situation. 

 A client’s past medical history is important for a variety of reasons. A medical history can give the provider insight into possible risk factors for mental disorders. It also will affect how the provider develops a treatment plan. American Psychiatric Association (2016) stated that the provider would also need to determine how any current medical conditions could be affecting the presentation of symptoms and how that will influence the diagnosis. An example of this could be head injuries. The medical history is also important because it will cover any allergies or drug sensitivities the client may have had in the past. Providers use this information when developing their treatment plan if it includes medications. Another crucial component of the medical history is the current medications and supplements the client is taking. The provider will need to ensure that anything they propose to add to the client’s regimen will not cause adverse effects. Lastly, a past medical history gives the provider insight into other professionals they can collaborate with regarding the client. The physical health of the client is important and should be monitored while receiving psychiatric treatment. 

 One tool that can be used during a psychiatric interview is the PANSS. This tool is used to determine the severity of the disorder and the client’s quality of life. Once the diagnosis of schizophrenia is decided on, this tool can be used to determine the direction of effective treatment. Therefore, this tool is only used at the end of an interview and only when the client has been appropriately diagnosed with schizophrenia. The symptoms of schizophrenia are classified as positive and negative. Positive symptoms include things like hallucinations, delusions, paranoia, and grandiosity. Negative symptoms include social withdrawal, blunted affect, difficulty communicating with a natural flow, and apathy. This assessment can take up to 45 minutes, so it may be beneficial to schedule a time to perform just this assessment after the first consultation and diagnosis are complete. Depending on the client’s condition, the provider should also plan to include caregivers during the evaluation and information gathered from previous providers. The client is rated in 30 different areas from one to seven. The areas are broken down into positive symptoms, negative symptoms, and general psychopathology. There is a PANSS-6 that only assesses six of the core symptoms of schizophrenia and a Simplified Negative and Positive Symptoms Interview (Kølbæk et al., 2018). These could be used in place of the more detailed assessment if time were a factor. One study I researched found that vitamin D levels directly correlated to the PANSS score. Prasanty et al. (2018) stated that the lower the level of vitamin D, the higher the PANSS score was. Ordering a vitamin D level would be worthwhile when treating a client with schizophrenia. 

 Psychiatric interviews should be client-centered, and the treatment should reflect the client’s goals, not those of the provider (Sadock et al., 2015). Client-centered interviews and treatment focus on the client’s strengths and culture, as well as areas identified by the client that need work. Providers should take the interview as an opportunity to begin a solid foundation of collaborative decision making between them and the client. Open-ended questions are helpful at the beginning of the interview, with more focused questions used to clarify the information required to determine differential diagnoses and treatment. Prioritizing the client’s symptoms and diagnoses will also be an important aspect of the assessment because many clients have comorbid conditions. The client’s social history, family history, and past medical history are all crucial aspects of the psychiatric interview. 

Erica

References

American Academy of Child and Adolescent Psychiatry. (1995). Practice parameters for the assessment and treatment of children and adolescents. https://www.aacap.or/App_Themes/AACAP/docs/practice_parameters/psychiatric_assessments_practice_parameter.pdf

American Psychiatric Association. (2016). Practice guidelines for the psychiatric evaluation of adults. (3rded.). https://psychiatryonline.org/doi/pdf/10.1176/appi.boooks.9780890426760

Kølbæk, P., Blicher, A. B., Buus, C. W., Feller, S. G., Holm, T., Dines, D., O’Leary, K. M., Sørensen, R. S., Opler, M., Correll, C. U., Mors, O., Bech, P., & Østergaard, S. D. (2018). Inter-rater reliability of ratings on the six-item Positive and Negative Syndrome Scale (PANSS-6) obtained using the Simplified Negative and Positive Symptoms Interview (SNAPSI). Nordic Journal of Psychiatry, 72(6), 431–436. https://doi-org.ezp.waldenulibrary.org/10.1080/08039488.2018.1492014

Prasanty, N., Amin, M. M., Effendy, E., & Simbolon, J. (2018). Low vitamin D serum level increases severity symptoms in schizophrenic patients measured by Positive and Negative Symptoms Scale (PANSS) in Batak Tribe Sumatera Utara, Medan-Indonesia. Bali Medical Journal, 7(1), 249-254. https://doi-org.ezp.waldenulibrary.org/10.15562/bmj.v7i1.921

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry(11thed.). Philadelphia, PA: Wolters Kluwer.

Sadock, B. J., Sadock V. A., & Ruiz, P. (2017). Kaplan and Sadock’s concise textbook of clinical psychiatry (4thed.). Philadelphia, PA: Wolters Kluwer.

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