Synopsis
Obtain a collaborative psychiatric history, describe the mental state precisely, assess immediate risk and capacity, and integrate medical, neurological, substance, developmental and social explanations without turning observation into unsupported diagnosis.
- Begin with the person's account and priorities, then establish a dated chronology of symptoms, function, treatment, physical health, substances, development, relationships and previous episodes.
- Explain privacy and its limits before sensitive questions; use a professional interpreter and communication adjustments rather than relying on relatives to translate clinical or risk information.
- The mental-state examination is a description made during the encounter: appearance and behaviour, speech, mood and affect, thought, perception, cognition, insight and judgement.
- Separate reported mood from observed affect, thought form from thought content, and perceptual experience from the person's interpretation of that experience.
- Ask directly and calmly about self-harm, suicide, harm to others, self-neglect, abuse, exploitation, dependants, access to means and factors that help the person remain safe.
- Assess capacity only when a particular decision is in doubt; diagnosis, detention, apparent irrationality or a low cognitive score does not establish incapacity.
- Seek consented collateral information when it can clarify baseline, chronology, adherence and risk, while documenting source, relationship, potential bias and any confidentiality decision.
- Complete physical observations and targeted examination when presentation, medicines or history indicate them; unexpected late onset or altered consciousness widens the medical differential.
- End by summarising what has been understood, acknowledging uncertainty, agreeing immediate actions and recording who will review outstanding risks, results and diagnostic alternatives.
Key red flags
Fluctuating attention or arousal, disorientation, fever, hypoxia, head injury, seizure, focal neurology or a new medicine exposure suggests an acute medical or neurological syndrome rather than uncomplicated primary psychiatric illness.
Current suicidal intent, a rehearsed or available method, recent high-lethality behaviour, command hallucinations, severe hopelessness or inability to collaborate with immediate safety measures demands same-day specialist assessment.
Threats linked to a named person, weapon access, escalating persecutory beliefs, intoxication or recent serious violence require specific inquiry, environmental safety and proportionate information sharing.
Mutism, posturing, stupor, marked negativism, excitement or autonomic disturbance can represent catatonia, which needs urgent medical assessment and must not be dismissed as non-cooperation.
A person who cannot understand, retain, use or weigh information about an urgent decision after practicable support needs a decision-specific capacity assessment and lawful substitute process.
Investigation priorities
Define symptoms, course, context, impairment, previous episodes, treatments and the person's goals.
Management branches
A person presents for psychiatric assessment in any clinical setting.
- Check immediate physical safety, privacy, communication needs and whether another person should be present before beginning a broad invitation.
- Build a dated account of symptoms, function, context, treatments and previous episodes, moving from open questions to focused clarification.
- Summarise periodically, distinguish observation from report and obtain permission before particularly sensitive or collateral enquiries.