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Mental Status Examination

The mental status examination is a structured assessment done by clinicians to evaluate their client’s emotional, cognitive and behavioural state on an ongoing basis.1, 2

eye observing a person talking
Gambling, Gaming & Technology Use
Knowledge Exchange

The mental status examination (MSE) is a structured way of assessing a client’s behavioural, emotional and cognitive state on an ongoing basis.1, 2 Clinicians perform the MSE on their clients using active observations, clinical judgment and specific questioning.1, 2, 3 Typically done through an interview process, the MSE can provide clinicians with information about their clients’ mental status changes over time, the effectiveness of ongoing treatment(s), the presence of co-occurring mental health problems and/or the need for further supports and referrals.2, 4, 5 Important to note is that the MSE is not done instead of a psychosocial assessment but as part of a client’s overall assessment.2, 6 That is, in addition to gathering information through the MSE, assessing the client’s interests, values, experiences and goals is also very important. In this evidence-informed practice section, the MSE is discussed, including how it is used, what it entails and how cultural competency plays a role in its administration and interpretation.

Importantly, a clinician administering the MSE must take into consideration factors that may affect client health beyond those assessed in the MSE, including the social determinants of health and other health disparities.5, 7 Learn more about social and cultural considerations relevant to the MSE.

Key Concepts

What is the mental status examination (MSE)?

The MSE is a structured assessment done by clinicians to evaluate their clients’ affect, cognition and behaviours on an ongoing basis.2 It is not a diagnostic tool but instead provides clinicians with a basis for understanding how their clients are presenting and functioning in relation to a suspected or confirmed diagnosis. Clinicians acquire information about their clients from interviewing and observing them as well as asking informed questions.1

The MSE was developed based on psychiatry principles that have evolved over many centuries. Although descriptions of mental health problems such as postpartum depression and psychosis were first documented in ancient Greece, much of the development of the modern-day MSE was done in the 1800s and 1900s.1, 8 The work of psychiatrist and philosopher Karl Jaspers is thought to have shaped the structure and method of the MSE. In his book General Psychopathology, Jaspers talks about the need for health care providers to analyze, think, observe and ask questions about mental health problems.8 He also studied the “psychology of meaningful connections,” highlighting the differences in obtaining information about the client’s mental state from the clients themselves and from clinical observation.8

Since that time, the MSE has been operationalized into checklists, scales and interviews. It is widely used by health care providers both nationally and internationally for ongoing assessment of clients’ mental health.1, 8 The core components assessed by the MSE include appearance, behaviour, mood/affect, speech, thought content (including suicidal ideation, homicidal ideation, etc.), thought form, perception, cognition (including orientation, memory, planning, alertness, etc.) and insight/judgment.2, 9 Learn more about the MSE components and what they encompass.

Importance of the MSE

The MSE has been called a “brain stethoscope”―it is similar to completing a physical examination in the area of medicine.2 Within the context of problem gambling, one of the MSE’s main objectives is to understand which affective, cognitive and behavioural patterns suggest the presence of a co-occurring mental health problem. The MSE provides information about the client’s baseline mental status, which when performed on an ongoing basis can help clinicians monitor any changes that occur relative to baseline, such as the presence of a concurrent disorder.2, 5 For people with problem gambling, research shows a heightened risk for co-occurring mental health problems, including substance use.10 As such, it is especially important to conduct and record the MSE for clients with gambling problems who have a diagnosis of mental illness or a suspected mental health problem.

Many hospitals and community mental health workers use the MSE as a routine assessment tool.1 Being able to present observations and client reports in a structured way through the MSE facilitates communication between mental health practitioners5, promoting an integrated care approach for the client. Using and documenting the MSE can help clinicians make appropriate mental health referrals.4

MSE results can also help contextualize less obvious concerns or observations into the client’s larger clinical profile. It allows the clinician to monitor a client’s overall mental status and provide necessary support in a consistent, structured and concrete manner.5

The MSE is meant to be administered on an ongoing basis—during each visit and interaction with a client—and is best done via an interview process.5 The interview process enables clinicians to gather information through client self-report as well as the clinician’s observations as they interact.2 MSE results are not typically shared with the client. Sometimes, however, a key component from the MSE is shared with the client to elicit further information or to assist with treatment planning. For example, a clinician may say, “You seem to be looking more down than during our last visit―have you noticed any shifts with your mood?” or “I noticed that your hygiene has improved quite significantly during our last few sessions―what has helped with this improvement? Perhaps we can include these strategies in your care plan.” By engaging in ongoing MSE assessment and monitoring, clinicians can identify the effectiveness of treatments, which can help in the development of treatment plans.2, 5 Clinicians can also detect if a client is experiencing a sudden change in functioning or a crisis such as suicidal thoughts and can develop safety plans or referral plans as needed.2, 5 They can also support their clients in noticing changes to their mental status (in either direction) and help build their clients’ self-awareness.

Some mental health and addictions agencies may have their own practice policies around using the MSE, such as how they structure the assessment, how components are named and organized, and how to document it.2 It is important to be familiar with and follow your own agency’s practice policy around the MSE wherever applicable. Although components may differ between organizations, the MSE will provide a structured way to record client information and present it to other mental health practitioners.

MSE components

The following table outlines the MSE components and indicates whether they are typically assessed through observation or inquiry. In some cases, clinicians may choose to use both observation and inquiry when assessing these components.

Please note that some practitioners and agencies may use different versions of the MSE that may include different components, names or descriptions.2

  • Appearance
  • Behaviour
  • Affect
  • Thought form (also referred to as though process)
  • Speech

  • Cognition (including orientation, memory, planning, alertness, etc.)
  • Perception
  • Mood
  • Thought content (including suicidal ideation, homicidal ideation, etc.)
  • Insight/judgment
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The following table contains a more detailed list of the MSE components, a brief description of each, a list of subcomponents and samples of documentation, highlighting how a clinician can capture and summarize each component in a client’s clinical chart.1, 2 Principles of health equity should be considered during both assessment and documentation of the MSE.5, 7

  • Refers to the client’s physical characteristics
  • Can provide useful clues about the client’s quality of self-care, mood, rate of aging, self-awareness, lifestyle and daily living skills
  • Is best assessed comparatively― comparing current appearance to the client’s baseline appearance (and taking safety needs into consideration)
  • Important to consider social and cultural norms and context of the interview
  • Gender, race and age (factual identifying features)
  • Apparent age
  • Clothing and attire
  • Grooming and hygiene
  • Other distinctive features
Dion, 21 years old: Client presented with poorer hygiene than usual at today’s Skills for Change group. He appeared ungroomed—unkempt hair, unshaven and slightly malodourous. Client was dressed in a stained T shirt and ripped jeans and was dressed appropriately for the warm weather.
  • Refers to what a person is doing during the examination, including non-verbal communication
  • Can provide clues about a client’s emotional state, attitude and psychomotor functioning
  • Body language and gestures
  • Posture
  • Eye contact
  • Facial expression
  • Response to assessment
  • Rapport and engagement
  • Level of arousal
  • Psychomotor activity and movement
  • Unusual features (e.g., twitches, tics, unusual mannerisms, pacing, grimacing, tremors)
Cedric, 67 years old: Client stayed for the entire session. He presented as calm and engaged, exhibiting a slouched posture and a slight tremor in his right hand. Client maintained appropriate eye contact throughout.
  • Refers to the client’s visible emotional state; the client’s external state
  • Notes similarities between the client’s affect and context of the situation
  • Range (e.g., restricted, blunted, flat, expansive)
  • Appropriateness (e.g., appropriate, inappropriate, incongruous)
  • Stability (e.g., stable, labile)
Lynn, 54 years old: Client displayed a flat affect. Affect was inappropriate to content discussed (e.g., client remained flat while discussing significant progress she made in meeting her gambling goals in the past week).
  • Refers to the client’s self-reported experience of their emotional state; the client’s internal state
  • Pervasive and sustained emotions that can colour a client’s perception of the world
  • Depth, intensity duration and fluctuation of mood (e.g., angry, depressed, guilty, anxious, irritable)
  • Behaviours that indicate mood
Sadie, 18 years old: Client reported mood as “angry,” stating that she yelled at the bus driver on the way here to let out some pent-up frustration. Reported that her anger is triggering and making her want to go to the casino despite her abstinence goal.
  • Refers to verbal expression in terms of form
  • Unusual speech can provide clues about emotional or cognitive issues
  • Rate (e.g., pressured, rapid, slow, tempo)
  • Volume (e.g., loud, normal, soft)
  • Quantity (e.g., minimal, voluble)
  • Tonality (e.g., monotonous, tremulous)
  • Ease of conversation
  • Coherence
  • Any impairments (e.g., stutters, slurring)
André, 39 years old: Client presented with slow, slurred speech and spoke loudly and excessively throughout the session. Client’s voice remained especially raised while discussing his recent slip with online poker.
Thought content
  • Refers to what the client talks about during the course of the interview
  • Delusions―fixed false beliefs not consistent with the client’s background or cultural norms
  • Overvalued ideas―less firmly held (e.g., superstitions)
  • Phobias
  • Obsession―unwanted, intrusive and recurring thoughts
  • Suicidal/homicidal ideation
  • Ideas of reference―client believes unrelated events apply to them
  • Ideas of influence―client believes outside forces are controlling actions
Ali, 38 years old: Client appears to endorse grandiose delusions, stating that she believes she has been selected by a deity to be the “chosen one,” and reports that she has been blessing strangers in bingo halls due to this belief.
Thought form (also referred to as thought process)
  • Refers to the formation, organization and coherence of thoughts
  • Assessment of how the client is communicating and the way ideas are produced and organized
  • Flight of ideas―connection between ideas apparent; rapid shifts in topics
  • Tangential―does not make a point or answer the question but remains logical
  • Circumstantial―contains an excessive amount of detail but does finally reach the point
  • Loose associations―words and sentences maintained; connections between ideas not obvious or are nonsensical
  • Word salad―words intact, but syntax is lost
  • Thought blocking―sudden and unexplained halt in the client’s speech
Sajid, 42 years old: Client remained goal directed and presented with organized, linear and coherent thinking throughout the therapy session. Client did not display any abnormal thought processes.
  • Refers to the process of experiencing the environment and making sense of sensory stimuli
  • Can help in detection of serious mental health problems such as psychosis, severe mood disorders and trauma
  • Perceptual disturbances may be disturbing or frightening to the client
  • Hallucinations―false sensory perceptions not associated with real external stimuli; can occur in all senses (e.g., auditory, visual, olfactory, etc.)
  • Illusions―perceiving things differently than usual but accepting that they are not real
  • Dissociative symptoms―derealization (feeling that one’s surroundings are not real); depersonalization (feeling detached from oneself)
Marisa, 29 years old: Client appeared to be responding to internal stimuli, as she was speaking aloud to herself at times throughout the session. When probed further, the client reported that she has been hearing voices telling her to run away from her home.
  • Refers to the client’s capacity to process information
  • Can also include orientation and memory
  • Level of consciousness (e.g., drowsy, alert, stuporous)
  • Orientation (e.g., awareness of the time, date and location and able to provide personal details)
  • Memory functioning
  • Attention and concentration
  • Ability to deal with abstract concepts
Korey, 33 years old: Client appeared alert and attentive throughout the session. He was oriented to time/date/location. Client was able to respond to questions appropriately and displayed the capacity to understand abstract concepts such as triggers, urges and coping strategies.
  • Insight refers to the client’s knowledge and awareness of a possible problem
  • Judgment refers to the client’s problem-solving and decision-making abilities in a more general sense
  • Can be particularly important in detecting potential safety issues
  • Insight―awareness of having an illness, understanding the possible treatment options and the need for treatment, and appreciation of the signs and symptoms involved
  • Judgment―soundness of decision-making abilities (e.g., can range from poor to fair to good)
  • Lu, 37 years old: Client displayed poor insight into his issues, showing a significant lack of understanding around the impact of his gambling behaviours on his work productivity and relationship with his spouse despite his recent termination from his job and threats from his spouse to leave him. Although client recognizes he is experiencing depressive symptoms, he demonstrates a lack of understanding around how these symptoms are interfering with his self-care, hygiene and activity engagement.
    Client’s judgment appears to be poor—he states he is finding it difficult to manage problems as they arise (e.g., client reported he did not know how to get help when he burned himself badly the other day while cooking dinner).

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    Research Snapshot

    The mental status examination (MSE) is an integral component in the assessment of psychological functioning and specific signs and symptoms of suspected mental illnesses. This information is gathered throughout therapists’ interactions with clients and can often provide a different dataset from clients’ direct responses.2, 5 Moreover, the MSE can provide an overview of a client’s mental status during the initial stages of treatment and draw attention to any changes that occur over time.11

    Research evidence surrounding the utility and efficacy of the MSE is scarce. However, the tool has been used in the mental health field for many years. In fact, the American Psychiatric Association (APA) lists the MSE as one of the essential domains of clinical evaluation.12, 13

    Please note that the MSE is not a diagnostic tool. The MSE is a component of the mental health interview that tests psychological functioning. Inquiries can then be made about the signs and symptoms of potential psychiatric conditions, which can be confirmed through further tests and assessments. 2, 5, 6

    Putting it Into Practice

    The content in this section demonstrates how the key concepts of the mental status examination (MSE) can be applied to working with clients with gambling problems. Many clinicians use a preferred framework or multiple frameworks in their practices, including holistic, anti-oppressive, systems-theory, disability or social-determinants-of-health frameworks. The information provided here is meant to complement whatever framework or theory may be guiding your clinical practice.

    When is it most important to conduct a comprehensive MSE?

    As mentioned previously, there are advantages to conducting a brief MSE at every interaction with a client with problem gambling5, regardless of how often you meet or in what context (both individual and group sessions). Based on clinical experience, conducting a comprehensive and complete MSE is most essential during the following situations:

    • When you suspect there may be co-occurring mental health problem(s).
    • During initial assessment and discharge sessions.
    • When you detect significant shifts in mental status.
    • During transitions in care.
    • After the client experiences a major loss.
    • After the client experiences a slip or relapse.
    • When an increased risk of aggressive behaviours is present.
    • When an increased risk of suicidal ideation or suicidal behaviours is present.14

    Reference cards

    Many MSE reference cards that outline and describe the different components of a MSE are available. These cards can provide useful guidelines when conducting and documenting the MSE of a client. It can be helpful to keep one of these cards by your workstation so that you can easily refer to it as needed.

    Suicide assessment is an important part of the MSE.2, 5 Several resources are available to help guide safe and effective suicide assessment. Learn more about suicide assessments.

    Mental health resources

    If you suspect or detect underlying undiagnosed mental health problems or worsening mental health symptoms based on the MSE, it is important to:

    • conduct further screening for these issues
    • refer to mental health supports as needed
    • provide care in an integrated, collaborative fashion along with your client’s mental health team.4

    Learn more about validated screeners for concurrent disorders.