Mental Health Assessment Guide

MSE Mental State Examination Overview

The MSE is a structured assessment of a patient's current mental functioning. Document observations objectively — describe what you see and hear, not interpretations. Conduct in a calm, private environment.

1. Appearance & Behaviour

Dress & GroomingAppropriate for setting/weather? Clean, dishevelled, eccentric, or formal? Cultural dress considered.

HygienePersonal hygiene maintained or neglected? Body odour, unkempt hair, poor dental hygiene may indicate self-neglect.

Eye ContactSustained, fleeting, avoidant, intense, or staring? Note cultural norms (some GCC patients may avoid eye contact with opposite gender).

Psychomotor ActivityAgitation: restlessness, pacing, hand-wringing (anxiety, mania, akathisia). Retardation: slowed movements, long latency, may indicate depression or sedation.

Rapport & EngagementCooperative, guarded, hostile, suspicious, or disinhibited? Ability to engage with interviewer.

Document example: "Patient appeared dishevelled, in hospital gown. Poor eye contact maintained. Psychomotor retardation noted — slow to respond, minimal spontaneous movement."

2. Speech

RateRapid (mania, anxiety, stimulant use), normal, or slowed (depression, sedation)

VolumeLoud, normal, quiet/whispered, or mute

FluencyFluent, dysarthric, stuttering, pressured (difficult to interrupt)

SpontaneitySpontaneous, only answers when asked (poverty of speech), monosyllabic

LatencyDelay before answering — prolonged latency in depression or thought disorder

ToneMonotonous (flat affect), prosodic, varied

3. Mood & Affect

Subjective MoodPatient's own words: "I feel low / fine / on top of the world." Use quotes. Ask: "How would you describe your mood over the past week?"

Objective AffectExaminer's observation: euthymic, dysphoric, elevated/euphoric, irritable, anxious, labile

Affect RangeFull range (normal), restricted/constricted (narrow emotional expression), blunted (reduced intensity), flat (absent emotional expression)

CongruenceIs affect congruent with mood/thought content? Incongruence may suggest psychosis (e.g., laughing while describing tragedy)

LabilityRapid, unpredictable shifts in affect — seen in mania, emotionally unstable personality disorder, organic brain conditions

4. Thought Process (Form)

NormalLogical, goal-directed thinking with clear connections between ideas

TangentialStarts on topic but drifts and never returns — patient does not answer the question

CircumstantialEventually reaches the point but via excessive, unnecessary detail and digressions

Flight of IdeasRapid progression from one idea to another — connections often present but too fast; seen in mania

Thought BlockAbrupt cessation mid-sentence — patient may report mind going blank; seen in schizophrenia

Loosening of AssociationsIdeas shift with no logical connection (knight's move thinking); seen in schizophrenia

PerseverationPersistent repetition of a word or topic despite changing questions — organic conditions

NeologismsMade-up words with personal meaning — seen in psychosis

5. Thought Content

Delusions (Fixed, false, unshakeable beliefs not culturally explained)

PersecutoryBelief that one is being harmed, followed, poisoned, or conspired against — most common type

GrandioseBelief of special powers, identity (royalty, prophet), or abilities — common in mania

ReferentialBelief that neutral events (TV, newspaper, strangers) have special personal meaning

NihilisticBelief that self, body parts, or world do not exist / are dead (Cotard syndrome)

Jealous (Othello)Morbid jealousy — unfounded belief partner is unfaithful

Erotomanic (de Clerambault)Belief that another person (usually of higher status) is in love with them

Other Thought Content

ObsessionsIntrusive, ego-dystonic, repetitive thoughts (OCD) — patient recognises them as irrational

RuminationsRepetitive dwelling on negative themes — common in depression

PreoccupationsOverconcern with specific themes (health, religion, finances)

Suicidal/Homicidal IdeationAlways explore — passive ideation vs active plans vs intent (see Risk Tab)

6. Perceptions

Auditory HallucinationsVoices — first/second/third person? Command hallucinations ("hurt yourself")? Commenting, conversing. Most common in schizophrenia.

Visual HallucinationsSeeing things not present. More common in organic conditions (delirium, dementia, substance use) than functional psychosis.

Olfactory/GustatorySmelling or tasting things that are not there — consider temporal lobe epilepsy or organic cause.

TactileFeeling sensations on/under skin — formication (insects crawling) in stimulant/alcohol withdrawal.

IllusionsMisperceptions of real stimuli (seeing a face in shadows) — not hallucinations; occur in anxiety or organic states.

DepersonalisationFeeling detached from one's own self/body ("outside observer"). Derealisation: surroundings feel unreal.

Ask: "Have you heard voices when no one is around? Do you see things others cannot see?"

7. Cognition

Orientation — TimeYear, month, day, date, time of day

Orientation — PlaceName of facility, city, country

Orientation — PersonOwn identity (usually preserved even in severe confusion)

Attention & ConcentrationSerial 7s (subtract 7 from 100 repeatedly), WORLD backwards, digit span (forward and backward)

Memory — ImmediateRegister 3 objects, recall at once (working memory)

Memory — Short-termRecall registered objects after 5 minutes

Memory — Long-termRemote autobiographical facts, public events

8. Insight & Judgement

Level	Description
1	No insight — denies being unwell
2	Acknowledges illness but blames external causes
3	Aware of illness but does not attribute to mental cause
4	Accepts mental illness but denies need for treatment
5	Full insight — aware of illness, accepts treatment, understands implications

Judgement

Assess via scenario: "What would you do if you found a stamped addressed envelope on the street?" Normal = post it. Tests social reasoning and problem-solving.

Risk in MSE — SAD PERSONS Mnemonic

SSex — Male gender (higher completed suicide risk)

AAge — Adolescents and elderly (bimodal risk)

DDepression — Primary risk factor for suicide

PPrevious attempt — Strongest predictor of future attempt

EEthanol/substance use — Markedly increases impulsivity

RRational thinking loss — Psychosis, command hallucinations

SSocial supports lacking — Isolation, no family support

OOrganised plan — Specific, detailed method increases risk

NNo significant other — Widowed, divorced, bereaved

SSickness — Chronic pain, terminal illness, disability

MSE documentation tip: Always end nursing notes with a risk statement. Example: "Suicidal ideation denied at time of assessment. No intent or plan elicited. Patient agreeable to safety planning."

PHQ-9 Patient Health Questionnaire — Depression

Over the last 2 weeks, how often have you been bothered by the following? (0=Not at all, 1=Several days, 2=More than half the days, 3=Nearly every day)

Score	Severity	Suggested Action
0–4	No depression	Monitor, watchful waiting
5–9	Mild	Psychoeducation, self-help resources
10–14	Moderate	Consider counselling or antidepressant
15–19	Moderately severe	Active treatment indicated
20–27	Severe	Immediate psychiatric referral

GAD-7 Generalised Anxiety Disorder Scale

Over the last 2 weeks, how often have you been bothered by the following?

Score	Severity
0–4	Minimal anxiety
5–9	Mild
10–14	Moderate
15–21	Severe

EPDS Edinburgh Postnatal Depression Scale

10-item scale for postnatal (and antenatal) depression. Validated across cultures including Arabic populations. Score range: 0–30.

Scoring

Score <9: Low risk — routine care
Score 10–12: Borderline — repeat in 2 weeks
Score ≥13: Likely depression — refer to doctor
Q10 any score ≥1: Immediate safety assessment

Key Questions

Q1: Able to laugh / see funny side
Q3: Blamed self unnecessarily
Q7: Unhappy — difficulty sleeping
Q10: Thoughts of self-harm

EPDS is validated in Arabic. Administer in patient's preferred language. Score ≥13 in any GCC antenatal/postnatal woman requires same-day doctor review and safety plan.

AUDIT-C / CAGE Alcohol Screening

Note: Alcohol use is underreported in GCC due to legal and cultural factors. Screen non-judgementally, emphasising confidentiality. Consider prescription drug misuse as an alternative.

AUDIT-C (3 Questions)

Q1: How often do you have a drink containing alcohol?
Q2: How many units on a typical day?
Q3: How often do you have 6 or more units on one occasion?

Score ≥5 (men) or ≥4 (women) indicates hazardous drinking. Refer for further assessment.

CAGE (4 Questions)

CCut down — Have you felt you should cut down?

AAnnoyed — People criticising your drinking?

GGuilty — Felt guilty about drinking?

EEye-opener — Drink first thing in the morning?

≥2 positive responses suggests alcohol dependence.

MMSE Mini Mental State Examination — Cognitive Screening

30-point scale. Takes 5–10 minutes. Language and education affect scores — use validated Arabic version where possible.

Domain	Max Score	Test Items
Orientation — Time	5	Year, season, month, date, day
Orientation — Place	5	Country, state/region, city, hospital, floor/ward
Registration	3	Name 3 objects; patient repeats immediately
Attention	5	Serial 7s (93, 86, 79, 72, 65) or spell WORLD backwards
Recall	3	Recall the 3 registered objects after 5 min
Language — Naming	2	Name a pencil and watch
Language — Repetition	1	"No ifs, ands, or buts"
Language — Commands	3	3-stage command: take paper, fold, place on floor
Language — Reading	1	Read and obey "Close your eyes"
Language — Writing	1	Write a sentence spontaneously
Visuospatial	1	Copy intersecting pentagons
TOTAL		30

24–30: Normal

Cognitive impairment unlikely. Baseline for future comparison.

18–23: Mild impairment

Consider MCI. Further neuropsychological assessment.

<18: Moderate–Severe

Significant impairment. Capacity assessment. Safeguarding considerations.

Depression — SIGECAPS

SSleep disturbance (insomnia or hypersomnia)

IInterest loss (anhedonia — unable to enjoy previously pleasurable activities)

GGuilt (excessive guilt, worthlessness, self-blame)

EEnergy low (fatigue, anergia)

CConcentration impaired (difficulty focusing, forgetfulness)

AAppetite change (decreased with weight loss, or increased)

PPsychomotor changes (retardation or agitation)

SSuicidal ideation (passive ideation to active plan)

Treatment Ladder

Step 1: Psychoeducation, sleep hygiene, exercise, self-help
Step 2: CBT (individual/group), structured support
Step 3: SSRIs (fluoxetine, sertraline, escitalopram) — 4–6 weeks for therapeutic effect; continue 6+ months after remission
Step 4: Combination therapy; consider SNRIs, mirtazapine, augmentation
Step 5: ECT (electroconvulsive therapy) for severe, treatment-resistant, or catatonic depression

GCC context: Depression often presents somatically (headache, chest pain, fatigue). "I feel heavy" or "my heart is broken" are common idioms of distress in Arabic-speaking patients.

Bipolar Disorder — Manic Episode: DIGFAST

DDistractibility — easily sidetracked

IImpulsivity / Indiscretions — reckless spending, sexual behaviour, substance use

GGrandiosity — inflated self-esteem, special powers

FFlight of ideas — racing thoughts

AActivity increased — goal-directed, psychomotor agitation

SSleep decreased — feels rested on 3 hours; does not feel tired

TTalkative — pressured speech, difficult to interrupt

Lithium Monitoring (Nursing Checklist)

Parameter	Frequency	Target / Action
Lithium level	7 days after initiation/dose change, then 3-monthly	0.6–0.8 mmol/L maintenance; 0.8–1.0 acute mania; toxic >1.5
Renal function (U&E, eGFR)	Baseline, 6-monthly	Lithium excreted renally — dehydration risk in GCC heat
Thyroid function (TSH)	Baseline, 6-monthly	Lithium causes hypothyroidism in up to 40%
ECG	Baseline, annually	T-wave flattening common; QT prolongation — alert doctor
Weight / BMI	Monthly	Weight gain is common side effect

Lithium toxicity signs: coarse tremor, ataxia, confusion, vomiting, drowsiness. STOP lithium, obtain urgent serum level, IV fluids, medical emergency team.

Schizophrenia — Symptoms & Antipsychotics

Positive Symptoms

Auditory hallucinations (voices)
Delusions (persecutory most common)
Disorganised speech and thought
Catatonia (stupor, posturing, waxy flexibility)

Negative Symptoms (4 As)

Affective flattening — reduced emotional expression
Alogia — poverty of speech
Avolition — lack of motivation / self-care
Anhedonia — inability to feel pleasure

Antipsychotic Side Effects — EPS (Extrapyramidal Symptoms)

EPS Type	Timing	Presentation	Treatment
Acute dystonia	Hours–days	Sustained muscle spasm — oculogyric crisis, torticollis, trismus	Procyclidine IM/IV or benztropine
Akathisia	Days–weeks	Subjective restlessness, inability to sit still — high suicide risk	Beta-blocker (propranolol), reduce dose
Parkinsonism	Weeks–months	Bradykinesia, rigidity, tremor, shuffling gait	Reduce dose, switch antipsychotic, procyclidine
Tardive dyskinesia	Months–years	Involuntary repetitive orofacial movements, choreoathetosis	Reduce dose, switch to clozapine, may be irreversible
NMS	Any time	Hyperthermia, rigidity, autonomic instability, confusion — MEDICAL EMERGENCY	Stop antipsychotic, cool, IV fluids, dantrolene

PTSD — Post-Traumatic Stress Disorder

Core Symptoms (PTSD)

Re-experiencing: flashbacks, nightmares, intrusive memories
Avoidance: of trauma reminders, emotional numbing
Negative cognitions: guilt, shame, self-blame
Hyperarousal: startle response, insomnia, irritability, hypervigilance

GCC-Specific High-Risk Groups

Refugees and war survivors (Syria, Yemen, Iraq, Somalia)
Domestic workers — exploitation, abuse, isolation
Domestic abuse survivors (especially female patients)
Construction workers — accidents, occupational trauma

Trauma-Informed Care Principles

Safety: Ensure physical and emotional safety before exploring trauma
Trustworthiness: Transparent, consistent, explain all procedures
Choice: Offer options and respect autonomy at every decision point
Collaboration: Work with patient — not on them
Empowerment: Build on strengths, avoid re-traumatisation through assessment process

Eating Disorders — Medical Monitoring

Anorexia Nervosa

Restriction of energy intake → low body weight
Fear of weight gain; disturbed body image
Amenorrhoea (menstrual loss in women)
BMI <17.5 kg/m² typical diagnostic threshold

Bulimia Nervosa

Binge eating episodes + compensatory purging
Vomiting, laxative misuse, excessive exercise
Normal or above-normal BMI
Dental erosion, Russell's sign (knuckle calluses)

Essential Nursing Monitoring

Electrolytes: Hypokalaemia (vomiting/laxatives) — cardiac arrhythmia risk; check K+, Mg2+, phosphate
ECG: Prolonged QT, arrhythmias from electrolyte disturbance
Refeeding syndrome: Life-threatening hypophosphataemia when reintroducing nutrition after prolonged starvation. Monitor phosphate closely during first 2 weeks of refeeding. Replace electrolytes proactively.
Vital signs: Bradycardia and hypotension in anorexia — may mask severity

Personality Disorders

Borderline PD (EUPD)

Fear of abandonment, unstable relationships
Identity disturbance, impulsivity
Recurrent self-harm, suicidality
Affective lability, intense anger
Approach: DBT (Dialectical Behaviour Therapy), validation, consistent boundaries, avoid splitting

Antisocial PD (ASPD)

Persistent disregard for rights of others
Deceitfulness, impulsivity, aggression
Lack of remorse; criminal behaviour
Approach: Clear firm boundaries, do not challenge or confront aggressively, risk management focus, liaise with security/legal

Suicide Risk — SLAP Framework

SSpecificity — Does the patient have a specific plan? Who, what, where, when?

LLethality — How lethal is the planned method? (Hanging/firearms > overdose > cutting)

AAvailability — Does the patient have access to means? Weapons, medications at home?

PProximity of help — Is anyone nearby to intervene? Isolated vs. supported

Static vs Dynamic Risk Factors

Static (unchangeable)

Previous suicide attempt
Family history of suicide
History of trauma/abuse
Chronic mental illness
Male gender, older age

Dynamic (modifiable)

Current suicidal ideation intensity
Active psychosis or agitation
Substance intoxication
Recent loss or stressor
Access to lethal means

Protective Factors

Religious belief against suicide Strong family support Reasons for living (children) Engaged with treatment Future orientation Problem-solving ability

Risk Formulation — Observation Levels

Low Risk

Passive ideation only, no plan, strong protective factors, engaged with care plan.

Observation: General observation — nurse aware of whereabouts; check as clinically indicated

Medium Risk

Active ideation with some plan, distressed, history of self-harm, limited supports.

Observation: 15–30 minute checks — documented patient location and mental state

High Risk

Active plan with means access, recent serious attempt, command hallucinations to harm self.

Observation: Enhanced 1:1 (eyesight) — nurse maintains continuous visual contact at all times, including bathroom (with dignity)

Level	Description	Frequency
General	Patient location known, routine ward checks	Each shift minimum
30-min	Nurse checks and documents every 30 min	Every 30 min
15-min	Enhanced intermittent — heightened awareness	Every 15 min
Eyesight	1:1 enhanced — continuous visual contact	Continuous
Arm's length	Physical proximity maintained (very high risk)	Continuous, within arm's reach

De-escalation — LOWERED Mnemonic

LListen — Active listening; let the patient vent without interruption

OOffer options — Give choices where possible to restore sense of control

WWait — Do not rush; silence is therapeutic; allow processing time

EEnvironment — Remove audience; move to quiet space; remove objects at risk

RReduce stimulation — Lower voice, dim lights if possible, limit number of staff

EEmpathy — Validate feelings: "I can see you're really distressed right now"

DDisengage — If escalating despite attempts, ensure safety, call for support, disengage

Brøset Violence Checklist (BVC)

Score each item 0 (absent) or 1 (present). Total ≥2 = significant risk — activate de-escalation and team alert.

Item	Description
Confusion	Appears confused, disoriented
Irritability	Easily annoyed, short-tempered
Boisterousness	Noisy, making demands
Physical threats	Threatening gestures, intimidating stance
Verbal threats	Verbalising threats to harm others
Attacking objects	Hitting furniture, walls, throwing items

Rapid Tranquilisation (RT)

RT is used when de-escalation has failed and patient poses immediate danger. It is NOT punishment. Verbal de-escalation must be attempted and documented first.

Step 1 — Oral (preferred if accepted)

Lorazepam1–2 mg oral / sublingual

Olanzapine5–10 mg oral (wafer preferred)

Haloperidol5 mg oral + lorazepam 2 mg

Step 2 — Intramuscular (if oral refused)

Lorazepam2 mg IM (max 4 mg/day)

Haloperidol5 mg IM (do NOT combine IM lorazepam + IM olanzapine — respiratory risk)

Aripiprazole9.75 mg IM — better tolerated, less EPS

Post-RT Monitoring (Nursing)

Parameter	Frequency	Alert Threshold
Level of consciousness	Every 5 min for 30 min, then every 30 min	GCS drop <14 — medical review
Respiratory rate	Every 5 min for 30 min	RR <10 breaths/min — medical emergency
SpO2	Every 5 min for 30 min	SpO2 <95% — supplemental O2, escalate
Blood pressure & HR	Every 15 min for 1 hour	SBP <90 or HR <50 — alert doctor
Muscle rigidity / temperature	30 min post-RT, then hourly x2	Fever + rigidity — NMS risk, medical emergency

Reversal agent for benzodiazepines: Flumazenil 0.2 mg IV — have available. For opioid combinations: Naloxone 400 mcg IV/IM.

Mental Capacity & Legal Framework

Mental Capacity Assessment — 4 Abilities Test

1. UnderstandCan the patient comprehend the information given about treatment?

2. RetainCan they hold the information long enough to make a decision?

3. Weigh UpCan they use the information to reach a decision (balance pros/cons)?

4. CommunicateCan they express their decision by any means (speech, gesture, writing)?

Capacity is decision-specific and time-specific. A patient may lack capacity for one decision but retain it for another. Always presume capacity unless proven otherwise.

GCC Legal Framework

UAE — Federal Law No. 28 of 2021 on Mental HealthEstablishes mental health rights, voluntary/involuntary admission criteria, protection from abuse. Involuntary admission requires: imminent danger to self/others AND lack of insight. Review within 7 days.

Saudi ArabiaMental Health Law requires psychiatric evaluation for involuntary admission. Patient rights protected. Guardianship considerations under family law.

QatarLaw No. 16 of 2016 on Mental Health — similar provisions; involuntary treatment committee review.

As a nurse, document clearly and objectively any capacity assessment, least restrictive alternatives considered, and reasons for any compulsory intervention.

Service	Location	Notes
NMC Royal Hospital	Abu Dhabi, UAE	Inpatient psychiatric unit, liaison psychiatry
Rashid Hospital — Psychiatric Unit	Dubai, UAE	Emergency psychiatric services, acute admissions
Erada Centre for Treatment & Rehabilitation	Dubai, UAE	Substance misuse, psychiatric rehabilitation
National Mental Health Centre	Doha, Qatar	Primary national mental health hospital
Al Amal Hospital	Dubai, UAE	Addiction and mental health specialist hospital
King Fahad Psychiatric Hospital	Jeddah, Saudi Arabia	Major tertiary psychiatric centre KSA

PHQ-9 Scoring

GAD-7 Scoring

Observation Levels

RT Doses (IM)