The article in the February 4 issue on the Hamilton Depression Rating Scale
("Is End Near for Popular Assessment Tool?) prompts us to suggest that
our standard mental status examination (MSE) be scrutinized as well and
The MSE, often characterized as psychiatry's equivalent of the physical
exam, is in fact a mixture of historical information, observations, and
conclusions. "Thought process" is known from examination, but what
we describe as "thought content" is history—phobias,
compulsive behavior, and suicide ideation, for example. Hallucinations
occurring at the time of the examination are "current mental
state"; yesterday's hallucinations are history. "Judgment"
is an evaluation.
The MSE is flawed because of a lack of agreement about the meaning of some
of the terms. "Mood" and "affect" are often
confounded. "Orientation to person" refers to the patient's
awareness of his or her own identity, but some take it to mean recognition of
the examiner, while "orientation to situation" is not a standard
question. "Judgment" may reflect the patient's answers to test
questions, or it may reflect recent conduct, such as fighting with a police
officer or giving money to a con man. Some describe a patient as having
impaired judgment if he or she has a drug habit or stops taking prescribed
Ritualistically, we ask questions intended to evaluate "abstract
thinking"—proverbs and similes—although subtle defects in
abstract thinking no longer have the diagnostic significance they did when
schizophrenia was a more frequently used diagnosis. Multidimensional concepts,
such as "insight," are handled simplistically.
Regulatory agencies and insurance payers routinely specify that the record
must show a "complete" mental status examination. The clinician's
response is a list of topics, each followed by a "zero" or"
plus," providing a pseudo-complete report that fails to reveal
what questions were asked or what answers given.
Modern psychiatry should employ instruments that are accurate and useful.
Education of residents should encourage critical thought. We suggest that APA
establish a committee to study the MSE, evaluate the validity and usefulness
of its components, and make recommendations for a new standard, with plans for
regular updates, perhaps in sync with revisions of the DSM.