Dr I Vinjamuri

Consultant Psychiatrist

CRHT, Liverpool

18/3/2020

Guidance for assessing mental state on the telephone

In , the examination of the mental state is important in diagnosis. This concerns the symptoms and behaviour at the time of interview or a phone call. There is always a degree of overlap between the history and the mental state examination, especially mood, and .

Appearance and behaviour

The general appearance of the patient is unfortunately not something we can assess unless they are in front of us. We must therefore focus on behaviour that we can pick up when we speak to a patient on the phone. Social norms and behaviour can be commented upon. Manic patients often break social conventions and may be over familiar with staff. Patients with may respond inappropriately. Patients with may be preoccupied, aggressive or disinhibited. Patients with antisocial personality may be aggressive. It may be important to give a clear description of what the patient actually says on the phone. The patient may also become impatient, change their tone as the conversation goes on and these need to be documented. It may also be important to think about whether the patient called or, if we called them for review. Irritability due to the patient not being in convenient surroundings for a phone call needs to be taken into consideration. We may be able to comment if the patient sounds drowsy. Anxiety can be sensed even on the phone. How the patient engages on the phone matters and staff could comment on whether the conversation was one-sided or more collaborative.

Speech

We must record how the patient speaks and what they say. The rate and quantity of speech is possible to assess on the phone. Speech may be fast and pressured in , hesitant and slow in depression. Patients with depression or dementia may pause for a long time and give short answers with not much spontaneous speech. We must watch out for unusual words used, mis-pronunciations, accent, sudden interruptions, rapid change from one topic to another indicating flight of ideas, lack of logic to read which may indicate thought disorder.

Mood

Although a lot of this information may be collected by history taking, we should be able to document if the patient was crying, low mood is indicated by hopelessness, pessimistic thoughts and guilt. We can comment on suicidal thoughts, any intent and plans. We should be able to pick up elation, the patient may be over enthusiastic, and unusually cheerful, demonstrate excessive self confidence and have extra again to plans. The patient’s mood can be labile and change throughout the telephone call and must be documented. There could be a lack of affect in the form of blunting or flattening. Incongruent mood such as giggling or laughing when describing difficult issues such as death may be noted.

Delusions

When ideas are revealed that may be delusional, the interviewer must find out how strongly these ideas are held. Patience and tact is required for this and we must try not to antagonise the patient. Further questions can be asked about whether delusions of , thought withdrawal and exist. They may also ask if they feel controlled by any outside force. We may be able to comment whether the is persecutory, grandiose, nihilistic, hypochondriacal, religious, et cetera.

Illusions and hallucinations

It may be very difficult to comment on these without seeing the patient and just on the telephone call. We may only be able to take the related history. We could of course ask questions about any ‘visions’ the patient experiences or ‘voices’ that they may hear. We need to also ask relevant questions to rule out physical health causes that may lead to in order to formulate appropriately.

Orientation

We may be able to comment about this with or without asking any specific questions. We can comment whether the patient is able to maintain and concentration throughout the phone call. There are numerous standardised guidelines and telephone assessments are available to assess the and cognitive state of patients which could be used if necessary.

Insight

It is important to keep in mind the complexity of the case in hand and remember that we do not have a full picture whilst speaking to patients on the phone. If we have met the patient previously, we may be able to comment better than if we have never met the person that we speak to on the phone. Direct questions can be asked to assess this. It would also be important to reiterate any plans made with the patient and understand their comprehension. It may be possible to assess patient’s capacity with a telephone call.

Risk Assessment

Although risk assessment is primarily a history taking task, staff should be able to use the mental state examination of the patient as described above to strengthen the risk assessment and telephone calls should not be a deterrent to asking difficult questions about suicidality, thoughts to harm others, et cetera.

Practical difficulties

 Need for an interpreter  Unresponsive patient  Overactive patient  Confused patient  Manipulative patient