About bipolar disorder Pendulum: stories and information Pre-diagnosis or newly diagnosed How psychiatric assessment works By Professor Guy Goodwin When psychiatrists conduct an assessment, they do so either in a consensual outpatient meeting or in a more highly-charged ‘Mental Health Act assessment’ when the patient may not be entirely happy to be there. In either case the objective of the psychiatrist is to understand what has been happening, to make an assessment of the patient’s mental state, to enquire about their personal story, generate a formulation (which may include a diagnosis), think about the need for additional tests or information and agree what to do next. In the case of an outpatient assessment, the psychiatrist will have received a more or less detailed letter from the referring GP. Speaking for myself, I prefer to have the patient bring along their most significant other – in the case of adults usually their partner. I will then see the patient alone and take about 30-40 minutes going through their account of events experiences and personal history. I will ask a lot of open-ended questions initially and then ask more directly about early adverse experiences, family history, personal development, employment and relationships. It is then often very helpful, with the patient’s consent, to see their significant other for 10 minutes and then spend another 10 minutes offering a formulation that summarizes my understanding and interpretation. Mental Health Act assessments are often, but not always of course, the prelude to compulsory admission to inpatient care. They usually take place in the patient’s home, but not always. For example, in an emergency the police can issue a warrant under section 135 of the Mental Health Act, which permits them to move or remove from home a patient to a “place of safety” (usually a hospital or police station). The personnel involved in assessment are an approved mental health professional, a psychiatrist who has “section 12 approval” (they have recently been on a recognized course) and another doctor (usually the patient’s GP). An “approved mental health professional” is traditionally a social worker, but psychiatric nurses, occupational therapists or clinical psychologists (but not medical doctors) with the necessary training can also act in this role. The principles and objectives of the assessment are ideally the same as those described previously. However, in practice the patient may be too preoccupied or over-active to participate normally in an interview. Every effort should be made at proper communication nevertheless. For the decision to be compulsory admission, both doctors must agree that a patient is suffering from a recognised mental disorder. The justification for overriding personal freedom in this way must be that it is in the interests of the patient’s own health and safety and/or to protect the safety of other people. One of two “sections” of the Mental Health Act may be invoked. Section 2 authorises detention in hospital for up to 28 days, primarily for assessment, and is the commonest outcome. Section 3 of the Act authorises detention in hospital for treatment for an initial period of up to 6 months, after which it can be renewed if necessary. Section 3 is only really appropriate when a patient’s need for treatment is well established on the basis of previous history. In the current pandemic, emergency legislation has modified some of the normal rules for Mental Health Act assessments. The most important practical change is that the requirement for patients to be seen in person has been relaxed to allow video assessment. This must be carefully justified and patients assessed in their homes should still be seen in person by the approved mental health professional and psychiatrist (not necessarily by the second doctor). Useful links: 5 things to know before attending your first psychiatry appointment. Mood scale Mood diary Details on apps for managing mood can be found here.