Nurses play an important role in ensuring not only the physical but also the mental health of their patients. Awareness of the importance of mental wellbeing in medical practice is growing, and nurses are becoming increasingly involved in assessing and managing patients' mental states.
More than one in five U.S. adults lives with a mental illness.
In this article, we will review the main tools and applications that nurses can use in their work to assess the mental status of patients and discuss their importance in everyday practice.
Conversation as The Main Tool
Clinical interview is the simplest yet most effective technique with which mental health nursing begins.
Medesk helps to automate record keeping and recreate an individual approach to each patient, paying maximum attention to him.
Learn more >>When talking to the patient, the nurse will find out what the patient thinks about his or her state of health (feelings, emotions, perception of his or her condition, and life situation).
For example, the patient may tell her that he hears voices, describe pain, its frequency, duration, localisation and intensity. Information from friends, relatives, and other health professionals is also important.
Here is the general flow of such an interview:
- The nurse begins the interview by establishing trust. She may introduce herself, explain the purpose of the meeting, and reassure the patient that their information is confidential.
- Then the nurse may ask general questions about how the patient is feeling at the moment. This may include questions about mood, anxiety level, sleep, and appetite.
- She may talk about the patient's psychosocial and medical history, including previous diagnoses, treatments, risk factors, and family and social history.
- Then follow questions aimed at assessing specific symptoms characteristic of mental disorders, such as depression, anxiety, restlessness, hallucinations, or delirium.
- The risk of self-harm or injury to others is assessed next. This may include questions about the presence of suicidal thoughts and suicide risk, plans or attempts, and the presence of aggression or violence.
- The nurse may ask about the patient's ability to perform daily functions such as self-care, work, and socialising with others.
- Based on the results of the interview, the nurse may work with the patient and other members of the healthcare team to develop an individualised care planning and treatment plan.
It is necessary to note and record verbal and non-verbal signs indicating the patient's condition:
- his posture;
- movements;
- facial expressions;
- gestures;
- ability to communicate;
- manner of speaking;
- adequacy of a reaction to a given question;
- logical construction of phrases and thought processes;
- features of voice.
The nurse analyses each patient's health problem and formulates it in the form of a brief conclusion (a nursing diagnosis). Providers and nurses use modern practice management software with pre-built templates for diagnostic sheets, questionnaires, and medical reports to facilitate and automate the process.
4 Mental Health Clinical Assessment Tools
Mental health assessment tools are field-tested guidelines for the assessment of patients suspected of various psychiatric conditions: psychosis, schizophrenia, obsessions, depression, and anxiety. We will review the main ones.
1. Generalized Anxiety Disorder 7 (GAD-7)
The GAD-7 is a brief self-report tool used to screen for and assess the severity of generalised anxiety disorder. It consists of seven items that ask about common symptoms of anxiety over the past two weeks, including nervousness, worry, and restlessness.
Each question is scored on a scale of 0 to 3, where 0 is "never", 1 is "some days", 2 is "most of the time", and 3 is "almost every day". The total score ranges from 0 to 21.
Here are the seven questions that make up the GAD-7:
- How often do you worry or feel nervous about various things?
- How much of a problem is it for you?
- How difficult is it for you to control your anxiety?
- How often do you worry that you might do something badly?
- How much does this prevent you from relaxing?
- How much do you become irritable because of it?
- How afraid are you of something bad happening to you?
The total score is then calculated and interpreted as follows:
0-4 points: Normal level of anxiety.
5-9 points: Mild anxiety.
10-14 points: Medium anxiety.
15-21 points: Severe anxiety.
This tool is a useful instrument for quick and effective assessment of GAD symptoms. Nurses use it in clinical practice for screening, assessing symptom severity, and tracking treatment effectiveness.
2. Hamilton Rating Scale for Depression (HAM-D)
The HAM-D consists of 17 or 21 questions (depending on the version) that assess the depression scale and various aspects of depression, such as mood, interests, energy, appetite, sleep, psychomotor activity, guilt, and suicidal ideation. Questions are worded so that they can be scored on a scale of 0 to 4 or 0 to 2, where 0 means no symptom and 4 or 2 means maximum symptom severity.
The HAM-D assessment process includes the following steps:
1) The nurse asks the patient a series of questions regarding their emotional and mental state over the past few days or weeks. For example:
"Over the past week, have you felt sad, down, or depressed most of the time?"
"Do you often feel guilty or blame yourself for things, even if they are not your fault?"
"Have you had any thoughts of harming yourself or ending your life in the past week?"
"Have you had trouble falling asleep or staying asleep at night?"
"Do you find yourself losing interest in activities that you used to enjoy?"
"Have you been feeling tired or lacking in energy, even after getting enough sleep?"
"Do you have trouble concentrating or making decisions?"
2) The patient's responses to the questions are scored according to the criteria of the HAM-D scale. Each symptom is scored on a scale of 0 to 4 or 0 to 2.
3) The scores for all questions are summed to determine a total scale score. Typically, the maximum possible total score is 52 or 66 (depending on the version of the scale).
4) The interpretation of the total score helps to determine the severity of the patient's depression. Typically, higher scores correspond to more severe symptoms of depression.
3. Mini Mental State Examination (MMSE)
The Mini Mental State Examination (MMSE) is a brief psychometric tool used to assess a patient's cognitive functioning and identify signs of pathology, such as dementia.
The MMSE covers orientation in time and space, memory, attention, speech, abstract reasoning, and the execution of simple commands. The creators' version of the MMSE includes 30 items, each of which is scored from 0 to 3 points, giving a maximum final score of 30.
The evaluation process using the MMSE typically involves the following steps:
1) Orientation in time and space:
"What is today's date?"
"What is the year, month, or day?"
"Where are we right now?"
"What is this place?"
2) Registration:
"I am going to say three words, and I want you to remember them. The words are: ball, hat, tree. Please repeat them after me and try to remember them for later."
3) Attention and counting:
"Count backward from 100 by subtracting 7 each time." (1 point for each correct subtraction; stop after five answers).
4) Reproduction:
"What were the three words I asked you to remember earlier?" (1 point for each correct word recalled).
5) Speech and abstract thinking:
"Follow a three-step command: Take the paper in your hand, fold it in half, and put it on the floor." (1 point)
"Read this and do what it says." (1 point for each correct step): (Show the patient a written command such as 'Close your eyes.')
6) Visual function and command performance:
"Draw a clock showing 10 minutes past 11."
Lower scores may indicate the presence of cognitive impairment or dementia and require further evaluation and assessment by a mental health professional.
4. CAGE Questionnaire
The CAGE Questionnaire is a short questionnaire used to assess the risk of alcohol dependence or substance abuse. The name "CAGE" is formed by the first letters of four key questions in English: Cut down, Annoyed, Guilty, Eye-opener.
Assessment with the CAGE Questionnaire typically involves the following steps:
1) The nurse explains to the patient that the questions are designed to assess their relationship to alcohol and can help determine if they have a drinking problem.
2) Questioning:
Cut down: "When you think about your alcohol consumption, have you ever tried to cut down on the amount you drink?"
Annoyed: "Do you ever feel annoyed or unhappy with criticism about your alcohol consumption?"
Guilty: "Have you ever felt guilty about your drinking?"
Eye-opener: "Have you ever drunk alcohol first thing in the morning to quench your thirst or calm your nerves?"
3) The nurse records the patient's responses to each question.
Medesk helps to automate record keeping and recreate an individual approach to each patient, paying maximum attention to him.
Learn more >>If the patient answered "yes" to one or more questions, this may indicate possible substance use problems. More positive answers may indicate an increased risk of alcohol dependence.
These screening tools can help nurses gather valuable information about patients' mental health symptoms, guide treatment planning, and monitor progress over time. However, it's important to remember that these tools should be used as part of a comprehensive assessment process and interpreted in conjunction with clinical judgement and other relevant information.
Classic tools for assessing mental health conditions are now also available online in the form of websites and apps that allow nurses to administer, score, and track patient responses.
We have gathered a selection of the most popular offerings on the IT market.
Professional Applications for Mental Health Nurses
DSM-5 Differential Diagnosis
The app from Unbound Medicine is designed specifically for accurate psychiatric diagnosis.
The app costs $69.99, but a free preview is available for you to evaluate the app's functionality: the 6-step diagnostic framework and interactive decision trees, to see how this app helps clinicians reach a diagnosis.
With the app, you can use DSM-5 classifications from the American Psychiatric Association, which will become a daily aid in making complex psychiatric diagnoses. Right in the app, using the decision tree, you can ask closing questions to establish initial diagnoses.
And after that, the DSM-5 app will give you tables of differential diagnoses to help confirm or present new options.
Additional features:
- ICD-codes
- A detailed breakdown of each diagnosis and disease
- Advanced app search
- Favourites tab.
Download the app:
App Store
Google Play
Connect2Care
Connect2Care is a free application from the University of Pittsburgh. It provides healthcare professionals with access to tools and resources for screening, brief intervention, and referral to treatment (SBIRT).
The app identifies patients who need interventions in real-time and supports professionals in providing these services. It is specifically designed for those who work with patients at risk of substance use disorder.
The app was developed over 5 years in collaboration with the Pennsylvania Department of Drug and Alcohol Programs (DDAP) in response to the escalating opioid epidemic.
Download the app:
App Store
Google Play
Connect2Care also supports Spanish, audio format, and large text. Based on screening results, the app will offer brief interventions and referral resources based on patient location and local treatment resources.
Read also:
APA Monitor+
Apa Monitor+ is a free application from the American Psychological Association. Although it does not contain instruments for assessing patients, you will find them in the app:
- the latest issues of Monitor on Psychology
- podcasts
- news
- evidence-based research in psychology and psychiatry.
You can register for educational programmes from APA, as well as connect with your peers and share experiences.
Download the app:
App Store
Google Play
ShinyMind
This is a free app developed for the NHS. The app doesn't diagnose patients, but the nurses themselves!
Here's what the creators of the app say themselves:
"We wanted to find a way to support the amazing staff who work in the NHS and have some of the most difficult, challenging, and stressful jobs."
The app contains over 100 interactive exercises and games to support the wellbeing and resilience of nurses and doctors. The programme is based on the company's new psychotherapy model, which includes:
- CBT
- transactional analysis
- and positive psychology.
Additional features:
- quick five-minute exercises for critical work situations
- communities and chats
- diaries and meditations.
Please note that an NHS email is required to register; you cannot register from a personal email account.
These apps help nurses assess the mental state of patients and detect disorders at an early stage.
Download the app:
App Store
Google Play
Apps such as ShinyMind, developed for mental healthcare workers, are essential to prevent burnout at work and reduced performance.
Did you like the article and feel your and your patients' fatigue symptoms recede? Then check out our blog, where we review new software and tools that make the lives of health service professionals more pleasant.
