NRNMP 6635 Discussion: The Psychiatric Evaluation and Evidence-Based Rating Scales

According to Barnhill, J.( 2017), the core goals of the initial psychiatric interview are to ensure safety, understand the patient , and develop a workable treatment plan. Knowing the mental state of the patient at the initial evaluation enables the clinician to know if the patient is a danger to himself and others. Their previous mental history and treatment course also determines the course of treatment and saves time as we can avoid resorting to previous unsuccessful treatment plans.

The interview itself if well conducted, becomes part of the treatment process, shapes the nature of the patient-physician relationship, and provides information necessary to create an individualized treatment plan.(Sadock, B. et al; 2015)

Zimmerman, M. et al (2017), observes that although the Hamilton Anxiety Rating Scale(HAM-A)  was originally developed  to assess the severity of anxiety symptoms, the format of this rating scale has been criticized for not being properly structured to address the level of anxiety of patients, and as a tool that can be said to be assessing the level of depression rather than anxiety in some of the multiple symptoms addressed. It is sometimes difficult to determine if the ratings reflect symptoms of anxiety or side effects of medication.

Psychiatric rating scales are used for diagnosis, functioning  and symptom  severity. The Hamilton Anxiety Rating Scale (HAM-A) may be used to determine the severity of the clinical symptoms of anxiety in a patient who has already been diagnosed as suffering from anxiety and enables proper monitoring of symptoms in measurable terms to determine improvement in prognosis. The length of time to administer, the experience and training needed, may make this test less practical for everyday clinical practice.( E. Thompson, 2015).

References

Barnhill, J. W. (2017). The initial interview. Co-occurring Mental Illness and Substance Use Disorders: A Guide to Diagnosis and Treatment, 1.

Euan Thompson, Hamilton Rating Scale for Anxiety (HAM-A), Occupational Medicine, Volume 65, Issue 7, October 2015, Page 601, https://doi.org/10.1093/occmed/kqv054

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Zimmerman, M., Martin, J., Clark, H., McGonigal, P., Harris, L., & Holst, C. G. (2017). Measuring anxiety in depressed patients: A comparison of the Hamilton anxiety rating scale and the DSM-5 Anxious Distress Specifier Interview. Journal of psychiatric research, 93, 59-63.

Assessment is the basis of evidence discovery as it pertains to establishing foundational diagnoses and treatment plans predicated on a patient’s presentation. These next steps in the process of caring for a patient cannot accurately be had without pertinent assessment data (Sadock, et al., 2017). Just as pertinent to this data in information discovery as other data such as chief complaints and past medical, surgical, and psychiatric histories in the holistic assessment of a patient is their substance abuse history (APA, 2016; Sadock, et al., 2017). Given that this such history may be difficult to discuss for a patient, however, due to their own concerns of privacy, shame, or embarrassment, there are different resources with exceptional reliability and validity to investigate such potential concerns delicately and sensitively (Sadock, et al., 2017). A potential to implement for assessment purposes could be the Michigan Alcoholism Screening Test (MAST) that is the predecessor to the more commonly seen AUDIT (Alcohol Use Disorders Identification Test) and has been acknowledged as a reliable resource since the seventies (Center for Substance Abuse Treatment, 1997; Selzer, 1971). 

For the psychiatric interview, many facets of the assessment can be deemed important, such as the past psychiatric history of a patient, their coping skills and support systems, and their substance abuse history as it is being discussed currently. Whereas the past psychiatric history of a patient serves a more self-explanatory purpose to the psychiatric interview, it is important nonetheless, as it establishes a relevant baseline for a patient’s current problems if any, past or potential concerns, and can identify disorders that may be frequently comorbid with other psychiatric sequelae. In investigating whether a person is experiencing the problems of a psychiatric disorder, their social history may be important, however, the specifics that can be included of a patient’s psychosocial supports and coping mechanisms is a noteworthy inclusion because not only will a person’s potential problems be acknowledged, but so will the resources they use to challenge and overcome them. Knowing a person has adequate support or can be self-sufficient in times of need as applicable is important because it leads to the concerns that arise when they cannot. When maladaptive coping strategies come into play, the last – but certainly not least important – factor of the psychiatric interview as being reviewed currently comes into play. The substance abuse history of a patient is intertwined with the past psychiatric history of a patient and their coping mechanisms as a positive substance abuse history can be a product of a cooccurring psychiatric disorder from a commonly comorbid condition and exemplifies what problems may be present if a person has coping deficiencies and helps establish when substance usage can range from occasional and recreational to harmful, addictive, and maladaptive. When all these factors are accounted for, significant portions of a psychiatric interview can be accounted for, however, what will further be investigated is the substance use history, and more specifically, screening a patient’s alcohol use.  

The longstanding and ever-present availability of the MAST is a product of its 94 to 97 percent validity serving as an important psychometric property to gauge whether this twenty-five yes or no self-assessment holds its own to help establish diagnoses for practitioners (Minnich, et al., 2018). Regarding diagnostic validity, this tool also helps identify alcoholism, if not problematic alcohol use at an eighty percent rate which can be conceding as varying based on the use of certain questions or abbreviated versions of this test (Minnich, et al., 2018). The tool is fast enough to be done in minutes and can be deemed appropriate for a patient who is a reliable self-reporter, however, as previously mentioned, the reliability, validity, and even consistency of this test can speak for itself when the test is provided in its entirety. Albeit the 13-question version shortened MAST (SMAST) and the ten-question version of the brief MAST (BMAST) are less consistent than the MAST, they are still available as resources for assessing a patient, just not as recommended (Minnich, et al., 2019). The ideal use of the test is to assess new patients from teenagers, students, and adults on their engagement in problem drinking or possibility of them facing alcoholism (Minnich, et al., 2018). Being accurate, efficient, free to use, and quick to perform, the use of the MAST can be indicated to use to initially screen all patients, patients reporting new alcohol use, or patients reporting concerns of their alcohol use (Minnich, et al., 2018). When results are interpreted, as already mentioned, scores can differentiate between problem-drinking and alcoholism by providing assessment criteria to be used towards diagnosis as questions answer how alcohol use affects family, social, and vocational aspects of a patient’s life, the severity of which problems have occurred, and the patient’s perception – if not acceptance – of their own potential problem (Minnich, et al, 2019; Minnich, et al., 2018). 

The gift and curse of healthcare is the variety of resources available to help assess and diagnose patients. Whereas the options are bountiful, it begs the responsibility of a provider to discern which resources are most applicable to be implemented and are psychometrically reliable, consistent, and have significant validities to be utilized for their best application(s). As it concerns the MAST, its existence and utilization spanning forty years is a product of its ability to provide psychometrically appropriate assessment data to help a provider diagnose a patient and further implement adequate interventions to not only address problematic alcohol use if present but help address psychosocial deficiencies in a patient’s life to provide for them not only acutely, but holistically. To provide optimal care, such a practice should be considered ideal, and it was with the MAST, this ideal can be achieved more frequently by providers.  

References 

American Psychiatric Association (APA). (2016). Practice guidelines for the psychiatric evaluation of adults (3rd ed.). https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426760. 

Center for Substance Abuse Treatment. (1997). A Guide to Substance Abuse Services for Primary Care Clinicians. Substance Abuse and Mental Health Services Administration (US). 

Minnich, A., Erford, B. T., Bardhoshi, G., Atalay, Z., Chang, C. Y., & Muller, L. A. (2019). Systematic Evaluation of Psychometric Characteristics of the Michigan Alcoholism Screening Test 13‐Item Short (SMAST) and 10‐Item Brief (BMAST) Versions. Journal of Counseling & Development, 97(1), 15–24. https://doi-org.ezp.waldenulibrary.org/10.1002/jcad.12231 

Minnich, A., Erford, B. T., Bardhoshi, G., & Atalay, Z. (2018). Systematic Review of the Michigan Alcoholism Screening Test. Journal of Counseling & Development, 96(3), 335–344. https://doi-org.ezp.waldenulibrary.org/10.1002/jcad.12207 

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2017). Psychiatric interview, history, and mental status examination. In Kaplan and Sadock’s Concise Textbook of Clinical Psychiatry (4th ed., pp. 9–15). Wolters Kluwer. 

Selzer M. L. (1971). The Michigan alcoholism screening test: the quest for a new diagnostic instrument. The American journal of psychiatry, 127(12), 1653–1658. https://doi.org/10.1176/ajp.127.12.1653