Patient Assessment, Diagnosis, and Monitoring
Build the assessment in layers
Assessment questions reward a systematic, biopsychosocial approach. Know the components of the mental status exam - appearance, behavior, speech, mood (patient-reported) versus affect (observed), thought process and content, perception, cognition, insight, judgment - and be able to separate a sign (observed) from a symptom (reported). DSM-5-TR diagnosis is criterion-based and requires excluding substance/medication-induced and general medical causes (thyroid disease, delirium, B12 deficiency, sleep apnea, steroid-induced mania) before labeling a primary psychiatric disorder.
Know what each instrument does
Screening and severity tools are commonly confused. The PHQ-9 and GAD-7 screen and track severity but do not diagnose. The C-SSRS structures suicide risk assessment. The AIMS screens for tardive dyskinesia (roughly 2 or more on two items, or 3 or more on one item, prompts action). YMRS tracks mania; MADRS/HAM-D track depression; PANSS/BPRS rate psychosis; the Mini-Cog or MoCA screen cognition.
Monitoring is where points hide
Baseline and periodic metabolic parameters for antipsychotics (weight/BMI, waist circumference, blood pressure, fasting glucose or HbA1c, lipids), lithium levels with renal, thyroid, and calcium monitoring, clozapine ANC on its mandated schedule, and QTc assessment when risk factors accumulate.
Traps and a rule of thumb
Traps include calling a screening score a diagnosis, treating a delirium as psychosis, and missing that a new symptom (akathisia, hypothyroidism, hyponatremia) is drug-induced rather than a relapse. Rule of thumb: any acute change in mental status in a patient on psychotropics demands a medication and medical cause review before a dose increase.