The mental state examination: how to do it and write it up on the ward

The mental state examination is the part of a psychiatric assessment that new doctors find hardest to write, and the part everyone after you reads first.

When I started in psychiatry I could list the headings but not fill them. I'd write "mood low, no psychotic features, insight poor" and move on. It looked complete, and it told the next person almost nothing.

Here's how I do it now on the ward: what to notice from the door, what to ask under each heading, what to write, and which findings mean you stop and act. There's a template further down you can copy into the notes.

What the mental state examination is, and what it isn't

The history is the story over time. The MSE is a snapshot: what you saw and heard in this interview, on this day. Think of it as the psychiatric version of the physical examination.

So every line should be something you observed, or something the patient described about their experience right now. "He heard voices last month" belongs in the history. "He says the voices are talking about him as we speak" belongs in the MSE.

Before you go in

Five minutes of preparation saves you from walking in blind. This is what I do before every review:

• Read the notes. Why they were admitted, the last MSE, and any history of self-harm, violence or absconding.

• Check the drug chart. A new antipsychotic, a recent dose change or a sedative given overnight changes how you read a tremor, restlessness or drowsiness.

• Ask the nurse who knows them. How they slept, whether they're eating and drinking, how they've been with others, and whether they seem to be listening to things nobody else can hear.

• Plan for safety. Pick a room where you can both leave easily and you sit nearer the door. Carry your alarm and know how it works. Tell someone where you're going, and take a colleague if the patient is new to you or you have any doubt. Try not to see patients alone

Tip: Ask the nurse one direct question: "Is there anything you've seen that worries you?" The nursing team has watched this person for a whole day. You'll have them for forty minutes.

From the door: appearance and behaviour

The examination starts before you say a word. Notice where the patient is and what they're doing. Lying in bed at midday with the curtains drawn tells you something. So does pacing the corridor, or chatting at the nurses' station.

Then, as you sit down and start talking, take in:

• Appearance. Clothing and whether it suits the setting and the weather, self-care, apparent age against real age, weight, and any injuries, old or new.

• Alertness. Awake and with you, drowsy, or drifting in and out. It's an easy observation to skip, and it can change the whole diagnosis.

• Eye contact and rapport. Whether they look at you, and whether you feel you've made a connection.

• Movement. Slowed or restless. Look for tremor, stiffness, abnormal mouth or tongue movements, and akathisia, where an inner restlessness keeps them shifting in the chair.

• Response to unseen stimuli. Pausing as if listening, glancing at an empty corner, muttering, or smiling at nothing you can see.

Describe rather than label. "Dishevelled" is a judgement. "Wearing the same clothes as on admission two days ago, hair unwashed" is a picture the next doctor can compare against.

Speech, mood and affect

Speech

You assess speech by listening, so let the patient talk early. I open with something broad, such as "Can you tell me what's been happening?", and try not to interrupt for the first couple of minutes.

Note the rate, the volume, how much they say without prompting, the tone, and how easy they are to interrupt. Slurred or effortful speech matters too.

Keep speech and thought apart in the notes. Speech is how the words come out. Thought form is how the ideas join up. Pressured speech is a speech finding, while flight of ideas is a thought finding, even though you often hear both at once. The chapter on disorders of speech and thought sets out the terms.

Mood

Mood is what the patient tells you, so ask and write their words in quotation marks:

• "How have you been feeling in yourself?"

• "If 0 is the lowest you could feel and 10 is the best, where are you today?"

• "Is it there all the time, or does it lift at all?"

If the picture suggests mania, ask about it directly: "Have you felt unusually high, full of energy, or as if your thoughts are racing?" Irritability counts as well as elation.

Affect

Affect is what you see. Write its range, whether it shifts with what you're discussing, and whether it fits what they've told you. "Mood 'fine', 7 out of 10, but tearful and restricted when talking about her father" is a mismatch worth recording. So is someone smiling while describing something frightening.

Thought and perception: the questions to ask

Thought form

You don't ask about thought form. You hear it. If the answers are logical and stay on track, write "goal-directed". If they don't, quote a sentence or two. A real example is worth more than a term you're unsure of, and the next doctor can judge it for themselves.

Thought content

Start broad: "Is anything worrying you or on your mind at the moment?" Then follow what you hear.

If a belief comes up, explore it without arguing or agreeing. "You said the neighbours are involved. How did you work that out?" Then ask how sure they are, what they think will happen, and whether they've done anything about it. That last answer is often the most important line in your risk assessment.

Ask about thought interference and passivity in plain words:

• "Have you ever felt that thoughts were being put into your head, or taken out of it?"

• "Does it ever feel as if someone or something else is controlling what you do?"

Ask about suicide plainly, building up step by step. A review of the evidence found no rise in suicidal thinking from being asked about it. In my experience, many patients are relieved someone asked. The steps I use:

1. "How do you see the future?"

2. "Have there been times lately when life hasn't felt worth living?"

3. "Have you had thoughts of ending your life?"

4. "What have you thought about doing? Have you done anything to get ready?"

5. "What has stopped you so far?"

Then ask about others: "Have you had any thoughts of hurting someone else?" If there's a name, write it down.

Perception

A normalising lead-in makes these questions easier to answer. "I ask everyone this. When people are under a lot of strain, some hear a voice when nobody's around. Has anything like that happened to you?"

If the answer is yes, find out what the voice says, how often, whether it talks to them or about them, and whether it seems to come from inside their head or through their ears. Ask about commands: "Does it ever tell you to do things? Have you ever done what it said?"

Ask about the other senses too: things seen, smelt, tasted or felt on the body. New visual hallucinations make me look hard for a physical cause, including delirium and substances, before anything else. The chapter on disorders of perception covers how to tell hallucinations, pseudohallucinations and illusions apart.

Cognition, insight and capacity

Cognition

Test cognition in proportion to the patient in front of you. A young adult with a clear, coherent story may need only alertness, orientation and a test of attention. Someone older, or anyone newly muddled, needs more.

Go in this order, because each step depends on the one before:

1. Alertness, which you've already watched.

2. Orientation to time, place and person.

3. Attention: months of the year backwards, or serial sevens from 100.

4. Memory: give a name and address, check they've registered it, and ask for it again at five minutes.

Insight

Insight comes in parts, so describe the parts rather than scoring it:

• "What do you think has been going on?"

• "Could any of this be down to an illness?"

• "Is there anything you think would help?"

• "How do you feel about the medication?"

Someone can accept they're unwell and still reject the diagnosis. They can accept the diagnosis and still refuse one particular drug. Write which parts are there.

Capacity is a separate question

Capacity isn't part of the MSE, but it gets muddled with insight. Under the Mental Capacity Act 2005, which covers England and Wales, capacity is about one decision at one time. The person must be able to understand the information relevant to it, retain it, use or weigh it, and communicate a choice.

Poor insight doesn't mean someone lacks capacity, and neither does a diagnosis. An unwise decision doesn't either. If a decision is needed, assess it for that decision and record it under its own heading.

Writing it up: a template you can copy

MENTAL STATE EXAMINATION

Seen: [date, time, place] Present: [who else was in the room]

Sources: patient; nursing report from [name, role]; notes

Appearance and behaviour: [dress, self-care, injuries, alertness, eye contact,

rapport, movements, response to unseen stimuli]

Speech: [rate, volume, amount, tone, ease of interrupting]

Mood: "[their words]", [score] out of 10

Affect: [range, reactivity, congruent with mood or not]

Thought form: [goal-directed, or a quoted example]

Thought content: [preoccupations; beliefs, how firmly held, any action taken;

thought interference or passivity; thoughts of suicide or self-harm with

intent, plans, preparations and what stops them; thoughts of harm to others]

Perception: [what, how often, commands and whether acted on; or "denies;

not seen responding to unseen stimuli"]

Cognition: [alertness; orientation; attention test and result; recall at

five minutes; or why not tested]

Insight: [their explanation; illness or not; views on help and treatment]

Risk: [to self, to others, from others; what raises it; what protects them]

Plan: [observation level, physical checks, collateral, who you discussed it with]

On risk, NICE's self-harm guideline advises against sorting people into low, medium or high risk to predict suicide or repeat self-harm. It asks for a risk formulation instead. So I write what the risk is, what would raise it, what protects them, and what we're doing about it.

What I'd do on your next admission

Ask your registrar or consultant to watch you do one and read your write-up afterwards. It's the fastest way I know to improve, and it can count as a workplace-based assessment.

In the CASC, the mental state stations test the same skills: a normalising lead-in, open questions before closed ones, and following up what you hear rather than reading down a list. Practising properly on the ward is the best preparation I can suggest.

Raj

References

1. National Institute for Health and Care Excellence. Self-harm: assessment, management and preventing recurrence (NG225). 2022. https://www.nice.org.uk/guidance/ng225

2. National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care (CG103). 2010, updated 2023. https://www.nice.org.uk/guidance/cg103

3. UK Parliament. Mental Capacity Act 2005, section 3: inability to make decisions (2005 c. 9). 2005. https://www.legislation.gov.uk/ukpga/2005/9/section/3