Mental Health

#Mental Health Assessment

S: Subjective

Presenting Problems:

Current Symptoms:
(-) Low/depressed mood 
(-) Anxiety 
(-) Mood swings 
(-) Reduced ability to cope with daily problems or stress 
(-) Lowered energy or motivation 
(-) Elevated energy/arousal 
(-) Initial insomnia 
(-) Early morning wakening 
(-) Daytime sleepiness 
(-) Excessive fears or worries, or extreme feelings of guilt 
(-) Confused thinking or reduced ability to concentrate 
(-) Detachment from reality (delusions), paranoia or hallucinations 
(-) Trouble understanding and relating to situations and to people 
(-) Changes in eating habits or appetite 
(-) Weight loss/gain 
(-) Libido changes 
(-) Excessive anger, hostility or violence 
(-) Other ->

Recent Stressors/Triggers: 
(-) Financial 
(-) Housing 
(-) Employment (workloads, conflict, performance management, job loss)
(-) Physical health concerns 
(-) Legal (including crime or victim of crime)
(-) Relationships (including partner, family, friends, social media) 
(-) Isolation/loneliness 
(-) Loss/grief 
(-) Psychological trauma 
(-) Emptiness / lack of a sense of meaning or purpose
(-) Other ->

Suicide/Self-Harm: 
(-) ideation/thoughts
(-) intent/plan ->

Harm To Others: 
(-) ideation/thoughts
(-) intent/plan ->

Past Mental Health History: 
(-) Anxiety 
(-) Depression 
(-) Substance abuse (alcohol/other drugs) 
(-) Psychological/psychiatric treatment 
(-) Other ->

Mental Health Treatment History:

Medical/Biological History: 
(-) Acquired brain injury 
(-) Dementia 
(-) Neurological conditions 
(-) Menstrual dysphoria 
(-) Endocrine conditions 
(-) Medication affecting mood 
(-) Other ->

Developmental History: 
(-) Delayed early childhood milestones
(-) Learning difficulty
(-) Adverse childhood experiences (ACE):
  Abuse: 
    (-) Emotional abuse
    (-) Physical abuse
    (-) Sexual abuse
  Neglect:
    (-) Emotional neglect
    (-) Physical neglect
  Household challenges:
    (-) Mother treated violently
    (-) Substance abuse
    (-) Mental illness
    (-) Parental separation/divorce
    (-) Crime/incarceration

Current Domestic Situation:

Employment History:

Alcohol And Other Drug Use History:

Family History:
(-) Anxiety
(-) Depression
(-) Substance use disorder
(-) Schizophrenia
(-) Suicide
(-) Other ->

O: Objective

Mental State Observations: **abnormalities**
(-) Appearance
(-) Behaviour
(-) Motor activity
(-) Speech
(-) Mood (patient subjective)
(-) Affect (examiner observations)
(-) Thought processes
(-) Thought content
(-) Perceptions
(-) Cognition
(-) Orientation
(-) Attention/concentration
(-) Memory
(-) Abstract reasoning
(-) Insight
(-) Judgement
(-) Numeric skills
(-) Construction and spatial skills
(-) Abstract thinking
(-) Other observations ->

Mental Health Assessment Tool (K10/DASS21):

A: Assessment

Clinical Summary:

Diagnosis / DDx:
- Situational reaction

- Post-traumatic stress disorder
- Acute stress reaction

- Depression
- Depression/anxiety
- Generalised anxiety disorder
- Bipolar disorder
- Adjustment disorder
- Other mood disorder

- Specific phobia
- Panic disorder
- Agoraphobia
- Separation anxiety disorder
- Substance-induced anxiety disorder
- Obsessive compulsive disorder

- Schizophrenia
- Other psychotic disorder

- Dissociative disorder
- Eating disorder
- Impulse-control disorder
- Sexual disorder
- Sleep disorder
- Somatoform disorder
- Substance-related disorder

- Attention deficit hyperactivity disorder (ADHD)
- Autism spectrum disorder (ASD)

- Personality disorder
- Requires further evaluation

Predisposing Risk Factors:

Protective Factors:

Impairment (social, educational, employment):

Other Potential Risk Factors: 
(-) culturally or linguistically diverse
(-) disadvantaged geographical area or residence
(-) financial disadvantage
(-) prenatal and postnatal depression
(-) older persons mental health - 65+
(-) severe/high mental health needs

P: Plan

Investigations:

Treatment Goals:

Prescribed Medication:

Patient Education / Home Care Advice:

Psycho Education/Internet Referrals Or Recommendations: 
* HeadToHealth.gov.au (Comprehensive list of Australian resources)
* OnTrack.org.au (Free access to online programs, information, quizzes and advice)
* myCompass.org.au (Personalised self-help tool for your mental health)
* ThisWayUp.org.au (Practical tools to take care of your mental health)
* MindSpot.org.au (Free, anonymous assessment and treatment for Australian adults experiencing stress, anxiety, depression, OCD, PTSD, and chronic pain)
* ecouch.com.au (Interactive self-help and evidence-based information for social anxiety)
* MoodGYM.com.au (Interactive self-help book which helps you to learn and practise skills which can help to prevent and manage symptoms of depression and anxiety)
* ReasonsToStay.com.au (Suicide prevention skills)

Support Services And Crisis Services:

Suicide Call Back Service (anyone thinking about suicide)
  www.suicidecallbackservice.org.au 
  1300 659 467
Lifeline (anyone having a personal crisis)
  www.lifeline.org.au
  13 11 14
Beyond Blue Support Service (anyone feeling anxious or depressed)
  www.beyondblue.org.au
  1300 22 4636
Kids Help Line (counselling for young people aged 5 to 25)
  www.kidshelpline.com.au
  1800 55 1800
MensLine Australia (men with emotional and relationship concerns)
  www.mensline.org.au
  1300 78 99 78
Open Arms (veterans and families counselling)
  www.openarms.gov.au
  1800 011 046

Actions to be undertaken by patient: 
- At least 20-30 minutes of physical activity (such as walking) daily.
- Social activity:

Referrals:

Review:

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MBS (Australia) item numbers

* Indicates telehealth services.

^ Indicates phone services.

GP mental health treatment PLANS
- Plan preparation
  - GPs who HAVE completed Mental Health Skills Training
    - Item 2715: 20-39 minutes
    - Item 92116: 20-39 minutes*
    - Item 2717: 40+ minutes
    - Item 92117: 40+ minutes*
  - GPs who have NOT completed Mental Health Skills Training
    - Item 2700: 20-39 minutes
    - Item 92112: 20-39 minutes*
    - Item 2701: 40+ minutes
    - Item 92113: 40+ minutes*
- Plan review
  - Item 2712
  - Item 92114*
  - Item 92126^
GP mental health CONSULTATIONS
- Item 2713: 20+ minutes
- Item 92115: 20+ minutes*
- Item 92127^

Mental Health

MBS (Australia) item numbers

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