How to do a Mental State Evaluation

I’ve been rotating through psychiatry, and it’s both more challenging and more fun than last year. One thing I’m happy about is that I already know how to perform a Mental State Evaluation (MSE). I remember it was really daunting to learn, and I’m also hearing from my friends in the year below me that they are having the same problem.

The problem is that it’s hard to teach the MSE. Here are some of my tips, for med students doing MSEs the first time. I’m by no means an expert, but these pointers have helped me.

how to mse

Before you start with the meat of the MSE, some things have to happen:

1. Know definitions

Knowing definitions in Psychiatry is kind of circular. Without knowing them, you’ll never recognise the signs in a patient. But without seeing the signs, the definitions will always be just some words strung together. I highly suggest knowing the definitions as well as possible before you do your first MSE. It’s pretty uncomfortable when you’re listening to a patient and you’re thinking, “I know something is very wrong here, but I don’t know what.” (It happens all the time. You’ll get better. Also, if you can’t name the sign: describe it.)

2. MSE is different to any examination you’ve learned

Realise that you’re learning this anew, and accept that it won’t come as easily as the inspection-palpation-auscultation trope you know so well. The thing about the MSE is that you perform it at the same time as you perform the history. The history is like your instrument for eliciting signs and symptoms.

3. Be safe and comfortable

Many students are worried about doing MSEs. They can be daunting. But as one of our professors put it, it’s the people on the street that are unpredictable. When someone has psychiatric pathology, you can predict them and protect yourself and them against possible risks. However, if you feel incredibly uncomfortable, don’t do an evaluation alone. Always position yourself nearest the door. If a patient is acutely manic, it may be best that he/she be sedated first, and your supervisor or the ward matron should be called in this regard.

4. To that end: establish rapport

Obviously, the first step to ANY consultation should be to establish rapport. But in the MSE, this is a wholly vital step, so much so that it is justifiable to spend even more time on it. I find it useful not to start right on in with, “What’s the matter?” but to ask some basic questions to make your patient feel more comfortable around you. Remember: nobody wants to go to a psychiatrist! (Or to a med student rotating through psychiatry.)

5. Context is important

I like to start by accumulating details about the patient. Where are they from? What is their race? Are they employed? In Psychiatry, these are very important as they directly affect not only the symptoms your patient presents with or the extent to which they effectively mask them, but they also directly affect how your patient will respond to different kinds of therapy. Don’t underestimate the PTSD a fifty-year-old man may have because he grew up in the Apartheid Era and was repeatedly detained without trial. Don’t underestimate the influence just growing up in a gang riddled neighbourhood may have on a toddler.

6. Ask about the main complaint

This is not part of the MSE yet, but it will help you examine the mental state. Note that a patient’s perception of their reason for presenting may be vastly different to the real reason.

7. Further questions on history

If you like talking or stories, you’ll love this. Psychiatry is interested in how the patient grew up, what happened to them during their childhood, even if they are now eighty years old! Don’t forget to ask about substances, forensic history, psychosexual experiences and familial relationships. Also the normal things like previous medical/surgical/psychiatric history.

8. Detail, detail, detail

An MSE is not a point-form examination. Your patient had TB? Great. They completed their 6 month regimen? Great. But were they ostracised by their community? Did they have trouble remembering to take their medication? Did they have any fearful experiences like coughing up litres of blood? Did they feel like a burden when they went to hospital? Did their estranged spouse attempt to have their children removed from their care?

Another example is that it’s not enough simply to write which drugs a patient has abused and for how long. Psychiatrists want to know why the patient started, why they like it, how they obtain it, and whether they have ever considered stopping.

9. Sometimes it’s hard to cut short

When you know you need loads of information, it can be hard to know when to interrupt your patient. And in psychiatry, when a patient is being tangential or circumstantial, it is REALLY hard to bring them back to the point. Like anything, this takes practice (I’m still bad at it). Sometimes you need to be firm and bring the patient back into focus. But take heed of how you phrase your questions. I slightly different manner of speaking may give much better results.

10. The embarrassed patient

Sometimes a patient is acutely aware that something is wrong. Some psychotic patients know that they shouldn’t be hearing voices, and some depressed patients are too proud to admit it. Empathy is the name of the game, but how do you put it into action? Again, it comes down to a lot of rephrasing.

Example: instead of asking a patient whether they have ever considered suicide, it may be useful to say, “Sometimes, when people have been through the things you have, they feel like they can’t go on with life. Have you ever felt that way?” It immediately conveys that you understand why they might feel that way.

Spot the thought-phenomenon.

Now, for the MSE. Most hospitals have pre-printed forms that can serve as guides, with more detailed headings. So I’m just going to discuss some broad headings. Better detail is available in all psychiatry textbooks. Note that order is NOT that important. You use the order that flows best in each situation.

1. Appearance and Behaviour

This is more than whether the patient is jaundiced or pale or obese. Is your patient well-kempt or shoddy? Have they combed their hair and shaved? Are they wearing pyjamas and slippers or day-clothes? What about their eye-contact – do they avoid it, or is it inappropriately obtrusive? Do they smile when you greet them? Are they restless or agitated? What about their attitude – are they co-operative or quite negative?

2. Cognition

You may have picked up on this during your interview. Is your patient oriented to date, place and person? Do they know their situation? What is your impression of their intellect? If you find you have to explain things the way you might to a child, there is a good chance for cognitive or intellectual deficits. Depending on how busy your hospital is you will either do a mini-mental on every patient, or only on those with potential cognitive deficits. Remember, it’s pretty hard to do an accurate MMSE on a patient who is acutely psychotic!

3. Speech

How fast is your patient speaking? How loudly? Is their speech pressured, or do you have to drag things out of them? Do they speak clearly? Is their speech logical? Do they make up new words? Do they take forever and a day to get to the point? Do they never reach the point?

4. Thoughts

Here we look at form and content. Note that speech and though overlap a little. Is your patient having flights of ideas or pressured thoughts, or does it appear as though they are thinking nothing? For content, are they delusional? Do they obsess over certain ideas? Do they think about harming themselves or others?

5. Perception

Here you are particularly interested in hallucinations or illusions experienced by the patient.

6. Mood and Affect

Be very clear about how the patient feels subjectively and what you witness objectively. Is the mood elevated or depressed? Remember to ask about functional symptoms like appetite, sleep and libido. Here I also usually enquire about anxiety symptoms.

7. Insight and judgment

Does your patient understand what is happening to them? Do they understand the necessity for treatment/therapy? Or do they think what has happened to them is nothing out of the ordinary? Do they understand the consequences of certain actions, and do they understand what is appropriate in interacting with others and their environment?

8. Risk assessment

Taking everything into context, you have to assess the patient’s risk to self and others. If their risk is moderate to high, you have to do a 72-hour assessment (under South African law – your country’s might differ slightly).

I have some more to say, but this post is getting pretty long. Feel free to add your tips (as I said, I’m NOT an expert) or ask questions (which I may or may not be able to answer). More later!

On a related-but-unrelated note: June is Mental Health Awareness Month with Ula and Leah. It’s a bookish event, so this post is not part of that, but here’s a heads-up that there will be some bookish posts about Mental Health! And some none-bookish ones too!


  1. I have been dx with a Severe Anxiety Disorder that is disabling. That dx actually took awhile and how does one really ascertain this, really? .

  2. Just…fantastic. More people should read this prior to their psychiatry rotations.

  3. harveylisam says:

    I’m glad you’re enjoying your psych rotation! And great reminder on the MSE 🙂

  4. good to see that u r busy helping other people but you were too busy to help me.i hate you.

    1. barefootmegz says:

      If you are going to post a rude comment on my blog, you may as well back it up and send me the link to where I did not help you.
      You should note that my blog is something I do for my own enjoyment and in my spare time. It is not my job. I respond to comments when I can, if I can, and I certainly do not have a duty to do so, but I respond as much as possible.
      You will do well to let go of your bitterness.
      I expect better from a student at Stellenbosch.
      If you choose not to back it up, I will be deleting your comment and all subsequent comments.

  5. yazi wena koot u ruined me.I shared my personal problems with u as your mentee and because I trusted u and u dicided to share them with your friends and everyone on campus knew about my problems.u discussed my academic perfomance with your friends, telling them im failing and now people look at me as a failure, asking people to help me academically and with textbooks without asking me first, there is a reason I told u not them.a mentunt that wanted to change my course to edp, that means u didnt believe in my potential, that im smart enough to pass mainstream, do u have any idea how that made me feel to know that u dont belive in me, a guy that I also happened to love.u do all these notes trying to help people while u couldnt help me as your mentee, u know other mentunts who care about their mentees they still helped them even in second year or throughout, they greet them and ask them about their academics, they are not like u, passing next to me like we never met .do u really want to know the main reason I was failing is because it was hurtful for me to see u with your girlfriend passing next to my window all cosy, knowing that u r inlove with another girl, I really couldnt concentrate.but other stuff as well did play a role but im not gonna share them with u have any idea how I feel when people say im struggling, knowing that I wasnt studying efectively because of u, it is not the point of not understanding the work, now people treat me like I dont know my work or like im dump or I need help from them because Im struggling, while u r busy thriving getting distinctions, if I could undo the past U WOULD PROBABLY BE THE PERson I wish I never met, who knows maybe if I never met u I would have been in 5th year by now and would have confidence in my self, I wouldnt feel like a failure and I would have never became family has lost trust in me that I would finish the course and my dream of becoming a doctor is at stake because I chose to distruct myself with u.u make feel stupid and weak and as my mentunt u should have just tried to help me by your self and if u couldnt u should have just asked my permission first before u ask other people and u definately shouldnt have discussed my personal problems and my academic perfomance with your friends.

    1. barefootmegz says:

      Girl, there are no words for the level of mistaken identity in this comment. My name is not Koot. I am not in Koot’s class. I do not even share Koot’s GENDER. All of these are things you would know if you took five minutes too look around this blog and see. It sucks that someone betrayed your confidence but THAT PERSON WAS NOT ME. I would actually delete your comment to save you the humiliation but I’ll leave it here in case you come looking for a reply. A gentle suggestion: discuss your grievance in person with the guy that hurt you. It’s the only way you will get closure. And consider getting help because you deserve healing.

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