Psychiatry, substance use and safeguarding

Mental state examination: ASEPTIC

The mental state examination describes the person’s current experience and your observations. ASEPTIC is a way to organise that description. Use accurate, neutral language and distinguish observed findings from answers to questions.

Depersonalisation describes feeling detached from oneself; derealisation describes the surroundings feeling unreal. Clarify the person’s actual experience before attaching a label. If an account seems unusual, remain curious and respectful rather than challenging it aggressively or agreeing that an unverified belief is true.

Present and plan

“The main problem is… The relevant mental state findings are… My immediate concerns are… I have not yet clarified… I would address the physical needs, discuss these findings with my supervisor and arrange the appropriate mental health assessment.”

Your summary should include the time course, functional effect, relevant background and reasons for concern. Do not report unasked questions as normal findings. Explain the proposed plan to the person, identify who will assess them next and keep physical treatment and mental health care connected.

After self-harm

Address injury, poisoning and immediate safety while arranging early, age-appropriate psychosocial assessment. Explore the circumstances, current needs, suicidal thoughts, support and the person’s own priorities. NICE advises against using risk scales or low/medium/high labels to predict suicide or repeat self-harm, or to decide treatment or discharge. An individual formulation and care plan are needed.

A collaborative safety plan may include warning signs, coping strategies, trusted contacts, crisis help and reducing access to means. Before discharge from a general hospital after self-harm, the responsible team should complete psychosocial assessment, management and discharge planning, with aftercare specified and communicated. Continuing safety concerns require initial aftercare within 48 hours of psychosocial assessment. NICE NG225: self-harm assessment and care.

As a student, recognise and communicate urgent concerns, contribute a careful history and explain your role. Do not independently decide that someone is safe to leave because they deny current intent, have a reassuring score or have promised not to harm themselves. If they want to leave before assessment, obtain urgent help and address their concerns while the responsible team considers capacity, safety and the lawful options.

AMTS: a brief screen, not a diagnosis

The Abbreviated Mental Test Score samples orientation and memory. The traditional ten prompts cover age, time, an address recalled later, year, current location, recognition of two people, date of birth, a historical date, the current monarch or specified leader, and counting backwards. Use the approved version and instructions in your setting rather than changing questions ad hoc. The original British Geriatrics Society AMTS form remains available as a teaching reference.

Record the score alongside the circumstances, including language, hearing, education, distress and baseline ability. A cutoff does not diagnose delirium or dementia, and neither a low nor a normal score decides capacity. A history of new or fluctuating change may matter more urgently than the total.

Delirium and the MMSE

Acute or fluctuating inattention or confusion should prompt assessment for delirium and its causes. NICE recommends the 4AT when indicators are present, used by a competent practitioner; CAM-ICU or ICDSC is used in critical care or postoperative recovery. A suitably experienced clinician makes the diagnosis and the team looks for contributing illness, medicines and unmet needs. NICE CG103: delirium.

The Mini-Mental State Examination is a different structured cognitive assessment. Use an authorised form and the correct administration instructions. Cognitive testing needs interpretation with history, collateral information and examination; a normal score alone does not exclude dementia. NICE NG97: dementia assessment.

When the adult has capacity

Respect a valid informed refusal, while exploring alternatives and offering follow-up and safety-net advice. Document the conversation and remaining concerns. Capacity is not an automatic discharge instruction: the responsible team must also consider the clinical situation and whether another lawful framework, such as mental health legislation, is relevant.

When capacity is lacking

Involve the person as much as possible and obtain help from the clinician responsible for the decision. In England and Wales, consider best interests, the person’s wishes and values, appropriate consultation, any relevant legal decision-maker and a valid applicable advance refusal. Choose the least restrictive suitable option and review when capacity may return. Lack of capacity is not blanket authority to restrain someone or deprive them of liberty; the legal basis and safeguards require careful consideration. Uncertainty or disagreement may need specialist, advocacy or legal support.

Children and young people

A person aged 16 or 17 is generally presumed able to consent. A younger child may be able to consent when they have sufficient understanding and maturity for the particular decision. Fraser guidance concerns contraceptive advice and treatment, rather than being a general test for every childhood decision. Refusal of important treatment by a young person raises legal issues that differ across the UK; do not reduce it to “children cannot refuse”. Involve senior paediatric and legal support when needed. GMC guidance on decisions with children and young people.

Take an informative history

• What substance, amount, strength and route? Establish timing, pattern, the last use and any combination with medicines or other substances. For alcohol, clarify container size and strength rather than accepting “a few drinks”.
• What happens when intake is reduced or stopped? Ask about morning drinking, previous withdrawal, seizures, delirium tremens and treatment.
• What has changed in physical or mental health, nutrition, injuries, work, relationships, finances and caring responsibilities?
• What does the person think about their use, what has helped previously and what support would they accept?

The CAGE prompts concern cutting down, others’ criticism, guilt and morning drinking. Those issues may be useful in a conversation, but current UK guidance favours a validated tool such as UK AUDIT or AUDIT-C for identification. An AUDIT-C score of five or more prompts the full AUDIT. A screen guides assessment; it is not a diagnosis. DHSC identification and brief interventions guidance, updated April 2026.

Discuss change and make a safe plan

“Would it be all right to talk about how drinking may be affecting your health? What changes, if any, have you been thinking about? We can work out what support would be useful.”

For adults who drink, UK lower-risk guidance advises not regularly exceeding 14 units weekly, spread over three or more days. Lower risk does not mean no risk. If dependence is possible, do not advise abrupt unsupported cessation: withdrawal can be dangerous. Arrange specialist assessment and a safe plan rather than treating brief advice as sufficient for dependence. NHS alcohol guidance.

Severe withdrawal, seizures, delirium or suspected Wernicke’s encephalopathy need urgent hospital treatment. Withdrawal medicines require a suitable regimen and monitoring. Thiamine treatment depends on clinical risk; suspected Wernicke’s requires prompt parenteral treatment. As a student, identify the concern and explain that the treating clinician will assess and prescribe, rather than promising a routine intravenous vitamin and sedative. DHSC alcohol care in acute hospitals.

Severe agitation

Describe the behaviour and physiological disturbance rather than using a label as a diagnosis. Use calm communication, reduce stimulation and obtain urgent skilled help. Look for causes such as hypoxia, hypoglycaemia, intoxication, withdrawal, delirium or head injury. Restrictive interventions and sedation require trained staff, a lawful basis, monitoring and the ability to manage complications; a student should not attempt them independently. Keep observing and communicating changes while the team responds.

A child discloses harm

“Thank you for telling me. You have not done anything wrong. I need to tell the people whose job is to help keep you safe, and we will explain what happens next.”

Do not repeatedly question the child to investigate the allegation. Record their words, address medical needs and follow the local child-protection pathway. Take advice before informing a parent or alleged abuser if doing so could increase danger. Resolve immediate safety arrangements with the responsible team before discharge. NICE child abuse and neglect guidance.

Adults, domestic abuse and FGM

For an older person, consider neglect, coercion, financial or physical abuse and care needs; age alone does not imply incapacity. With domestic abuse, speak privately and consider whether contact, written information or disclosure could increase risk. Ask what support the person wants and follow the applicable adult-safeguarding framework. NICE domestic violence and abuse guidance.

FGM is a safeguarding concern. In England and Wales, regulated health and social care professionals and teachers have a specific police-reporting duty for known cases in under-18s identified through disclosure or visual identification in the course of their work. A student must raise the concern promptly with the responsible professional and safeguarding team; do not perform an examination simply to establish whether the reporting duty applies. Suspected risk also needs safeguarding action. Government FGM reporting guidance.

Mental health scenarios

Practise assessments involving postpartum depression, acute psychosis, severe eating disorders and delirium. Assess physical and psychological needs together, including the safety of a baby or other dependants where relevant. New severe mental illness after childbirth needs prompt specialist assessment; do not dismiss it as ordinary tiredness. In an eating disorder, physical instability may be serious despite a reassuring appearance. Use Medical Emergencies in Eating Disorders (MEED), which replaced MARSIPAN, alongside the treating team’s assessment.