Understanding Mental Health Medical Reports: A Guide to Psychiatric Evaluations and Testing
Learn how to understand mental health evaluations, psychiatric assessments, and psychological testing reports to better advocate for your mental health care.
Table of Contents
Mental Health Assessment Overview
Mental health medical reports are comprehensive documents that help healthcare providers understand your psychological well-being, diagnose conditions, and develop treatment plans. Unlike physical health tests, mental health assessments rely heavily on clinical observation, standardized questionnaires, and detailed interviews.
Why Mental Health Documentation Matters
- • Establishes baseline mental health status
- • Tracks progress over time
- • Guides treatment decisions and medication adjustments
- • Supports insurance coverage and disability claims
- • Facilitates communication between providers
- • Helps identify patterns and triggers
Understanding your mental health reports empowers you to participate actively in your care, ask informed questions, and make decisions about your treatment options.
Types of Mental Health Evaluations
Initial Psychiatric Evaluation
Components Include:
- • Chief complaint and present illness
- • Past psychiatric history
- • Medical history and medications
- • Social and family history
- • Mental status examination
- • Risk assessment (suicide, violence)
Typical Duration:
- • 60-90 minutes for comprehensive evaluation
- • May require multiple sessions
- • Follow-up appointments typically shorter
- • Urgent evaluations may be abbreviated
Psychological Testing
Cognitive Testing:
- • IQ tests (WAIS, WISC)
- • Memory assessments
- • Attention and concentration tests
- • Processing speed evaluations
- • Executive function assessments
Personality Testing:
- • MMPI-2 (Minnesota Multiphasic Personality Inventory)
- • PAI (Personality Assessment Inventory)
- • Rorschach Inkblot Test
- • TAT (Thematic Apperception Test)
Neuropsychological Testing:
- • Brain function assessment
- • Learning disability evaluation
- • Dementia and cognitive decline testing
- • ADHD assessment
Specialized Assessments
Substance Use Evaluation:
- • AUDIT (Alcohol Use Disorders Identification Test)
- • DAST (Drug Abuse Screening Test)
- • Addiction severity assessment
- • Readiness for change evaluation
Trauma Assessment:
- • PTSD Checklist (PCL-5)
- • Trauma history questionnaire
- • Dissociative experiences scale
- • ACES (Adverse Childhood Experiences)
Understanding Psychiatric Reports
Mental Status Examination (MSE)
The MSE is a structured assessment of a patient's psychological state at the time of evaluation. It's like a "snapshot" of mental functioning.
Appearance and Behavior:
- • Grooming and hygiene
- • Dress and appearance
- • Psychomotor activity
- • Eye contact and cooperation
Speech and Language:
- • Rate, rhythm, and volume
- • Clarity and coherence
- • Spontaneity
- • Language abnormalities
Mood and Affect:
- • Stated mood (what you report)
- • Observed affect (what's observed)
- • Range and appropriateness
- • Stability over time
Thought Process and Content:
- • Organization and flow of thoughts
- • Presence of delusions
- • Obsessions or preoccupations
- • Suicidal or homicidal ideation
Diagnostic Impressions
DSM-5 Diagnostic Criteria
Mental health diagnoses are based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Each diagnosis has specific criteria that must be met.
Diagnostic Format:
- • Primary diagnosis (main condition)
- • Specifiers (severity, course, features)
- • Additional diagnoses or conditions
- • Rule-out diagnoses (being considered)
Provisional vs. Confirmed Diagnoses
Initial impression requiring more information or time to confirm
Diagnosis meets full criteria based on available evidence
Risk Assessment Documentation
Suicide Risk Assessment
- • Ideation (thoughts of suicide)
- • Intent (plan to act on thoughts)
- • Plan (specific method and timing)
- • Means (access to method)
- • Protective factors
- • Risk level (low, moderate, high)
Violence Risk Assessment
- • History of violent behavior
- • Current thoughts of violence
- • Specific targets or threats
- • Substance use factors
- • Impulse control
Safety Planning
High-risk assessments should include safety planning, crisis contacts, and follow-up arrangements. Don't hesitate to ask about your safety plan if you're at risk.
Psychological Testing Results
Understanding Test Scores
Standard Scores and Percentiles
| Standard Score | Percentile | Classification |
|---|---|---|
| 130+ | 98th+ | Very Superior |
| 120-129 | 91st-97th | Superior |
| 110-119 | 75th-90th | High Average |
| 90-109 | 25th-74th | Average |
| 80-89 | 9th-24th | Low Average |
| 70-79 | 2nd-8th | Borderline |
| Below 70 | Below 2nd | Significantly Impaired |
Important Notes About Test Scores:
- • Scores represent performance on a specific day
- • Cultural, linguistic, and educational factors can affect results
- • Test anxiety or fatigue may impact performance
- • Patterns across tests are more meaningful than isolated scores
- • Scores should be interpreted by qualified professionals
Common Psychological Tests Explained
MMPI-2 (Minnesota Multiphasic Personality Inventory)
567-item questionnaire that assesses personality traits and psychopathology.
Clinical Scales:
- • Depression
- • Anxiety
- • Hysteria
- • Psychopathic deviate
- • Paranoia
- • Psychasthenia
- • Schizophrenia
- • Hypomania
- • Social introversion
Validity Scales:
- • Response consistency
- • Over-reporting symptoms
- • Under-reporting symptoms
- • Defensiveness
- • Random responding
Beck Depression Inventory (BDI-II)
21-item self-report measure of depression severity.
Minimal
Mild
Moderate
Severe
GAF (Global Assessment of Functioning)
0-100 scale rating overall psychological, social, and occupational functioning.
- • 91-100: Superior functioning
- • 81-90: Absent or minimal symptoms
- • 71-80: Transient symptoms
- • 61-70: Mild symptoms
- • 51-60: Moderate symptoms
- • 41-50: Serious symptoms
- • 31-40: Major impairment
- • 21-30: Severely impaired
- • 11-20: Danger of harm
- • 1-10: Persistent danger
Common Mental Health Screening Tools
Depression Screening
PHQ-9 (Patient Health Questionnaire)
9-item depression screening tool
- • 0-4: Minimal depression
- • 5-9: Mild depression
- • 10-14: Moderate depression
- • 15-19: Moderately severe
- • 20-27: Severe depression
Anxiety Screening
GAD-7 (Generalized Anxiety Disorder)
7-item anxiety screening tool
- • 0-4: Minimal anxiety
- • 5-9: Mild anxiety
- • 10-14: Moderate anxiety
- • 15-21: Severe anxiety
PTSD Screening
PCL-5 (PTSD Checklist)
20-item PTSD screening tool
- • Score ≥33: Probable PTSD
- • Assesses symptom clusters
- • Tracks symptom severity
- • Monitors treatment response
Substance Use Screening
AUDIT (Alcohol Use Disorders)
10-item alcohol screening tool
- • 0-7: Low risk
- • 8-15: Hazardous use
- • 16-19: Harmful use
- • 20+: Alcohol dependence
Psychiatric Medication Monitoring
Blood Level Monitoring
Some psychiatric medications require regular blood tests to ensure therapeutic levels and monitor for side effects.
| Medication | Therapeutic Range | Monitoring Frequency |
|---|---|---|
| Lithium | 0.6-1.2 mEq/L | Every 3-6 months |
| Valproic Acid | 50-125 μg/mL | Every 6-12 months |
| Carbamazepine | 4-12 μg/mL | Every 6-12 months |
| Clozapine | 350-600 ng/mL | Monthly |
Side Effect Monitoring
Common Lab Tests:
- • Complete Blood Count (CBC)
- • Comprehensive Metabolic Panel
- • Liver function tests
- • Thyroid function (TSH)
- • Lipid panel
- • Prolactin levels
- • HbA1c (diabetes screening)
Physical Monitoring:
- • Weight and BMI
- • Blood pressure
- • Heart rate and rhythm
- • Movement disorders (tardive dyskinesia)
- • Skin changes
- • Sexual side effects
Side Effects to Report:
- • Unusual mood or behavior changes
- • Suicidal thoughts or self-harm urges
- • Severe or persistent side effects
- • New or worsening symptoms
- • Allergic reactions
- • Problems with coordination or movement
Treatment Planning and Goal Setting
Components of a Treatment Plan
Problem Identification:
- • Primary symptoms or concerns
- • Functional impairments
- • Risk factors
- • Strengths and resources
Treatment Goals:
- • Specific and measurable objectives
- • Timeframes for achievement
- • Methods for tracking progress
- • Patient preferences and values
Interventions:
- • Psychotherapy approaches
- • Medication recommendations
- • Lifestyle modifications
- • Support services
Monitoring Plan:
- • Follow-up appointments
- • Progress measurements
- • Safety assessments
- • Treatment adjustments
Evidence-Based Treatment Approaches
Psychotherapy Types:
- • CBT (Cognitive Behavioral Therapy): Changes thought patterns and behaviors
- • DBT (Dialectical Behavior Therapy): Emotional regulation and distress tolerance
- • EMDR (Eye Movement Desensitization and Reprocessing): Trauma processing
- • ACT (Acceptance and Commitment Therapy): Mindfulness and value-based living
- • IPT (Interpersonal Therapy): Relationship and communication skills
Medication Classes:
- • Antidepressants: SSRIs, SNRIs, tricyclics
- • Anxiolytics: Benzodiazepines, buspirone
- • Mood stabilizers: Lithium, anticonvulsants
- • Antipsychotics: Typical and atypical
- • ADHD medications: Stimulants, non-stimulants
Self-Advocacy Tips for Mental Health Care
Preparing for Appointments
- • Keep a symptom diary or mood tracker
- • List medications and side effects
- • Prepare specific questions
- • Bring support person if helpful
- • Note what treatments have/haven't worked
- • Track functional improvements or decline
Questions to Ask
- • What do my test results mean?
- • How was my diagnosis determined?
- • What are my treatment options?
- • What are the risks and benefits?
- • How will we measure progress?
- • When should I expect improvement?
- • What should I do in a crisis?
Understanding Your Rights
Healthcare Rights:
- • Access to your medical records
- • Second opinions
- • Informed consent for treatment
- • Confidentiality and privacy
- • Participate in treatment decisions
When to Seek Help:
- • Suicidal or homicidal thoughts
- • Severe medication side effects
- • Worsening symptoms
- • Concerns about treatment
- • Need for disability accommodations
Need Help Understanding Your Mental Health Reports?
Upload your psychiatric evaluations, psychological testing reports, or mental health assessments to get clear, compassionate explanations that help you understand your mental health journey.
Related Articles
Understanding Blood Test Results
Learn how to interpret blood work that may be related to mental health conditions.
Preparing for Doctor Appointments
Get the most out of your mental health appointments with proper preparation.
Questions to Ask Your Doctor
Important questions to ask about your mental health treatment and progress.