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Peter Yellowlees

There are advantages in meeting patients on their home ground.

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• When undertaking a psychiatric assessment in the community, success depends on engaging with the patient's major concerns first, winning trust and laying the foundation for more formal assessment of diagnosis and treatment later.
  
• The setting within the community may provide additional data that are valuable in the assessment (e.g., evidence of the patient's living skills and social connections).
  
• For effective assessment and follow-up, it is important to work with other services and mental health professionals, such as community mental health care teams.
  
• Some assessments in the community can be stressful or even dangerous; clinicians should take steps to look after themselves during and after stressful situations.

Box 2:
Decision tree for brief emergency assessments

Little has been written about the "real world" of psychiatric assessment in community practice, with no references on this topic appearing on Medline or Psychlit from 1983 to 1996. Major psychiatric textbooks^1-3 give detailed descriptions of how to examine the mental state of patients, as do textbooks on general practice.⁴ Such an assessment is all that one can make when seeing a patient in a controlled office or clinic setting, and the descriptions in the literature of how to do mental state examinations are generally written from that perspective. This article concentrates on psychiatric assessments as made by general practitioners and uses the mental state assessment as only one of a range of data-gathering exercises that are often required in community settings.

One important issue in community practice is the focus of the psychiatric presentation, because this is what gives the assessment its purpose. It is crucial to be pragmatic and to clarify what are the patient's major concerns before addressing any of one's own. This frequently means that considerable time is spent on issues such as finance, food, housing and carers' needs, which often need instant action.⁵ In community settings exploration of psychopathology and symptomatic treatment strategies is often of less immediate importance and can usually be more easily addressed later, once the trust of the patient has been engaged.

In emergency situations, assessments may often be fairly brief, especially if a situation is out of control. Such assessments should generally be aimed at answering the simple questions that differentiate whether a patient is psychiatrically unwell, physically unwell or has a personality disorder. Obviously, any combination of these can occur; Box 2 shows a decision tree using these broad categorisations.

Various approaches to mental state assessments and other structured diagnostic assessments^6-8 are documented in the literature. Structured diagnostic assessments differ from mental state assessments by taking into account other historical and background information with the aim of formulating a diagnosis, rather than simply describing an individual's mental state. The mental state is a vital part of any diagnostic process and should be noted separately from the results of a structured diagnostic assessment. Box 3 describes a simple form of mental state assessment that I use in my own practice. There are only 10 headings to remember and these can easily be kept in the front of the diary, or on a card on the desk, to aid recall if necessary. Brief cognitive assessments³ are also invaluable tools if there is concern about dementia, delirium or other cognitive impairment. The most commonly used brief instrument for such targeted assessments is the "mini mental state examination",⁸ which takes less than five minutes to complete. Experienced clinicians will not, of course, use all aspects of these assessments at all times.

Kitchens and backyards are of particular importance. If possible it is always worthwhile looking inside a fridge, with the patient's consent, of course. This is generally given as most people are happy to show you around, and pleased at your genuine concern and interest in their welfare. Some patients are impoverished, or spend their money on large amounts of cigarettes and alcohol. This is not necessarily obvious until the fridge and bins are checked. In the case of elderly patients a review of the kitchen can rapidly indicate whether they are really able to look after themselves independently. If there is some question of dementia then it is crucial to make sure that there is electricity rather than gas in the house, and that kettles have not been burned through by being left on the stove for extensive periods of time.

During a home visit I generally try to go for a wander in the backyard, not only to get an idea of the patient's interests and activities, but also to look for empty beer bottles that might suggest that the patient's idea of "social" drinking is rather different from my own.

There are, of course, some home visits that are memorable. I have seen homes that were almost impossible to enter because of the piles of rubbish accumulated over decades. In other homes there has been no power or running water, while in some places animals seem to have taken priority over the human inhabitants. Some assessments have been made easier because patients have scribbled their psychotic ideas, in the form of graffiti, on walls either inside or outside the house. Almost every home visit substantially improves my understanding of the patient.

When assessing patients by telephone it is invaluable to discuss their mental state, and therefore potentially their diagnosis and management, with someone else in the house if this is possible, and if the patient consents. This may provide more information on the patient's mental state than the patient will give over the telephone, and is particularly helpful in assessing safety and dangerousness issues. Teleconferences between a psychiatrist, patient and community mental health team members and/or general practitioners may be helpful for patients living in remote areas.

Videoconferencing, as a relatively new communications technology, is becoming increasingly popular in Australia, and there are now several articles describing the process of psychiatric interviews on telemedicine videoconferencing systems.^11,12

Case history 2:
A team approach

Over the past 30 years, mental health care has been gradually deinstitutionalised. The National Mental Health Plan¹⁷ supports a move to community-based treatment programs, with the development of multidisciplinary community mental health care teams based in local clinics. Home visits in psychiatric practice now have key clinical importance. Most community mental health teams have a protocol and policy in place for home visits, although admittedly these tend to be mainly for ensuring staff safety rather than looking at the assessment and home visit process itself. The issues of main significance in performing home visits for psychiatric assessments are as follows:

Control: At home the patient has much more control than in the normal clinical interview setting in a health facility. Clinicians can only be invited in (except in certain legally defined circumstances) and can equally easily be asked to leave. It is the patient who is on familiar territory rather than the clinician, and, while the patient may be anxious regarding the visit and assessment, the same applies to the clinician. The latter does not have all the usual clinical trappings, not only of authority and power, but also of access to secretarial staff, telephones, privacy, patient information kits, medications, and perhaps escape routes.

Sociocultural issues: An amazing amount can be learned on a home visit regarding a patient's sociocultural background, class, activities and interests. Most patients, if they know you are coming, will try and make you feel comfortable. I personally tend to find that sitting around the kitchen table with a cup of tea is usually both more appropriate, and more comfortable, than using the lounge room, which is often offered out of politeness. Patients are generally pleased to see you at their home, and often comment, in later interviews, that they really know that you know how they live, and that it was good that you had taken the trouble to come and see them rather than the other way around. I believe that home assessments should be performed much more frequently than they are at present, especially in relation to patients who need to be hospitalised, an expensive process that can often be shortened by a better understanding of the patient's home situation.

Safety issues: Home visits may be dangerous, particularly if the clinician has been asked to certify a patient, is uninvited, or is seeing a patient who feels very threatened. If there is any suggestion that the home visit is likely to be dangerous then it is essential to be accompanied. Community mental health teams are starting to work more closely with general practitioners, so that a team member may assist general practitioners in this situation.

If it is necessary to do a home visit that is likely to be dangerous then it should be performed with an appropriate number of police officers. There is nothing clever about losing control of a situation when the patient is likely to need admission to hospital against his or her will. Planning beforehand is essential, as it is the police who are the experts at immobilising people, not clinicians.

A mobile phone is necessary for any home visit, to allow the clinician to organise a bed for the patient immediately, contact relatives, or speak to other clinicians. This allows decisions to be made and implemented during the home visit itself, which is particularly important if the patient is overtly unwell and needs immediate assistance.

Process: There are some obvious points that will help make a home visit successful. It is essential to allow adequate time for the visit, properly introduce yourself and explain why you are there. An identification card may be required as proof of identity. It is important to have a quiet environment in which to interview the patient and family, bearing in mind that you may wish to see the patient alone as well. This means asking for the television to be turned off, for noisy animals to be removed and, if necessary, for children to be controlled, or looked after in another room. None of these are necessarily straightforward requests in some households. Essential small talk is much easier on patients' home ground, and much can be learned about the patient's functional capacity and ability by asking about, for instance, trophies on the walls, or how they look after their pets. Frequently, offers of drinks, cakes, cups of tea and the like are made, and I generally accept these, except in some instances when it is obvious that the process of making a cup of tea is going to take a long time and interfere with the interview process, or when a serious lack of hygiene is evident. Ethical issues of confidentiality and privacy are vital and must be considered. This is particularly important when talking to family members, neighbours, police and any other people who might be involved with the patient.

If the presentation has been frightening or traumatic, then it is important to allow yourself to "debrief". This may simply range from having a cup of coffee and a few minutes' time out, to making sure that you are included in a full debriefing process with appropriate professional support. Most of the time it is sufficient to talk to trusted colleagues and to monitor yourself -- but it is important to do this talking, and not to deny the emotional impact of dealing with difficult situations. In the event of significant continuing stress, or after a major traumatic event, doctors are just as likely as other health care professionals or members of the community to develop anxiety, depression or post-traumatic stress disorders. It is crucial that these are treated appropriately and that colleagues are consulted for advice.

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17. National Health Ministers Conference. 1992. National Mental Health Plan. Commonwealth of Australia. Canberra: Commonwealth Department of Health, Housing and Community Services, 1992.

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