Adult Mental Health Services Assessment 2022

Adult Mental Health Services
CONSUMER ASSESSMENT
Date: Time:
URN: 8675309
Family Name: Leroy James Smith
Given Name(s):
Address: 11 Salisbury Lane, Ipswich, QLD,
4306
Date of Birth: 25th December 1983
MENTAL STATE EXAMINATION
General
appearance
Leroy dress not so appropriately but is groomed.
Behaviour He seemed to be alert but rarely maintain eye contact while talking as evident
by his actions during interview. He also depicted signs of abnormal movements
of head such as continous shaking while responding.
Speech Fluent but more than normal volume and rate as evident by the way of his
response. No defect with verbalizations
Mood and
Affect
Leroy is subjectively shows “emotional instability”, anxious behavior as
evident by his claim of his parents as crazy. Objectively he is a little blunted
with a labile affect. The range of affect seems restricted to limited range as
evidenced by his spontaneous break when asked about medications on mood
swing or substance use.
Thought process
Continuity of thoughts, tangential thought with subject digression, sometimes
inclusion of thoughts which are not related and relevant for the subject such as
abusing individuals and claiming his parents require a treatment.
Thought content
No delusion as evident by his reponse to the interviewer on questions related to
hearing voices on TV or radio, obsessive thoughts over great ideas of business
plans in the mind, incoherent, feeling of drepression on watching TV, no
suicidal thoughts
Perception Quite Normal
Cognition
Quite goal oriented and clearly attentive as evident by Leroy’s statements on
his great ideas of business plans. No sign of reduced concentration or
symptoms of dementia.
Judgment &
Insight
Leroy is unable to acknowledge that he is unwell and is not ready to take any
mediactions or treatment for his mood swings or change in behaviour.
SYMPTOM INTERVENTIONS
Neurovegetative:
1. CBT
Level 1 evidence is considered for CBT. CBT also referred to as Cognitive
behavioral therapy combined with behavior based treatments are recognized to
depict enhanced level of effectiveness to treat patients like Leroy who suffer

sleep, appetite from sleep disorder. Various types of small studies as well as case studies have
suggested that CBT could be used to treat frail individuals as well as patients
with moderate cognitive impairment (Grover, Gautam, Jain, Gautam & Vahia,
2017).
2. Interpersonal Psychotherapy
Interperonal therapies such as sleep hygiene as well as education are recognizd
to be effective if used in combination. It involves examination of sleep habits,
various sleep behaviors as well as other factors such as environmenta related
factors. Studies have reported that the intervention involves educating the
patients regarding basic habits/practices interfering with sleep while
implementing approaches to avoid it (Mulsant, Blumberger, Ismail, Rabheru &
Rapoport, 2014)
Substance
Abuse
1. Contingency management (i.e.,CM)
It is also known as voucher-based therapy, a type of evidence-based
intervention on the basis of principles to modify behavior. The major aim is to
encourage positive behavior through positive reinforcement while the patient is
progressing forward with different types of treatment goals and maintaining
punitive measures in case of undesirable behavior of patient. A study evidence
the use of vouchers, different type of privileges, and in some cases a moderate
level of price money to increase the behavior and to treat substance use
disorders (Chaborski, Bitterlich, Alteheld, Parsi & Metzner, 2015). Another study
stated that CM helps in improving adherence for any substance substitution
programs.
2. Motivational interviewing (i.e.,MI)
MI has its use in exploring and resolving the patients ambivalence regarding
substance use while initiating positive changes in behavior as well as
psychology. It involves to express empathy by the process of reflective
listening, to devlop discrepancy among the goals, values as well as recent
behaviour, to avoid augmenting with confronting them, etc. As evident in a
meta-analysis based on 22 studies recognized that studies reviewed the
evidence of MI being an efficient treatment modality to reduce substance
within the short-term (Jhanjee, 2014).
Mood: Mania
1. Psychoeducation
It forms Level 1 evidence which will helps in providing Leroy the information
regarding his mental health along with symptom recognition while facilitating
creation of coping strategies. As suggested in a review, it includes upto 3
sessions to teach Leroy on self-management tools, including workbooks on
self-help, videos to address diagnosis, and treatment of mania with relapse
prevention plans (Miklowitz, 2016).
2. Family-Focused Therapy
It forms the Level II evidence characterized through the modules which
conists of psychoeducation, and training to provide communication and