Mental State Assessment Report: Applying CRC and MSE to Alison's Case

This report provides a comprehensive mental state assessment of a 38-year-old divorced mother named Alison, who is suffering from clinical depression. The assessment utilizes the Clinical Reasoning Cycle (CRC) as a framework to analyze Alison's situation, focusing on the rationale for assessment and the components of the Mental State Examination (MSE). The report details the steps of the CRC, including understanding Alison's situation, collecting cues and information (observing her soft tone, lack of eye contact, and cognitive state), processing information using DSM-5 criteria to diagnose depression, identifying financial issues as a major contributing factor, establishing goals to manage financial pressure, and recommending interventions such as antidepressants and cognitive behavioral therapy. The evaluation of outcomes is also discussed. The report highlights the importance of assessing Alison's mental state, including her mood, thought process, and content, to inform the development of targeted interventions and improve her overall well-being. References to relevant literature such as DSM-5 and cognitive behavioral therapy are included to support the analysis.

Running head: MENTAL STATE ASSESSMENT
1
Mental State Assessment
Student’s Name
University

MENTAL STATE ASSESSMENT
2
Mental State Assessment
Introduction
The clinical reasoning cycle offers steps for understanding analyzing patient situations to
develop goals and clinical interventions for assisting the patients to overcome the challenge that
they are facing. This means that it applies an individual-centered approach for determining the
state of the patient and the challenges that this situation brings to determine the best mechanism
for addressing such needs.
Step one: Patient’ situation
The first step of the clinical reasoning cycle is understanding the state situation of the patient to
inform the clinical goals that will be developed towards the needs of the patient. The case of
Alison presents a 38-year-old single divorced mother with two children who and she is suffering
from clinical depression. Based on her situation she is having financial challenges that have
created the inability for her to meet her domestic needs. This has led to low mood, difficulty
sleeping, poor appetite which has led to the loss of weight and even affected her social life
making it difficult for her to cope with both her children and boyfriend. These signs are
indicators of poor mental health which is the reason why she has sought the assistance of mental
health professional.
Collection of cues and information
In this phase, the focus is on understanding the patient and the mental state that they have by
focusing on the issues in the life of the patient. Alison is speaking in a soft tone which can be
attributed to her low mood and probably the slowly fading social esteem. She seems to be
avoided eye contact with the mental health worker and can be seen wringing her fingers as the
professional engages her. The assessment of the level of cognition can be described as good

MENTAL STATE ASSESSMENT
3
since she is conscious, attentive, concentrating well and has a good memory based on the
account of the events that she has been experiencing recently (Töreki, et al., 2013). The thought
process assessment shows that she is flowing and connecting well as seen in the way she
explains and connects different events that she is going through. The thought content shows no
signs of illusionary or preoccupation content that is worrying and indicates high signs of
increased depression (Roiser, Elliott, & Sahakian, 2012). The effect state of the patient can be
defined dysphoric with no signs of excessive depression and irritation. The description of her
mood based on the information that has been provided can be defined as “loss of appetite,
difficulty falling asleep, challenges dealing with her children and boyfriend and lastly the feeling
of worthlessness”.
Process information
In this step, the focus is on the application of the DSM-5 to determine the nature of the problem
that the patient is facing. This tool provides measures for determining if a patient is suffering
from clinical depression or not. Hasin, Sarvet, & Meyers (2018) suggests that this means that one
can only be described as having depression if the symptoms occurred repeatedly for a period of
two weeks and lead to a depressed mood or loss of pleasure in some aspects of life. In the case of
Alison, she has had these episodes for over two weeks which is the reason why she is seeking
assistance. She has registered diminishing interests in her social life and she is no longer
interested in the people around her like the boyfriend and children. Other characteristics of
depression are weight loss, loss of appetite, diminishing interest in life, feeling of worthlessness
that is making full of guilt and feeling like a less mother and difficulty sleeping (Smith-Nielsen,
Matthey, Lange, & Væver, 2018). Thus from the characteristic, I can conclude that she is
suffering from DSM-5 depression due to the symptoms that she is showing where the moods are

MENTAL STATE ASSESSMENT
4
not high and the periods of mania that she experiences are not high. This is why she manages to
sleep and wakes up at 4:00 am and she sometimes feels like she is not there or her children.
Identification of the issues
From the Alison case study, I have concluded that her financial status is the source of the
problem that she is having and the level of depression. This can be seen from the fact that the
challenges have made it difficult for her to meet the needs of her children like the kids want new
video games and she cannot afford them and thus feels inadequate.
Establishment of goals
The goal for this patient is to assist her to learn how to manage the financial pressure that is
leading to her increased depression.
Take action
The first step is to cool down the psychophysiological symptoms that Alison is facing by giving
her antidepressants that will assist her cool down and reduce the pressure of the symptoms that
she is facing.
After this, Alison needs to be enrolled in a cognitive program that will assist her to improve the
mental state that she is facing to overcome the distortions that she is experiencing. This will
entail the application of alternative formulation cognitive approach that is based on developing a
worksheet that allows her to develop ways of dealing with the problem. In this case, she is
supposed to be assisted to learn how to use an alternative formulation worksheet for listing
vulnerabilities and triggers of the depression (Driessen & Hollon, 2010; Wiles, et al., 2016).
Once the triggers have been identified, she needs to work together with the mental health
professional to develop coping strategies that can be applied in the depressing situations that
have been identified. From the case of Alison, she needs to be assisted to cope with the financial

MENTAL STATE ASSESSMENT
5
situation that she is facing by learning how to develop alternatives in every situation that she
faces and thus be able to overcome the financial problem and avoid being depressed.
Evaluation of outcomes
Evaluation entails following up the patient to determine if the patient is coping with the proposed
method of intervention by ensuring that the patient is able to follow the laid down procedures for
addressing the problem that she was facing.
Conclusion
Therefore, Alison is showing signs of depression based on the analysis of the information that
was collected shows signs of DSM-5 depression which makes her feel worthlessness, lose
appetite, weight and even experiencing difficulty sleeping. Thus the focus of the intervention is
to assist her to learn how to manage the situation any time it arises.

MENTAL STATE ASSESSMENT
6
References
Driessen, E., & Hollon, S. D. (2010). Cognitive Behavioral Therapy for Mood Disorders:
Efficacy, Moderators and Mediators. Psychiatr Clin North Am, 33(3), 537-555.
Hasin, D., Sarvet, A., & Meyers, J. (2018). Epidemiology of Adult DSM-5 Major Depressive
Disorder and Its Specifiers in the United States. JAMA Psychiatry, 75(4), 336-346.
Roiser, J. P., Elliott, R., & Sahakian, B. J. (2012). Cognitive Mechanisms of Treatment in
Depression. Neuropsychopharmacology, 37(1), 117-136.
Smith-Nielsen, J., Matthey, S., Lange, T., & Væver, M. S. (2018). Validation of the Edinburgh
Postnatal Depression Scale against both DSM-5 and ICD-10 diagnostic criteria for
depression. BMC Psychiatry, 18(393).
Töreki, A., Ando, B., Keresztúri, A., Sikovanyecz, J., Dudas, R., Janka, Z., & Kozinszky, Z.
(2013). The Edinburgh Postnatal Depression Scale: translation and antepartum validation
for a Hungarian sample. Midwifery, 29(4), 308-315.
Wiles, N. J., Thomas, L., Turner, N., Garfi, K., Kounali, D., Campbell, J., . . . Lewis, G. (2016).
Long-term eff ectiveness and cost-eff ectiveness of cognitive behavioural therapy as an
adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up
of the CoBalT randomised controlled tria. Lancet Psychiatry, 3, 137-144.