Intent:
To record the presence of indicators observed in the last 3 days, irrespective of the assumed cause of the indicator (behavior).
Definitions:
The mental state indicators may be expressed verbally through direct statements or through non-verbal indicators or behaviors that can be monitored by observing the person during usual daily routines.
Made negative statements — e.g., “Nothing matters; Would rather be dead than live this way; What’s the use; Regret having lived so long; Let me die.”
Persistent anger with self or others — e.g., easily annoyed, anger at care received.
Expressions, including non-verbal, of what appear to be unrealistic fears — e.g., fear of being abandoned, being left alone, being with others; intense fear of specific objects or situations.
Repetitive health complaints — e.g., persistently seeks medical attention, incessant concern with body functions.
Repetitive anxious complaints/concerns (non-health related) — e.g., persistently seeks attention/reassurance regarding schedules, meals, laundry, clothing, relationships.
Sad, pained, or worried facial expressions — e.g., furrowed brows, constant frowning.
Crying, tearfulness — Distress may also be expressed through such non-verbal indications.
Recurrent statements that something terrible is about to happen — e.g., believes he or she is about to die, have a heart attack.
Withdrawal from activities of interest — e.g., long standing activities, being with family/friends.
Reduced social interactions -
Expressions, including non-verbal, of a lack of pleasure in life (anhedonia) — e.g., “I don’t enjoy anything anymore”
Process:
Feelings of psychic distress may be expressed directly by the person who is depressed, anxious, or sad. Distress can also be expressed through non-verbal indicators. Initiate a conversation with the person, being cognizant of earlier statements by (or observations of) the person. Some persons are more verbal about their feelings than others and will either tell someone about their distress, or will at least tell someone when asked directly how they feel. For per-sons who verbalize their feelings, ask how long these conditions have been present. Other persons may be unable to articulate their feelings (i.e., cannot find the words to describe how they feel, or lack insight or cognitive capacity). Observe the person carefully for any indicator, both at the time of the planned assessment and in any direct contacts you may have with the person during the three days covered by this assessment. Consult with family members who have direct knowledge of the person's typical and current behavior, and any other clinicians working with the person (e.g., the primary care provider if available).
Remember to be aware of cultural differences in how these indicators may be manifested. Some people may be more or less expressive of mental health concerns, emotions, or feelings because of their cultural norms. Be cautious not to minimize your interpretation of an indicator based on your expectations about the person’s cultural background. On the other hand, it is important to be especially sensitive to these indicators when assessing a person whose culture may make him/her more stoic in his/her expressions.
Coding:
Based on your interaction with and observation of the person, code each indicator based on the person’s behavior over the last three days using one of the following codes. Remember, code each item based on what you see or is re-ported to you, regardless of what you believe the cause to be.
0. Not Present
1. Present but not exhibited in last 3 days — Note: Use this code if you know the condition is present and
active, even though it was not observed over the last 3 days.
2. Exhibited on 1-2 of last 3 days
3. Exhibited daily in last 3 days