Mental Health Assessment, Diagnosis, and Treatment in the US

Mental Health Professionals and Their Roles

The assessment, diagnosis, and treatment of mental illness in the United States is, for the most part, a basic issue of scale. The degree to which the symptoms of any given recognized mental disorder affect an individual's life determines whether a diagnosis is warranted. Diagnostic tools have been developed over time to allow professional clinicians to evaluate impact based on reported beliefs, thoughts, and behaviors — their frequency of occurrence and the manner in which they affect an individual's daily life. There are essentially three categories of mental health professionals trained to assess and treat mental illness: the licensed professional counselor (sometimes called a mental health counselor), the psychologist, and the psychiatrist. In most cases, a formal diagnosis must be made by a psychiatrist, who is a specially trained medical doctor, though there are exceptions, and either of the other two professionals can form a clinical opinion on diagnosis and develop a treatment course.

In most cases, neither the mental health counselor nor the psychologist can write mental health prescriptions, and when medication is needed as part of a treatment course, the individual must be referred to a psychiatrist for both formal diagnosis and prescription. Once this step is completed — often through a single appointment — the individual can be treated relatively independently by a range of other professionals, including mental health counselors and psychologists, who typically conduct weekly assessment sessions. Communication among treatment professionals is essential, particularly regarding the effective use of medications and for billing purposes that depend on formal diagnosis (Seaburn, Lorenz, Gunn, Gawinski, & Mauksch, 1996, p. 20).

Mental health counselors are often responsible for the weekly treatment or counseling of an individual and may initiate referrals to a psychiatrist for formal diagnosis and possible prescriptions. Individuals can also receive mental health referrals from primary care physicians or from mental health nurses in a clinical setting. The mental health counselor — typically holding a master's degree in counseling with a specialty area — performs the day-to-day and week-to-week work with the individual, continuously assessing progress in both the counseling they personally provide and any outside treatment such as medication. For example, the counselor monitors whether medication choices are helping the individual or whether a second referral to a psychiatrist is needed for adjustment. Mental health counselors may practice independently in the community or work within an institution such as a hospital or mental health care facility.

A psychologist typically holds a PhD, though in some cases may be a medically trained specialist in psychiatry. Like mental health counselors, most psychologists cannot write prescriptions. They assess and treat individuals for diagnosed disorders and address the behaviors, thoughts, and feelings that affect the individual's ability to live daily life. They meet with clients on a regular basis in community, hospital, or mental health facility settings. The primary distinction between a mental health counselor and a psychologist lies in the theoretical orientation and treatment specialty — psychologists draw on frameworks rooted in psychological theory, while counselors may specialize in other treatment modalities. While individual psychologists may appear to have a broader theoretical base and the capacity to treat a wider range of conditions, like counselors they frequently specialize in particular treatment types, disorders, populations, or demographic groups.

Psychiatrists are specially trained physicians with additional clinical training in the diagnosis and treatment of mental health diseases and disorders. They are often the first clinical contact when an individual is institutionalized for a mental health condition, as they will assess, diagnose, and outline a short- and long-term course of treatment — whether as an inpatient or outpatient. Most mental health admissions are oriented around short-term stabilization, lasting from one week to a few weeks or possibly months, depending on the severity of symptoms and the individual's ability to stabilize and function in a community setting. There are limited exceptions, such as individuals deemed criminally insane who have acted violently — typically those who committed murder or other violent acts during a mental health crisis. Those considered a danger to themselves may be held for longer periods, until assessment determines that the crisis has passed and the individual is unlikely to repeat such behaviors. While psychiatrists sometimes serve as ongoing counselors, most of their work focuses on assessment, diagnosis, and treatment course recommendations; the individual is then referred to subsidiary counselors such as a mental health counselor or psychologist for ongoing therapeutic work.

Collaboration and Communication in Mental Health Care

Collaboration and communication are essential aspects of mental health treatment. Because psychiatrists are not available in abundant numbers within the system, they must for practical purposes function primarily as referral resources for diagnosis and medication management. Other health care counselors must therefore be utilized for ongoing formal counseling. In most cases, counseling is considered both necessary and beneficial, and the psychiatrist will refer the individual out — either within the institution or care setting, or to a community-based practice or individual provider (Seaburn, Lorenz, Gunn, Gawinski, & Mauksch, 1996, p. 15).

The suicidal individual requires careful and thorough assessment. Those at greatest risk are often individuals who have previously reported suicidal ideation or who have exhibited parasuicidal or suicidal behaviors. Most people do provide hints to those around them that they are considering suicide before any attempt is made. While this is not a foolproof assessment tool, it can serve as an important indicator of intent and the need for intervention.

Suicide Risk Assessment

It is also significant for clinicians to be aware of any prescription medications an individual is taking, as some antidepressants have been shown to cause or exacerbate suicidal thoughts, particularly in children and young adults. A full history of the individual may be necessary to contextualize other warning signs. Importantly, clinicians should know that risk is often elevated at the point when an individual appears to be emerging from the depths of a depression — when energy returns and activity increases, the likelihood of acting on suicidal thoughts may actually be at its highest. Acute stressors such as serious loss — the death of a loved one, loss of a relationship, or job loss — can also heighten suicidal risk. In younger individuals, the loss of a romantic relationship may be a precipitating factor, while in older individuals it may be job loss, the death of a parent, or the end of a long-term relationship through death or divorce. A new diagnosis of a life-threatening illness can also create heightened risk in some individuals.

In general, women of all ages are more likely to attempt suicide, while men are more likely to die by suicide, largely because men tend to choose more lethal methods. Most religions and some cultures carry strong taboos against suicide, which may create reluctance in some individuals to act on suicidal thoughts. As people age, the likelihood of experiencing severe loss, chronic illness, or other risk factors increases; however, it is still adolescents and young adults who are at greatest statistical risk, as they are most susceptible to the impact of rejection and loss that is often part of the developmental experience ("Suicide," 2007).

Individuals may exhibit behavioral cues outside of explicit statements of suicidal intent — for example, unusually emotional behavior such as reaching out to express feelings to people they rarely contact, or conveying profound sentiments to those they see regularly. They may give away prized possessions or make meaningful, atypical gestures. Self-harming behaviors can also precede suicide attempts, including self-cutting or dangerous risk-taking such as reckless driving, involvement in accidents that appear intentional, or other similar incidents (Heeringen, 2001).