The mental status exam through video-clips of simulated psychiatric patients: an online educational resource

Abstract

Objective

mental status exam (MSE) is a core component of psychiatric education. Innovative ways of teaching the MSE by making it ‘come alive’ may prove useful in a wide range of curricular initiatives.

Methods

The authors developed a publicly available online repository of sixteen video-based depictions by simulated psychiatric patients (SPPs) of ten common forms of psychopathology. They tested the practical feasibility and didactic efficacy of including the video clips through an education trial embedded into two pre-clinical psychiatry courses.

Results

One hundred fifty-three students participated in the study (75 medical, 78 nursing). Students in the intervention group (n = 73) performed better on an objective MSE standardized instrument’s overall score than did those in the control group (n = 80; F_2,150 = 4.817, p = 0.009), with a main effect for intervention over control (beta = 2.69, 95% CI = 0.56, 4.82, p = 0.014), but none for discipline. Among medical students, those in the intervention group improved on MSE knowledge and competence subjective self-ratings, compared to those in the control group (p ≤ 0.001).

Conclusions

Video-clips of SPPs depicting psychopathology are an effective complement to teaching the MSE and enhance students’ sign and symptom recognition on objective and subjective measures. This publicly available online video resource can help psychiatric educators enhance their teaching efforts to different types of learners.

The mental status exam (MSE) is a core component of the psychiatric interview. Becoming comfortable with psychiatric sign and symptom recognition and nomenclature are early building blocks toward clinical competence. Innovative ways of teaching the MSE by making it ‘come alive’ can prove useful in a wide range of curricular initiatives, particularly for inexperienced learners with little or no clinical exposure. Appreciating the superiority of multi-modal and multisensory didactic resources, video clips have proven particularly well suited for teaching the MSE content to novice learners¹. Video clips can show subtleties in facial expression, emotional range and intonation (among many other traits) that, short of live human interaction, would be inconceivable through other means. Video clips can be a powerful way of making good on the educational dictum to ‘show, don’t tell’.

Educational video clips for this purpose can derive from several sources: 1) recorded clinical encounters with real patients; 2) commercially produced documentaries, films, and shows ^{e.g. 2–4}; 3) a wide range of online content; and 4) curated repositories of clinical encounters with standardized or simulated patients. Each of these approaches has merit and ongoing utility, but notable limitations and challenges as well. There are several potential ethical concerns with the use of actual patients: for example, even if providing written consent to use their materials, some patients may not be fully competent, particularly during the more symptomatic phases of illness that could make for more compelling didactic portrayals; others may feel subtly coerced to participate.

Commercially available materials certainly provide a veritable treasure trove for the depiction of psychopathology and have already done as much to improve as to damage realistic perceptions. As one example of such damage, a systematic review of media portrayals of electro-convulsive therapy (ECT) showed that the majority of those depictions are exaggerated, frightening, and only loosely related to the actual practice⁵. Apart from careful selection, commercial products may be subject to copyright restrictions, and may be difficult to manipulate digitally. In our experience, watching a movie in its entirety and using it as a springboard for discussion seems a much better use of a film than ‘cherry-picking’ its scenes for their educational value.

Online repositories of video materials can provide ‘one-stop shopping’ for interested educators. Two salient examples include the Psychiatry Teacher site of Newcastle University⁶ and the Clinical Simulation Initiative eModules of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP)⁷. Of particular relevance is their use of simulated psychiatric patients (SPPs).

In this study we describe the creation of a curated collection of video-based content to teach the MSE, building on the ADMSEP and Newcastle experience of using SPPs toward this educational goal. We sought to fill two gaps in the existing literature by: 1) expanding the diagnostic and clinical range of available clinical depictions using state-of-the-art audio and video archival materials; and 2) testing empirically the utility of these educational materials. To that end, we first describe the creation of the video-clip collection, and next present findings of a trial in which we explored the logistic feasibility and educational efficacy of using the materials to teach pre-clinical students in medical and nursing schools. We hypothesized that our video-enhanced training module would improve objective and subjective measures of MSE sign and symptom recognition, independent of professional background.

Critically, we ensured that the video collection at the core of this report became easily available online at no cost, as our hope is for its fair use in novel educational initiatives.

Methods

We created scripts for ten common forms of psychopathology: anorexia nervosa, bipolar disorder, borderline personality disorder, delirium, dementia, depression, generalized and social anxiety, obsessive compulsive disorder, opiate dependence and withdrawal, and schizophrenia. Our intent was not to be comprehensive and encyclopedic, but rather focus on conditions that are common in routine medical and psychiatric practice. We followed best practice standards in case development, role portrayal, and actor training, consistent with the Association of Standardized Patient Educators (ASPE) guidelines⁸. We recorded the performance of nine professional actors with extensive experience as standardized patients; videos were edited into sixteen short highlight clips (a mode of 2 clips per diagnosis; range 1 to 3), each clip with a duration of under 3 minutes (mean, 100 seconds; range, 39 to 160). We paid close attention to digital video and audio quality, using two Lavalier microphones and hiss- and noise-reduction software. Table 1 summarizes our sample of didactic video clips; all clips are accessible in the supplementary materials.

Table 1.

Video clips of simulated patients illustrating mental status signs and symptoms of select psychiatric conditions

Clip	Simulated patient	Primary diagnosis	Stage of illness
1	Emma (A)	Anorexia nervosa	Initial diagnosis
2	Emma (B)	Anorexia nervosa	Following inpatient hospitalization
3	Sally (A)	Bipolar disorder	Hypomania
4	Sally (B)	Bipolar disorder	Acute mania
5	Anne (A)	Borderline personality disorder	Interpersonal crisis
6	Anne (B)	Borderline personality disorder	Interpersonal crisis
7	Stan (A)	Dementia	Middle stage
8	Stan (B)	Dementia	Delirium overlay
9	Freddie (A)	Depression	Moderately symptomatic
10	John (A)	Generalized and social anxiety	Outpatient appointment
11	Ravi (A)	OCD	Partial remission
12	Ravi (B)	OCD	Acute exacerbation
13	Freddie (B)	Opiate dependence	Acute withdrawal after naloxone administration
14	Freddie (C)	Opiate dependence	On maintenance treatment following acute detoxification
15	Deanah (A)	Schizophrenia	Exacerbation
16	Deanah (B)	Schizophrenia	Remission

Note: All video clips are available in the supplementary materials and range in duration from 39 to 100 seconds.

We next incorporated the curated video clip selection into a one-hour didactic on the MSE. The didactic was part of two different pre-clinical didactic courses in psychiatry (one for medical students, one for nursing students). The lecture introduced students to the ABC-STAMPS approach to the MSE⁹ (the acronym stands for Appearance, Behavior, Cooperation; and Speech, Thought [Process and Content; TP and TC], Affect, Mood, Perceptions, and Suicidality). Over the course of one hour, we incorporated the sixteen clips to exemplify different components of the MSE following the ABC-STAMPS rubric, relying on video depictions for descriptive purposes and as a springboard for discussion.

We obtained approvals from the Yale Human Investigations Committee (#000024005) and the Tel-Aviv University Institutional Review Board (#13231027) before starting data collection. We collected no personal identifying information, and the study was deemed exempt, with survey completion standing for tacit consent. The study was conducted as part of regular didactic activities. We quantified students’ ability to objectively identify psychiatric symptoms seen in routine clinical practice through the use of an online MSE assessment tool¹⁰.

In addition to objective performance on the MSE assessment tool, we asked students about their subjective perceptions on three aspects of their own mastery of the MSE: ‘How knowledgeable are you on the MSE and its components?’; ‘How competent are you on identifying and naming the components of the MSE?’; and ‘How comfortable will you be when you next have to describe a MSE?’ (future performance). Each item was rated on a 5-point Likert scale ranging from ‘very much’ (5) to ‘not at all’ (1).

Students were randomly assigned to intervention or control groups, which differed only in the timing of their exposure to the new MSE educational component: after or before the web-based assessment, respectively. This design required the video-enriched lecture to be repeated twice, but ensured that all students were equally exposed, in keeping with best practices in medical education¹¹.

Students completed surveys through their preferred, WiFi-enabled personal device. We collected information securely through Qualtrics (Provo, UT), and analyzed data using SPSS version 25 (Armonk, NY). We first used chi square to compare nominal characteristics of our study sample participants across discipline (medicine or nursing). We next used Spearman rho (ρ) correlation coefficients to examine the potential impact of six ordinal characteristics on our main outcome of interest (i.e. overall summary score on the MSE instrument). Finding no significant associations, we did not include any of those baseline factors in the subsequent regression analysis. We then conducted a multiple linear regression with overall summary score as dependent variable, and didactic (Intervention vs Control) and discipline (MD or RN) as independent variables of interest. Finally, we conducted univariate analyses of variance (ANOVA) to compare continuous measures between Intervention and Control groups.

Results

One hundred fifty-three students participated in the study. Our study population blended three separate group of students: English-speaking medical students from the New York State Program at Sackler Faculty of Medicine of Tel-Aviv University (TAU, 2^nd year, N=52), and the St. George University of London Program at Sheba Medical Center (SGUL, 3^rd year, N=23); and nursing students (N=78) from the Graduate Entry Program in Nursing (GEPN) at Yale School of Nursing (YSN, 1^st year).

All eligible students participated in the intervention and the assessment (n = 153; MD = 75; RN = 78). Baseline demographic data were missing for 25 students (6 MD and 19 RN). There were no differences in age or prior MSE training across disciplines. Medical students were more likely than nursing students to consider psychiatry as a future career choice (68 vs 49%, p = 0.04). Nursing students were twice as likely to have had prior experience in the care of psychiatric patients (66 vs 35%, p < 0.001), more likely to have had a friend or relative diagnosed with a mental illness (86 vs 62%, p < 0.001), and almost threefold as likely to have ever been diagnosed themselves (29 vs 13%, n.s.) None of these baseline characteristics correlated with the main outcome of interest, although heterogeneity in prior MSE educational experiences is a likely confounder in determining the likely synergistic role of prior training.

The multiple linear regression model with overall summary score as dependent variable was significant (F_2,150 = 4.817, p = 0.009), with a main effect for intervention over control (beta = 2.69, 95% CI = 0.56, 4.82, p = 0.014), but none for discipline. Performance on the MSE assessment instrument with this sample yielded an overall average score (38.1 ± 6.6) lower than that of board-certified, experienced psychiatrists in an earlier study¹⁰ (mean difference [CI] = −7.46 [−8.6, −6.4], p < 0.000), but higher than that of novice users (3.5 [2.4, 4.6], p < 0.000), providing additional support of the instrument’s discriminant validity.

Subjective measures in the intervention as compared to the control groups, collected only among medical students, revealed higher levels of self-perceived current knowledge and competence (p < 0.001), but not of future performance. There was no correlation between subjective measures and objective performance on the instrument (r = 0.11, n.s.)

The video-enriched lecture and online assessment were well received by students, who rated the activities as among the highest in their respective courses. Free text entries by course end included the following representative comments: ‘the videos will help me remember all the disorders present in the course. I am a visual learner, so I thought this really helped categorize the disorders in my head’; ‘the videos were probably my favorite way to learn the material, as now I am able to associate an illness with a patient’; ‘the interactive video and questionnaire format was highly engaging’; ‘I believe the most valuable portion of this course was seeing the video of the patients (actors) with mental illness, watching their progression and discussing what we would do to treat them’; and ‘highly interactive in its use of videos, which helped me to understand and retain the material better.’

Discussion

We found that video-clips of SPPs depicting psychopathology are an effective complement to teaching the MSE. The incorporation of video-based materials improved objective and subjective measures of MSE sign and symptom recognition in a diverse group of learners that included medical and nursing students in their preclinical years of training. The publicly available online video resource library that we have created has the potential of helping psychiatric educators complement and enhance their teaching efforts to different types of learners.

The videoclips are not intended as stand-alone educational materials, but rather as audiovisual complements to other curricular efforts. The results of this report are based on the use of all sixteen clips within a one-hour teaching slot. However, with average and cumulative durations of 100 seconds and 27 minutes, respectively, the clips have the potential of being flexibly used as parts or in whole in order to enhance a typical teaching slot of 45 to 60 minutes. In our own teaching, we usually incorporate half of the clips into a basic MSE lecture; depending on questions or aspects requiring clarification, we maintain the other half on reserve as backup. The evocative stimuli provided by the videoclips contributes to active engagement and practice-based, experiential learning. Speaking to the verisimilitude of the actors’ clinical portrayals, students often thought the patients were ‘real’. We never ‘tricked’ learners, and always provided this information, but usually at the end, after first asking for their thoughts on the matter of ‘real’ vs not.

We were interested in whether the video-based materials were differentially useful depending on professional trajectory or prior level of expertise. We found no such differences, emphasizing that the materials, though initially developed with preclinical students in mind, can be useful in a range of educational settings. For example, clips could be used for patient psychoeducation or information to a lay audience on one side of the spectrum, or for higher-level refinements in clinical observation among advanced-level fellows or faculty. The use of the same SPPs at different time points can be useful in showing course of illness changes, and ease the learning process, as when showing the subtleties between hypomania and mania, for example, which can be otherwise confusing for novice learners.

We consider a potential ‘by-product’ of our video-based materials their possible role in helping increase awareness and destigmatization of patients with serious mental illness, particularly among learners who will not go on to pursue careers in mental health (i.e. the majority). The mental health stigma literature emphasizes how actual encounters with individuals with lived experience is an indispensable component of effective anti-stigma initiatives^12–14. Filmed social contact has been found to be effective, and more practical and economically advantageous that real-life interactions¹⁵. Filmed social contact improves attitudes toward mental illness¹⁶, with effects enduring at two-year follow-up¹⁷. We conceptualize the exposure of early learners to realistic video-based depictions of individuals with mental illness as part of a continuum. Our repository can be construed as existing in a liminal space that is close to actual clinical experience, though not technically ‘real’.

We recognize the inevitable limitation in our selection of clips and note the specific lack of SPs in the younger and older sides of the age spectrum, which makes our clips of limited utility for teaching in child, adolescent, or geriatric psychiatry. We made a concerted effort to be as representative of ancestry, culture, sex, and sexual orientation as possible, but acknowledge that fully diverse representation is not possible with only nine actors. Additional limitations include a modestly sized and exclusively preclinical sample, which can limit the generalizability of our findings to other learners. Our students were highly motivated volunteers with virtually complete participation, making for a potentially non-representative sample. As noted before, our results are applicable to one specific type of curricular approach, and may not be applicable to the variations we encourage others to try in their own teaching.

In summary, videoclip depictions by SPPs of common forms of psychopathology are feasible, scalable, resource non-intensive, and logistically easy to implement when compared to teaching through in-person encounters. Such videoclips may be particularly useful for a large number of learners in their preclinical years of training. We have made sure that our video content is easily available online to interested readers, in the hope that they may incorporate it in novel educational ways. We encourage the creation of additional case scenarios and video vignettes that address not only our study’s shortcomings, but that build on the specific needs of diverse communities, languages, and local learning environments.