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The Importance of Mental Health

Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

Akeem Marsh, MD, is a board-certified child, adolescent, and adult psychiatrist who has dedicated his career to working with medically underserved communities.

Westend61 / Getty Images

Risk Factors for Poor Mental Health

Signs of mental health problems, benefits of good mental health, how to maintain mental health and well-being.

Your mental health is an important part of your well-being. This aspect of your welfare determines how you’re able to operate psychologically, emotionally, and socially among others.

Considering how much of a role your mental health plays in each aspect of your life, it's important to guard and improve psychological wellness using appropriate measures.

Because different circumstances can affect your mental health, we’ll be highlighting risk factors and signs that may indicate mental distress. But most importantly, we’ll dive into all of the benefits of having your mental health in its best shape.

Mental health is described as a state of well-being where a person is able to cope with the normal stresses of life. This state permits productive work output and allows for meaningful contributions to society.

However, different circumstances exist that may affect the ability to handle life’s curveballs. These factors may also disrupt daily activities, and the capacity to manage these changes. 

The following factors, listed below, may affect mental well-being and could increase the risk of developing psychological disorders .

Childhood Abuse

When a child is subjected to physical assault, sexual violence, emotional abuse, or neglect while growing up, it can lead to severe mental and emotional distress.

Abuse increases the risk of developing mental disorders like depression, anxiety, post-traumatic stress disorder, or personality disorders.

Children who have been abused may eventually deal with alcohol and substance use issues. But beyond mental health challenges, child abuse may also lead to medical complications such as diabetes, stroke, and other forms of heart disease.

The Environment

A strong contributor to mental well-being is the state of a person’s usual environment . Adverse environmental circumstances can cause negative effects on psychological wellness.

For instance, weather conditions may influence an increase in suicide cases. Likewise, experiencing natural disasters firsthand can increase the chances of developing PTSD. In certain cases, air pollution may produce negative effects on depression symptoms.  

In contrast, living in a positive social environment can provide protection against mental challenges.

Your biological makeup could determine the state of your well-being. A number of mental health disorders have been found to run in families and may be passed down to members.

These include conditions such as autism , attention deficit hyperactivity disorder , bipolar disorder , depression , and schizophrenia .

Your lifestyle can also impact your mental health. Smoking, a poor diet , alcohol consumption , substance use , and risky sexual behavior may cause psychological harm. These behaviors have been linked to depression.

When mental health is compromised, it isn’t always apparent to the individual or those around them. However, there are certain warning signs to look out for, that may signify negative changes for the well-being. These include:

• A switch in eating habits, whether over or undereating
• A noticeable reduction in energy levels
• Being more reclusive and shying away from others
• Feeling persistent despair
• Indulging in alcohol, tobacco, or other substances more than usual
• Experiencing unexplained confusion, anger, guilt, or worry
• Severe mood swings
• Picking fights with family and friends
• Hearing voices with no identifiable source
• Thinking of self-harm or causing harm to others
• Being unable to perform daily tasks with ease

Whether young or old, the importance of mental health for total well-being cannot be overstated. When psychological wellness is affected, it can cause negative behaviors that may not only affect personal health but can also compromise relationships with others. 

Below are some of the benefits of good mental health.

A Stronger Ability to Cope With Life’s Stressors

When mental and emotional states are at peak levels, the challenges of life can be easier to overcome.

Where alcohol/drugs, isolation, tantrums, or fighting may have been adopted to manage relationship disputes, financial woes, work challenges, and other life issues—a stable mental state can encourage healthier coping mechanisms.

A Positive Self-Image

Mental health greatly correlates with personal feelings about oneself. Overall mental wellness plays a part in your self-esteem . Confidence can often be a good indicator of a healthy mental state.

A person whose mental health is flourishing is more likely to focus on the good in themselves. They will hone in on these qualities, and will generally have ambitions that strive for a healthy, happy life.

Healthier Relationships

If your mental health is in good standing, you might be more capable of providing your friends and family with quality time , affection , and support. When you're not in emotional distress, it can be easier to show up and support the people you care about.

Better Productivity

Dealing with depression or other mental health disorders can impact your productivity levels. If you feel mentally strong , it's more likely that you will be able to work more efficiently and provide higher quality work.

Higher Quality of Life

When mental well-being thrives, your quality of life may improve. This can give room for greater participation in community building. For example, you may begin volunteering in soup kitchens, at food drives, shelters, etc.

You might also pick up new hobbies , and make new acquaintances , and travel to new cities.

Because mental health is so important to general wellness, it’s important that you take care of your mental health.

To keep mental health in shape, a few introductions to and changes to lifestyle practices may be required. These include:

• Taking up regular exercise
• Prioritizing rest and sleep on a daily basis
• Trying meditation
• Learning coping skills for life challenges
• Keeping in touch with loved ones
• Maintaining a positive outlook on life

Another proven way to improve and maintain mental well-being is through the guidance of a professional. Talk therapy can teach you healthier ways to interact with others and coping mechanisms to try during difficult times.

Therapy can also help you address some of your own negative behaviors and provide you with the tools to make some changes in your own life.

A Word From Verywell

Your mental health state can have a profound impact on all areas of your life. If you're finding it difficult to address mental health concerns on your own, don't hesitate to seek help from a licensed therapist .

World Health Organization. Mental Health: Strengthening our Response .

Lippard ETC, Nemeroff CB. The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders . Am J Psychiatry . 2020;177(1):20-36. doi:10.1176/appi.ajp.2019.19010020

 Helbich M. Mental Health and Environmental Exposures: An Editorial. Int J Environ Res Public Health . 2018;15(10):2207. Published 2018 Oct 10. doi:10.3390/ijerph15102207

Helbich M. Mental Health and Environmental Exposures: An Editorial. Int J Environ Res Public Health . 2018;15(10):2207. Published 2018 Oct 10. doi:10.3390/ijerph15102207

National Institutes of Health. Common Genetic Factors Found in 5 Mental Disorders .

Zaman R, Hankir A, Jemni M. Lifestyle Factors and Mental Health . Psychiatr Danub . 2019;31(Suppl 3):217-220.

Medline Plus. What Is mental health? .

National Alliance on Mental Health. Why Self-Esteem Is Important for Mental Health .

By Elizabeth Plumptre Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

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What is Mental Health?

Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act, and helps determine how we handle stress, relate to others, and make choices.

Mental health is important at every stage of life, from childhood and adolescence through adulthood. Over the course of your life, if you experience mental health problems , your thinking, mood, and behavior could be affected.

Mental Health Conditions

Mental illnesses are disorders, ranging from mild to severe, that affect a person’s thinking, mood, and/or behavior. According to the National Institute of Mental Health, nearly one-in-five adults live with a mental illness.

Many factors contribute to mental health conditions, including:

• Biological factors, such as genes or brain chemistry
• Life experiences, such as trauma or abuse
• Family history of mental health problems

Some mental health topics include:

• Antisocial personality disorder
• Anxiety disorders (including generalized anxiety, panic disorders, obsessive-compulsive disorder (OCD), phobias, and social anxiety)
• Attention-deficit hyperactivity disorder (ADHD)
• Bipolar disorder
• Borderline Personality Disorder (BPD)
• Eating disorders (including Anorexia Nervosa, binge eating Disorder, and Bulimia Nervosa)
• Post-traumatic Stress Disorder (PTSD)
• Schizophrenia
• Seasonal affective disorder (SAD)
• Suicide and suicidal behavior

A Serious Mental Illness (SMI) is a mental illness that interferes with a person’s life and ability to function. Despite common misperceptions, having an SMI is not a choice, a weakness, or a character flaw. It is not something that just “passes” or can be “snapped out of” with willpower.

View SAMHSA's Public Message about Serious Mental Illnesses .

Early Warning Signs & Symptoms

Not sure if you or someone you know is living with mental health problems? Experiencing one or more of the following feelings or behaviors can be an early warning sign of a problem:

• Eating or sleeping too much or too little
• Pulling away from people and usual activities
• Having low or no energy
• Feeling numb or like nothing matters
• Having unexplained aches and pains
• Feeling helpless or hopeless
• Smoking, drinking, or using drugs more than usual
• Feeling unusually confused, forgetful, on edge, angry, upset, worried, or scared
• Yelling or fighting with family and friends
• Experiencing severe mood swings that cause problems in relationships
• Having persistent thoughts and memories you can't get out of your head
• Hearing voices or believing things that are not true
• Thinking of harming yourself or others
• Inability to perform daily tasks like taking care of your kids or getting to work or school

Do you think someone you know may have a mental health problem? Talking about mental health can be difficult. Learn about common mental health myths and facts and read about ways to help you get the conversation started.

Tips for Living Well with a Mental Health Condition

Having a mental health condition can make it a struggle to work, keep up with school, stick to a regular schedule, have healthy relationships, socialize, maintain hygiene, and more.

However, with early and consistent treatment—often a combination of medication and psychotherapy—it is possible to manage these conditions, overcome challenges, and lead a meaningful, productive life.

Today, there are new tools, evidence-based treatments, and social support systems that help people feel better and pursue their goals. Some of these tips, tools and strategies include:

• Stick to a treatment plan. Even if you feel better, don’t stop going to therapy or taking medication without a doctor’s guidance. Work with a doctor to safely adjust doses or medication if needed to continue a treatment plan.
• Keep your primary care physician updated. Primary care physicians are an important part of long-term management, even if you also see a psychiatrist.
• Learn about the condition. Being educated can help you stick to your treatment plan. Education can also help your loved ones be more supportive and compassionate.
• Practice good self-care. Control stress with activities such as meditation or tai-chi; eat healthy and exercise; and get enough sleep.
• Reach out to family and friends. Maintaining relationships with others is important. In times of crisis or rough spells, reach out to them for support and help.
• Develop coping skills. Establishing healthy coping skills can help people deal with stress easier.
• Get enough sleep. Good sleep improves your brain performance, mood and overall health. Consistently poor sleep is associated with anxiety, depression, and other mental health conditions.
• If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org .
• To learn how to get support for mental health, drug, and alcohol issues, visit FindSupport.gov .
• To locate treatment facilities or providers, visit FindTreatment.gov or call SAMHSA’s National Helpline at 800-662-HELP (4357) .
• National Helpline
• SAMHSA's 2021 National Survey on Drug Use and Health
• Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC)
• SMI Adviser | American Psychiatric Association (APA) and SAMHSA
• Technology Transfer Centers (TTC) Program
• Centers for Disease Control and Prevention: Stress and Coping
• NIMH: Caring for Your Mental Health

Mental Health

Find Resources for Help and Support

• Children’s Mental Health
• Teen Mental Health
• Support for Public Health Workers
• Coping with a Disaster or Traumatic Event
• Data and Statistics

Learn how  social connectedness  can lead to better mental health and improved  emotional well-being

If you or someone you know needs support now, call or text 988 or chat 988lifeline.org

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• Brochures and Fact Sheets
• Help for Mental Illnesses
• Clinical Trials

Older Adults and Mental Health

Why is it important to take care of our mental health as we age.

As people age, they may experience certain life changes that impact their mental health, such as coping with a serious illness or losing a loved one. Although many people will adjust to these life changes, some may experience feelings of grief, social isolation, or loneliness. When these feelings persist, they can lead to mental illnesses, such as depression and anxiety.

Mental health is important at every stage of life. Effective treatment options are available to help older adults manage their mental health and improve their quality of life. Recognizing the signs and seeing a health care provider are the first steps to getting treatment.

What are symptoms of mental disorders in older adults?

• Noticeable changes in mood, energy level, or appetite
• Feeling flat or having trouble feeling positive emotions
• Difficulty sleeping or sleeping too much
• Difficulty concentrating, feeling restless, or on edge
• Increased worry or feeling stressed
• Anger, irritability, or aggressiveness
• Ongoing headaches, digestive issues, or pain
• Misuse of alcohol or drugs
• Sadness or hopelessness
• Thoughts of death or suicide or suicide attempts
• Engaging in high-risk activities
• Obsessive thinking or compulsive behavior
• Thoughts or behaviors that interfere with work, family, or social life
• Engaging in thinking or behavior that is concerning to others
• Seeing, hearing, and feeling things that other people do not see, hear, or feel

Help is available : If you are unsure where to go for help, ask a health care provider or visit NIMH's Help for Mental Illnesses webpage. Communicating well with your health care provider can improve your care and help you come up with a treatment plan that works for you. Read about tips to help prepare and get the most out of your visit . For additional resources, including questions to ask your health care provider, visit the Agency for Healthcare Research and Quality  .

Health hotlines

• 988 Suicide & Crisis Lifeline   : The Lifeline provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week, across the United States. Call or text 988 to connect with a trained crisis counselor. Support is also available via live chat   . Para ayuda en español, llame al 988 . 
• Veterans Crisis Line   : This helpline is a free, confidential resource for veterans of all ages and circumstances. Call 988 then press 1; text 838255 ; or chat online   to connect with 24/7 support.
• Disaster Distress Hotline   : This helpline from the Substance Abuse and Mental Health Services Administration provides immediate crisis counseling for people experiencing emotional distress related to any natural or human-caused disaster. The helpline is free, multilingual, confidential, and available 24 hours a day, 7 days a week. Call or text 1-800-985-5990 .
• NIH Health Info Lines  

Health topics and resources for older adults

Featured health topics.

• Anxiety Disorders
• Bipolar Disorder
• Coping with Traumatic Events
• Eating Disorders
• Medications: Older Adults
• Post-Traumatic Stress Disorder
• Suicide Prevention

Featured brochures and fact sheets

Federal resources

• Depression Is Not a Normal Part of Growing Older  : This Centers for Disease Control and Prevention webpage describes signs of depression and how depression can be different for older adults.
• Healthy Aging  : This U.S. Department of Health and Human Services webpage lists links to health resources and services for older adults.
• National Institute on Aging (NIA): Health Topics  : NIA offers health information on various topics, including depression  .
• Older Adult Mental Health  : The National Library of Medicine’s MedlinePlus offers resources on aging and mental health ( en español  ).
• Resources for Older Adults  : The Substance Abuse and Mental Health Services Administration offers publications and digital products for and about older adults.
• Mental Health and Older Adults Facebook Live Q&A : Learn about mental and emotional wellness in later life, signs and symptoms of depression, and ways to maintain and improve mental health.

Research resources

• NIMH Geriatrics and Aging Processes Research Branch : This NIMH branch supports programs of research, research mid-career development, and resource development in the etiology, pathophysiology, and course of mental disorders of late life; the relationships between aging and mental disorders; the treatment and recovery of persons with aging-related disorders; and the prevention of these disorders and their consequences.

Why should older adults participate in clinical trials?

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although people may benefit from being part of a clinical trial, they should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others can be better helped in the future.

Researchers at NIMH and around the country conduct many studies with patients and healthy volunteers. We have new and better treatment options today because of what clinical trials have uncovered. Talk to a health care provider about clinical trials, their benefits and risks, and whether one is right for you.

To learn more or find a study, visit:

• NIMH’s Clinical Trials webpage: Information about participating in clinical trials

In addition, NIMH researchers are also studying mental disorders that affect older adults. To find studies being conducted at NIMH, visit Join a Study: Adults .

Our studies take place at the NIH Clinical Center  in Bethesda, Maryland, and require regular visits. If you don’t live nearby, you can find a  clinical trial near you  .

It is important for clinical trials to have participants of different ages, sexes, races, and ethnicities. When research involves a group of people who are similar, the findings may not apply to or benefit everyone. When clinical trials include diverse participants, the study results may have a much wider applicability.

Researchers need the participation of older adults in their clinical trials so that they can learn more about how new drugs, therapies, medical devices, surgical procedures, or tests will work for all people. For more information, check out National Institute on Aging’s What Are Clinical Trials and Studies?  tip sheet.

Last Reviewed: May 2023

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Case presentation in academic psychiatry: The clinical applications, purposes, and structure of formulation and summary

Narayana manjunatha.

Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

INTRODUCTION

Case presentation in an academic psychiatry traditionally follows one of the following three formats: 4DP format (ideal and lengthy format; described in the following section), “Case Summary” (CS) (medium format), or “Case Formulation” (CF) (short format), in order of the decreasing length, duration, and the gradual transition from the use of layman terms (in the history with a goal of layman understanding) to technical terms (in diagnostic formulation [DF] with a goal to communicate with professionals). However, the medium and short formats (CS and CF) are often preferred as a rule rather than exception routinely than the ideal and lengthy 4DP format in the area of academic psychiatry.

An ideal case presentation in academic psychiatry follows 4DP format: first is the “Detailed presentations of all clinical information,” second is the “Diagnostic summary” (DS) (it is optional, see below), third is the “Diagnostic formulation,” fourth is the Diagnosis or differential diagnosis (usually International Classification of Diseases-10 (ICD-10)/Diagnostic and Statistical Manual of Mental Disorders-5 [DSM-5]) and discussion of diagnosis with points in favor and against, and finally is the “Plan of management.” The goal of this article is to overview the clinical applications, purposes, and structure of the “formulation” and “summary” in this article with review from published literatures. Table 1 represents these formats of presentation graphically.

Graphical representation of different formats of case presentations in psychiatry

*Includes complete history, physical examination, and detailed mental status examination. DD – Differential diagnosis

CONCEPTS OF “FORMULATION” AND “SUMMARY:” SHORTCOMINGS

Despite the availability of substantial literatures, the concepts of “formulation” and “summary” are rather confusing concepts in academic psychiatry, especially with psychiatric residents. There are few shortcomings of these concepts causing this confusion. The presence of various models of formulations in psychiatric literatures is one of the reasons for this confusion such as “psychodynamic formulation,” “psychotherapeutic formulation,” and “cultural formulation.” It is essential to understand the purposes of the existing models of these psychiatric formulations. The “psychodynamic formulation” focuses on psychodynamic understanding of the problems of patients and may involve interventions with psychodynamic psychotherapy, the “psychotherapeutic formulation” aims to understand the problems of patients and helps to choose the different schools of psychotherapy, and the “cultural psychiatric formulation” focuses on understanding of the patient's problems from his/her cultural background. Lack of clarity on this pair of terminologies such as “case formulation” versus “diagnostic formulation” and “case summary” versus “diagnostic summary” in published literatures is another significant reason for confusion. Kuruvilla and Kuruvilla[ 1 ] in their article entitled “diagnostic formulation” denotes the inclusion of diagnosis (at least the differential diagnosis) and plan of management in the formulation. The author wishes to convey that “diagnostic formulation” and “case formulation” (formulating a case) are rather different concepts with different purposes. The concept “CF” denotes for formulating a case for the purpose of both diagnostic and management purposes, whereas “DF” with the term “diagnostic” denotes diagnostic point of view only (where term itself denotes diagnosis), which excludes the “plan of management.” The similar explanation is offered to differentiate “CS” and “DS.” Often, these pairs of terminology are used synonymously causing confusion. Further discussion in this article is based on the above explanations of all these four terms. However, if examiners/teachers ask to present DF, it means formulating his/her case for the purpose of diagnostic purpose, which need not include the management plan. For the sake of better clarity, the author wishes to discuss student-friendly models of formulation, summary, and diagnosis, edited by Professor David Goldberg. Along with experienced teachers, trainees themselves are involved in deriving these concepts in explaining Professor D. Goldberg's concepts which is an interesting point.

CLINICAL APPLICATION OF DIAGNOSTIC FORMULATION AND SUMMARY

Often, the choice of presentation from one of either “DS” or “DF” in academic psychiatry depends on whether the detailed clinical information is presented or not. If detailed clinical information is presented, “DS” may be skipped and proceed directly to presentation of the third step of ideal 4DP format, i.e., “DF.” In case detailed clinical information is not presented for any reasons, the case presentation may begin with “DS” and then may proceed to “DF” (however, it is optional). In either of the ways, both “DS” and “DF” are followed by the fourth step of ideal 4DP format, i.e., the “diagnosis or differential diagnosis” (usually ICD-10 and DSM 5) and discussion of diagnosis with points in favor and against, and finally is the “plan of management.”

The choice of the presentation either “DS”/“DF”, at times, depends on the availability of time with examiners/listeners/faculties. When ample of time are available, the examiners/teachers ask residents to present a detailed presentation of all clinical data in the usual 4DP format of “presenting complaint,” “history of presenting illness,” etc., followed by “DF,” and then plan of management, and this format has the minimal scope of “DS” presentation. However, whenever time is a constraint, residents shall be asked to present the “DS” without a detailed presentation of clinical data followed by with or without “DF.” In any case, psychiatric residents shall be encouraged to learn both DS and DF for any eventuality during examination.

As discussed above, the “CF” traditionally includes only the last three steps (3 rd , 4 th , and 5 th ) of 4DP format of psychiatric case presentation. This has relevance from psychodynamic explanation of psychiatric disorders. In view of the significant development in the neurobiology of psychiatric disorders in the last few decades and high dependency of making clinical diagnosis based on the current classificatory system (ICD-10 and DSM 5), the “DF” is preferred which excludes the plan of management than the “CF” as authors believe that the presentation of the “plan of management” itself is an important skill which is expected from psychiatric residents during training and examination. However, whenever a psychiatric resident is asked to present “CF,” he/she shall include the third to fifth steps of ideal format.

PURPOSE OF DIAGNOSTIC FORMULATION AND SUMMARY

The important goal of the “DF” is to facilitate the communication of clinical information of patients with another professional/s who are familiar with technical jargons (i.e., psychopathological/psychiatric terminology), whereas the purpose of “DS” is to convey the clinical information of patients to lay persons and/or nonprofessionals and comprises all the components of a DF, but in layman's terminology. The contents of DS may be used for the purpose of psychoeducation to patients and their family.

STRUCTURE OF DIAGNOSTIC FORMULATION AND SUMMARY

The purposes of “DF” and “DS” are important to understand their structure or contents. Since “DF” is targeted for professionals, the technical jargons are used in its content, whereas “DS” is targeted for lay persons or nonprofessionals, and then layman terms are used in its content. The “DF” should be quite brief to just re-orientating the listener to the salient features of the case, often just the key demographics and major diagnostic criteria described in technical terms in as less words as possible without repetition of any word/s. The technical jargons in “DF” often include the terminology of descriptive psychopathology or diagnostic points of classificatory system (ICD-10 and DSM-5). In simple words, the structure of both DF and DS is, more or less, similar in contents, but the difference lies in the use of technical terms and layman's terms, respectively, in its structure/contents. Further details of the structure of DF and DS are discussed below in the proposed format and case vignettes.

RECOMMENDED SIZE AND TIME TO PRESENT “DIAGNOSTIC FORMULATION AND “DIAGNOSTIC SUMMARY

The completed DF shall last for about 5 min, and the recommended length for a written version is not more than one side of a A4 paper when typed,[ 1 ] which is equivalent to 10 to 15 sentences, whereas the completed DS should be short enough to cover about two sides of a A4 paper when typed,[ 2 ] which should not be more than 10 min.

SUMMARY, FORMULATION, AND DIAGNOSIS: MODEL BY PROFESSOR DAVID GOLDBERG

The following paragraphs exerted in italic (without any edition to preserve the semantic) from “ The Maudsley Handbook of Practical Psychiatry ” were edited by Professor David Goldberg. The author feels that these paragraphs are important to understand the difference between the process of summary, formulation, and diagnosis. The author intentionally deleted diagnostic points and management plan from the discussion to keep focus on DF only.

A SUMMARY is a descriptive account of collected data: Objective and impartial. In contrast, a FORMULATION is a clinical opinion: Weighing up the pros and cons of conflicting evidence, that leads to a diagnostic choice. An opinion inevitably implies a subjective view point, by virtue of assigning relative importance to each piece of evidence; in doing so, both theoretical bias and past personal experience invariably come to play. No matter how accurate the final verdict, an analysis is inextricably bound up with subjective judgments and decisions. When assigning the same patient, two experts may produce two similar summaries, but two different formulations with divergent conclusions. This is the fundamental difference: A SUMMARY is a descriptive, whereas a formulation is analytical. Therefore, a summary calls for the qualities of thoroughness, restraint, and objectivity, while a formulation demands the composite skill of methodological thinking, incisive analysis and intelligent presentation.

THE SUMMARY

It is an important document which should be drawn up with care. Its purpose is to provide a concise description of all the important aspects of the case, enabling others who are unfamiliar with the patient to grasp the essential features of the problem without needing to search elsewhere for further information. The completed summary should be short enough to cover about two sides of A4 paper when typed.

THE FORMULATION

Formulating a case with clarity and precision is probably the most testing yet challenging and crucial part of a psychiatric assessment. The skills of writing a good formulation depend upon the ability to differentiate what are merely the incidental and circumstantial biographical details from what are the salient and discriminatory features and it is this that forms the cornerstone of a clinical diagnosis. Certain features are discriminatory because they support one diagnosis as more likely candidate and discount another diagnosis as less likely.

THE DIAGNOSIS AND FORMULATION

A diagnosis involves a nomothetic (literally “law-giving”) process. This means that all cases included within the identified category have one or more properties in common. By contrast, the formulation is an idiographic process (literally “picture of the individual”). This means that it includes the unique characteristics of each patient's case which are needed for the process of management. So, while nomothetic processes are the only way we can advance knowledge about a disease, we use idiographic methods to understand and study the individual.

THE FORMAT OF THE FORMULATION

The formulation follows a logical sequence.

Demographic data: Begins with name, age, occupation, and marital status of the patient.

Descriptive formulation: Describe the nature of onset,– for example, acute or insidious; the total duration of the present illness; and course; for instance, cyclic or deteriorating. Then list of the main phenomena (namely, symptoms and signs) that characterize the disorder. As you become more experienced you should try to be selective by featuring those phenomena that are most important, either because of their diagnostic specificity or because of their predominance in severity or duration. Avoids long lists of minor or transient symptoms and negative findings. These basic data are chiefly derived from history of the present illness; the mental state and physical examinations are used to determine the syndrome diagnosis in the next section. Note that this is not usually the place to bring in other aspects of the history: That comes later. If we know the diagnosis of a previous episode of mental illness, this should also be taken into account, but remember, the present disorder may not be connected and the diagnosis may be different.

Etiology: The various factors that have contributed should be evident mainly from the family and personal histories, the history of previous illness, and the premorbid personality. Try to answer two questions: Why this patient developed this particular disorder, and why has the disorder developed at this particular time?

PROPOSED FORMATS OF “DIAGNOSTIC SUMMARY” AND “DIAGNOSTIC FORMULATION”

The general formats of “DS” and “DF” are essentially similar with slight changes in order of the presentation, which aim to reduce the number of words as well as to avoid the repetition of words.

• Sociodemographic data
• Elaboration of chief complaint with focus on positive aspects with relevant negative aspects: Presenting the long list of minor or transient symptoms and negative findings is advisable in DS to differentiate in the differential diagnosis which may be avoided in DF. Treatment history also needs to be briefed here. Please note that layman terms shall be used in DS, whereas technical jargons are used in DF
• Past psychiatric and medical history: Briefly describe the symptoms of the past psychiatric disorder and then write possible name for that psychiatric disorder in DS, whereas directly write psychiatric diagnosis in DF
• Family history: Briefly describe symptoms and age of the onset of psychiatric disorder, and then write possible name of that psychiatric disorder in DS, whereas directly write psychiatric diagnosis in DF
• Personal history: Briefly describe the positive aspects of personal history in DS, whereas the use of possible technical jargon in DF is advised
• Premorbid personality: Describe briefly each headings of premorbid personality followed by impression in DS, whereas give directly the impression in DF, i.e., well-adjusted or schizoid/schizotypal/anxious avoidant/personality traits/disorder
• Physical examination: Briefly describe positive findings in DS, whereas technical comments in DF using medial jargons
• Mental Status Examination (MSE): Briefly describe positive findings first, then give impression of that finding using psychopathological terms in DS, whereas directly write technical jargons using psychopathological terms in DF. Please note here that, in case of DF, the psychopathological findings in MSE may be similar to the history of presenting illness (HOPI). In this case, mention as “concurred with HOPI findings” in order to avoid repetition of terms (see in case vignette of DF).

Note: Please note that findings from the family and personal histories, the history of previous illness, and the premorbid personality give the etiology of presentation of case. The sequence in the format of DS may be preferred in the same way as above, whereas in DF, etiology-related history such as past, family, and personal histories as well as premorbid personality may be presented before presenting complaints, which reduce the number of words by avoiding the repetition of words (please see in case vignettes of DS and DF).

CASE VIGNETTES: DEMONSTRATION OF THE STRUCTURE OF “DS “ AND “DF “

Diagnostic summary.

A 36-year-old married and postgraduation-completed male, currently working as a software professional hailing from urban-middle socioeconomic background from Bengaluru, presented with adequate and reliable information of 20-day illness of abrupt onset and continuous course characterized by overcheerfulness, hyperactivity, and unable to sit at one place, overtalkativeness, overfamiliarity, and overspending most of the time in the last 20 days and false and firm claims that he is a minister and demand respect from people in the last 12 days, with decreased need of sleep and appetite disturbance along with socio-occupational dysfunction in the absence of organicity and schizophrenic and depressive symptoms. There was a family history of episodic mental illness suggestive of bipolar disorder in first-degree relative with age of onset at about 23 years with maintaining asymptomatic with lithium prophylaxis and past history suggestive of episodic mental illness of bipolar disorder in the last 12 years with four similar manic episodes with each 3–5 months' duration and another three depressive episodes characterized by depressed mood, reduced interest, easy fatiguability, and early-morning awakening for about 6–8 months with poor medication adherence, with nil significant personal history and well-adjusted premorbid personality. No abnormality was found in physical examination. MSE reveals overfamiliarity; easily established rapport; increased tone, tempo, and volume in speech; pacing around excessive suggestive of increased psychomotor activity; expression and observation of overcheerfulness suggestive of elated mood and affect; and delusion of grandiosity of identity for the above claim with impaired judgment and partial insight (total 250 words).

Diagnostic formulation

Mr. Sri, a 36-year-old married and postgraduation-completed male, currently working as a software professional hailing from urban-middle socio-economic status from Bengaluru, with a family history of bipolar disorder in first-degree relative with maintaining remission on lithium prophylaxis, with past history of four manic episodes and three depressive episodes in last 12 years with poor medication adherence, with nil significant personal history and well-adjusted pre-morbid personality, presented with adequate and reliable information of 20-day illness of abrupt onset and continuous course with characterized by elated mood, increased psychomotor activity, inflated self-esteem, excessive and rapid speech, overfamiliarity, and delusion of grandiosity of identity in the last 12 days with severe bio-socio-occupational dysfunction. No abnormality was found in physical examination. MSE is concurred with the above psychopathology with impaired judgment and impaired insight (total 131 words).

Please note that the above case vignettes are not exclusive and minor variation/s are still possible.

The aims of CF/CS are different from that of DF/DS. CF/CS focuses on understanding of the case-as-whole, but DF/DS aims for diagnostic points of view. The clinical applications, purposes, and structure of DF and DS are different. The authors explained hypothetical explanation of case presentation in academic psychiatry, which we feel is relevant in order to reduce the confusion in minds of present and prospective psychiatric residents. The author hope that these hypothetical explanations explained here is welcomed by the community of academic psychiatry.

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Conflicts of interest.

There are no conflicts of interest.