Psychiatry: core clinical skills
Assessment, formulation & rating scales
This subject covers how psychiatrists combine all their information into a formulation and use standardised rating scales to measure symptoms, severity and progress. It turns a long assessment into a clear plan.
Depth by stage, Pre-U → Consultant (details)
What is it?
After the interview and examination, the psychiatrist writes a formulation: a short explanation of what is going on, why it has happened now and what keeps it going. A common framework covers biological, psychological and social factors that predispose, precipitate, perpetuate and protect.
Rating scales are structured questionnaires or interviews that measure particular symptoms. Some are filled in by the patient (for example PHQ-9 for depression or GAD-7 for anxiety); others are completed by the clinician (for example the Hamilton or Montgomery-Åsberg depression scales, or PANSS for psychosis).
Scales help with screening, measuring severity, tracking progress and research. Their usefulness depends on whether they have been validated in the local language and culture, so Malaysian versions of several common tools are used where available.
Why does a psychiatrist need it?
A formulation guides a personalised treatment plan and helps the whole team and family understand the patient. Rating scales make progress visible, support decisions such as when to change treatment, and are essential in research and audits. Psychiatrists need to choose appropriate tools and interpret scores sensibly rather than treating them as diagnoses.
What level is expected at each stage?
Scale: 1. Aware → 2. Understands → 3. Applies → 4. Masters / Teaches. What the levels mean.
- Pre-UNot expected
- Pre-clinicalAwareAware of questionnaires and screening principles (sensitivity, specificity).
- ClinicalUnderstandsUses simple screening scales and writes a basic biopsychosocial summary.
- HousemanshipAwareUses delirium and cognitive screens on the wards.
- Medical officerAppliesUses common rating scales in clinics and writes formulations with supervision.
- Psych traineeMasters / TeachesWrites structured formulations, knows the main scales and their properties, and uses them in research and exams.
- Specialist / consultantMasters / TeachesProduces sophisticated formulations for complex cases and selects outcome measures for services.
What are the key topics?
Formulation
- Biopsychosocial model
- Predisposing, precipitating, perpetuating and protective factors
- Psychological formulations (cognitive, psychodynamic)
- Cultural formulation
- Sharing a formulation with patients and families
Scale properties
- Reliability (inter-rater, test–retest, internal consistency)
- Validity (content, construct, criterion)
- Sensitivity, specificity, predictive values
- Cut-off scores and their limits
- Translation and cultural validation
Common scales
- Depression: PHQ-9, HAM-D, MADRS, Beck Depression Inventory, Edinburgh Postnatal Depression Scale
- Anxiety: GAD-7, Hamilton Anxiety Rating Scale
- Psychosis: PANSS, BPRS
- Mania: Young Mania Rating Scale
- OCD: Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
- Cognition: MMSE, MoCA, ACE
- Substance use: AUDIT, ASSIST
- General: DASS-21, Clinical Global Impression, HoNOS
Structured diagnostic interviews
- SCID (Structured Clinical Interview for DSM)
- MINI International Neuropsychiatric Interview
- Uses in research versus everyday practice
Using scales in practice
- Measurement-based care
- Side-effect rating scales (e.g. for movement disorders)
- Child and adolescent tools completed by parents and teachers
- Avoiding over-reliance on scores
How is it learned and assessed?
- Introduction in undergraduate psychiatry and epidemiology teaching
- Applied in clinics and wards as MO and trainee
- Formulation and scales examined in MMed Psychiatry and MRCPsych (Paper A for psychometrics, Paper B and CASC for application)
- Used heavily in the MMed dissertation
Typical textbooks and resources
- Handbook of Psychiatric Measures — American Psychiatric Association
- Measuring Health — Ian McDowell
- Oxford Handbook of Psychiatry — assessment chapters
- Malaysian validation studies of common scales published in local journals such as the Malaysian Journal of Psychiatry
Titles are widely used examples; editions change. Use university libraries or legitimate purchases.
Common questions
Can a questionnaire score diagnose depression?
No. A high score suggests that depression is likely and needs proper assessment, but diagnosis comes from a clinical interview. Scores are best used for screening and tracking change.
What is a formulation?
It is the psychiatrist's explanation of a person's difficulties: what made them vulnerable, what triggered the current problem, what keeps it going and what strengths they have. It goes beyond the diagnosis and guides a personalised plan.