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PHIPPS FACTS: The MMSE Earns Top Title

News from the Johns Hopkins Department of Psychiatry and Behavioral Sciences

In 1973, after making her rounds of geriatric patients at Cornell Medical Center’s Westchester Hospital, resident Susan Folstein would report on their mental state to husband Marshal Folstein, who happened to be attending psychiatrist. “She’d tell me, ‘Mrs. Jones is doing better today, or she’s doing worse,’” says Marshal. “But I’d always reply, ‘How do you know that?’”

Hopkins’ well-known psychiatrist Paul McHugh, now University Distinguished Service Professor, was then the residency training director at Cornell. “Because Susan was married to Marshal,” McHugh jokes, “she could only put up with this so long.” Finally, an exasperated Susan asked one day, “Why don’t you just write down the questions you want me to ask?” So that night Marshal did.

His previous neurology training prompted questions that were simple, direct, objective—What day is it? Count backward from 100 to seven—but they were also extraordinarily telling. They measured orientation, comprehension, recall, reading, writing, drawing (visuospatial) tasks. He called the final 11-question product the Mini Mental State Examination (MMSE). Patients could take it in 10 minutes.

Ultimately, the Folsteins set up a trial of the MMSE with 206 patients to see if it could distinguish various cognitive disorders. It could. Scores reliably teased out dementia or depression from normal cognitive function. “We were just kids; we didn’t have any training,” recalls Marshal. They just wanted something to improve their work. But the test was revolutionary.

“It became obvious,” says McHugh, “that nobody else had anything like it.” With his help, the pair submitted their study to the Journal of Psychiatric Research; it was published in 1975.

The rest is history. Once at Hopkins, the Folsteins and their colleagues put the MMSE to work in definitive epidemiological studies on the scope of mental illness, for a starter. Now it’s been translated into more than 35 languages. Referenced in almost 20,000 journal articles, the MMSE is the most cited paper in neuroscience and geriatrics and, as noted in a recent psychiatric journal letter, probably the most frequently cited ever in medicine.

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