What is the recommended approach for a psychiatric intake, including history of present illness (HPI) and treatment plan?

Comprehensive Approach to Psychiatric Intake and History of Present Illness

A thorough psychiatric intake must follow the American Psychiatric Association's structured evaluation framework, which systematically assesses psychiatric symptoms, medical conditions, substance use, risk factors, and psychosocial elements to develop an effective treatment plan. 1

History of Present Illness (HPI) Components

The HPI forms the cornerstone of psychiatric assessment and should include:

Core Elements

• Chief complaint and presenting symptoms - Document exact nature, onset, duration, and progression of symptoms 1
• Psychiatric review of systems - Systematically assess mood, anxiety, psychosis, sleep, appetite, energy 1
• Impulsivity assessment - Document any impulsive behaviors or thoughts 1
• Sleep patterns - Assess sleep abnormalities including possible sleep apnea 1
• Anxiety symptoms and panic attacks - Document frequency, intensity, and triggers 1

Risk Assessment

• Suicidal ideation - Current thoughts, plans, intent, access to means, and protective factors 1
• Prior suicide attempts - Details including context, method, lethality, and intent 1
• Self-injurious behaviors without suicidal intent 1
• Homicidal/aggressive ideation - Thoughts of physical or sexual aggression 1
• Prior aggressive behaviors - History of violence or threats 1

Treatment History

• Previous psychiatric diagnoses - Document all past and current diagnoses 1
• Psychiatric hospitalizations - Dates, duration, and reasons 1
• Past psychiatric treatments - Types, duration, doses, and response 1
• Treatment adherence - Patterns of compliance with medications and therapy 1

Substance Use History

The APA specifically recommends integrating substance use assessment into the psychiatric evaluation rather than relegating it to the social history section 1, 2:

• Comprehensive substance inventory using the SORTED approach 2:
  • Street drugs (illicit substances)
  • OTC medications
  • Rx medications (prescribed and non-prescribed use)
  • Tobacco products (including e-cigarettes)
  • EtOH (alcohol)
  • Dietary supplements (caffeine, vitamins, herbal products)
• Current patterns of use - Frequency, amount, last use 1
• Changes in substance use patterns - Recent increases or decreases 1
• Substance use disorders - Current or recent diagnoses 1

Medical History

A thorough medical history is essential as medical conditions can present with or exacerbate psychiatric symptoms 1:

• Allergies and drug sensitivities 1
• Current medications - All prescribed and non-prescribed medications, supplements 1
• Primary care relationship - Ongoing relationship with PCP 1
• Medical illnesses and hospitalizations - Past and current conditions 1
• Neurological/neurocognitive disorders 1
• Physical trauma - Especially head injuries 1
• Sexual and reproductive history 1

Additional Medical Considerations

• Cardiopulmonary status
• Endocrinological diseases
• Infectious diseases (HIV, hepatitis, etc.)
• Pain conditions 1

Family History

• Psychiatric disorders in biological relatives 1
• Suicide history in family (especially important for patients with suicidal ideation) 1
• Violent behavior in family (particularly relevant for patients with aggressive ideation) 1

Personal and Social History

• Psychosocial stressors - Financial, housing, legal, occupational, relationship problems 1
• Trauma history - Comprehensive assessment of past traumas 1
• Exposure to violence - Combat, childhood abuse, domestic violence 1
• Legal history - Especially related to aggressive behaviors 1
• Cultural factors - Cultural background and its influence on symptoms 1
• Need for interpreter - Language barriers 1

Mental Status Examination

• General appearance and nutritional status 1
• Coordination and gait 1
• Involuntary movements 1
• Sensory function - Sight and hearing 1
• Speech - Fluency and articulation 1
• Mood and anxiety level 1
• Thought content and process 1
• Perception and cognition 1
• Hopelessness - Specifically assess for feelings of hopelessness 1

Treatment Plan Development

After completing the comprehensive assessment, develop a treatment plan that:

1. Addresses primary psychiatric diagnosis based on gathered information
2. Manages any identified risks (suicide, violence, self-harm)
3. Treats comorbid conditions including substance use disorders
4. Incorporates psychosocial interventions based on identified stressors
5. Considers medical conditions that may impact psychiatric treatment

Common Pitfalls to Avoid

• Incomplete substance use assessment - Missing substance use can lead to misdiagnosis and treatment failure
• Overlooking medical causes - Psychiatric symptoms may be caused by underlying medical conditions
• Inadequate risk assessment - Failing to thoroughly assess suicide and violence risk
• Cultural insensitivity - Not considering cultural factors in symptom presentation
• Relying solely on patient self-report - Collateral information is often essential, especially in cases of psychosis, cognitive impairment, or substance use

Special Considerations

• First-episode psychosis requires particularly careful medical evaluation 1
• Elderly patients need more comprehensive medical assessment 1
• Substance users require detailed evaluation for medical complications 1
• Patients with no prior psychiatric history need thorough medical workup 1

The narrative structure of the HPI itself can be therapeutic when properly conducted, helping patients make cognitive sense of their illness while sharing the emotional burden with the clinician 3.