How do you assess a patient's mental health history?

Comprehensive Assessment of a Patient's Mental Health History

A thorough mental health history assessment should include a structured psychiatric review of symptoms, past psychiatric treatment history, substance use evaluation, medical history review, family psychiatric history, psychosocial assessment, and a complete mental status examination, as recommended by the American Psychiatric Association guidelines.

Key Components of Mental Health History Assessment

1. Current Psychiatric Symptoms

• Assess current symptoms including severity, frequency, duration, and impact on functioning 1
• Evaluate anxiety symptoms, panic attacks, and sleep abnormalities 1
• Document impulsivity and mood changes 1
• Use example screening questions to quickly assess common mental health problems (see below) 1

2. Past Psychiatric History

• Document past and current psychiatric diagnoses 1
• Record prior psychiatric hospitalizations and emergency department visits 1
• Detail past psychiatric treatments (type, duration, dosage) 1
• Assess response to past treatments and adherence patterns 1
• Document prior suicidal ideation, suicide plans, and suicide attempts, including details of each attempt (context, method, damage, potential lethality, intent) 1
• Note prior intentional self-injury without suicidal intent 1
• Document prior psychotic or aggressive ideas and behaviors 1

3. Substance Use History

• Assess use of tobacco, alcohol, and other substances (marijuana, cocaine, heroin, hallucinogens) 1
• Document any misuse of prescribed or over-the-counter medications or supplements 1
• Evaluate for current or recent substance use disorders 1

4. Medical History

• Review allergies and drug sensitivities 1
• Document all current and recent medications and their side effects 1
• Assess for ongoing relationship with primary care provider 1
• Review past/current medical illnesses and hospitalizations 1
• Document relevant past treatments, including surgeries and alternative treatments 1
• Assess for neurological or neurocognitive disorders 1
• Document physical trauma, including head injuries 1
• Review sexual and reproductive history 1

5. Family History

• Assess history of psychiatric disorders in biological relatives 1
• Document family history of suicidal behaviors (especially for patients with current suicidal ideas) 1
• Note family history of violent behaviors (especially for patients with current aggressive ideas) 1

6. Psychosocial Assessment

• Evaluate psychosocial stressors (financial, housing, legal, occupational, relationship problems) 1
• Assess social support systems 1
• Review trauma history 1
• Document exposure to violence or aggressive behavior 1
• Assess cultural factors related to the patient's social environment 1
• Evaluate personal/cultural beliefs about psychiatric illness 1

7. Mental Status Examination

• Document general appearance and nutritional status 1
• Assess coordination, gait, and involuntary movements 1
• Evaluate speech patterns 1
• Assess mood, anxiety level, thought content/process, perception, and cognition 1
• Document hopelessness 1
• Evaluate current suicidal/homicidal ideation 1
• If suicidal ideas present, assess:
  • Patient's intended course of action if symptoms worsen
  • Access to suicide methods including firearms
  • Motivations for suicide
  • Reasons for living
  • Quality of therapeutic alliance 1

Screening Approach

1. Begin with focused medical history on mental health 1
2. Use example screening questions to quickly assess common mental health problems 1
3. For patients reporting mental health problems, refer to a mental health professional for further assessment with validated instruments 1
4. Prompt referral to mental health specialist for diagnostic assessment if mental health symptoms are identified 1
5. Immediate referral for severe mental health problems that could interfere with patient safety 1

Documentation Requirements

• Document an estimate of suicide risk, including factors influencing risk 1
• Document the rationale for treatment selection 1
• Include patient treatment preferences 1
• Provide explanation of differential diagnosis, risks of untreated illness, and treatment options 1

Common Pitfalls to Avoid

• Overlooking medical causes of psychiatric symptoms, especially in first-episode psychosis, elderly patients, patients with substance use disorders, and patients with abnormal vital signs 2
• Relying solely on cognitive screening tools without clinical judgment 2
• Neglecting cultural factors in symptom presentation and interpretation 2
• Failing to obtain collateral information from family/caregivers 2
• Assuming lack of capacity based on diagnosis alone 2
• Ordering unnecessary laboratory and imaging studies 2

Special Considerations

• For patients on psychiatric medications, assess for emergence of concerning symptoms including anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, mania, unusual behavior changes, worsening depression, and suicidal ideation 3
• Advise families and caregivers to observe for the emergence of such symptoms on a day-to-day basis 3
• Consider social determinants of health in assessment, as these have significant impact on overall health outcomes in people with mental disorders 4

By following this comprehensive approach to mental health history assessment, clinicians can ensure thorough evaluation of psychiatric conditions while identifying potential medical causes of psychiatric symptoms, ultimately improving patient outcomes related to morbidity, mortality, and quality of life.