What are the recommended questions and assessments for an initial psychiatric intake?

Recommended Questions and Assessments for an Initial Psychiatric Intake

The American Psychiatric Association recommends a comprehensive initial psychiatric evaluation that includes assessment of psychiatric history, substance use, medical history, family history, personal/social history, mental status examination, risk assessment, and treatment planning to ensure optimal patient outcomes. 1

Core Assessment Components

Psychiatric History and Present Illness

• Document the patient's chief complaint in their own words 2
• Assess current psychiatric symptoms, including onset, duration, and severity 1
• Evaluate past psychiatric diagnoses and treatments, including response and adherence 1
• Document prior psychotic or aggressive ideas and behaviors 2
• Assess prior suicidal ideas, plans, and attempts, including context, method, and intent 2

Substance Use History

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

Medical History

• Document allergies and drug sensitivities 1
• List all current medications (both prescribed and non-prescribed) 1
• Assess whether the patient has an ongoing relationship with a primary care provider 1
• Document past or current medical illnesses and related hospitalizations 1
• Evaluate past or current neurological or neurocognitive disorders 1
• Document physical trauma, including head injuries 1
• Assess sexual and reproductive history 1

Family History

• Document psychiatric disorders in biological relatives 2
• For patients with suicidal ideas, assess history of suicidal behaviors in biological relatives 1
• For patients with aggressive ideas, assess history of violent behaviors in biological relatives 1

Personal and Social History

• Identify psychosocial stressors (financial, housing, legal, occupational, relationship problems) 1
• Review the patient's trauma history 1
• Assess exposure to violence or aggressive behavior, including combat exposure or childhood abuse 1
• Document legal or disciplinary consequences of past aggressive behaviors 1
• Evaluate cultural factors related to the patient's social environment 1
• Assess patient's need for an interpreter 1

Mental Status Examination

Physical Appearance and Behavior

• Assess general appearance and nutritional status 1
• Evaluate coordination and gait 1
• Document involuntary movements or abnormalities of motor tone 1
• Assess sight and hearing 1

Cognitive and Emotional Assessment

• Evaluate speech, including fluency and articulation 1
• Assess mood, level of anxiety, thought content and process, perception, and cognition 1
• Document hopelessness 1
• Use open-ended questions initially to build rapport before moving to more specific questions 3, 4

Risk Assessment

Suicide Risk

• Assess current suicidal ideas, plans, and attempts, including active or passive thoughts of suicide or death 1
• If suicidal ideas are present, evaluate:
  • Patient's intended course of action if symptoms worsen 1
  • Access to suicide methods including firearms 1
  • Patient's possible motivations for suicide 1
  • Reasons for living 1
  • Quality and strength of the therapeutic alliance 1

Violence Risk

• Assess current aggressive or psychotic ideas, including thoughts of physical or sexual aggression or homicide 1
• Document an estimated risk of aggressive behavior, including factors influencing risk 1

Treatment Planning

• Ask about the patient's treatment-related preferences 1
• Explain the differential diagnosis, risks of untreated illness, treatment options, and benefits and risks of treatment 1
• Document the rationale for treatment selection, including discussion of specific factors that influenced the treatment choice 1
• Consider using quantitative measures of symptoms, level of functioning, and quality of life 1

Special Considerations for Adolescents

• Screen for depression using validated instruments such as the Patient Health Questionnaire (PHQ)-9 or PHQ-2 1
• Ask about Internet use, as pathologic Internet use correlates with suicidal ideation 1
• Begin with open-ended, nonthreatening questions before addressing mental health concerns directly 1
• Assess for bullying experiences, both face-to-face and cyberbullying 1

Practical Interview Techniques

• Use a directive style with specific probes and requests for detailed descriptions to obtain better-quality factual information 3
• Avoid double questions as they may result in ambiguous answers 3
• Consider asking patients three key questions about treatment options: "What are my options?", "What are the benefits and harms?", and "How likely are these?" 5
• When discussing medication options, consider eight key factors: diagnosis, efficacy/tolerability profile, comorbidities, concurrent medications, past treatment history, family history, patient preferences, and cost 6

Documentation Requirements

• Document an estimate of the patient's suicide risk, including factors influencing risk 1
• Record the rationale for treatment selection 1
• Authenticate all documentation with date, time, and clinician signature 2

Remember that while these guidelines provide a comprehensive framework, clinical judgment remains essential in tailoring the psychiatric evaluation to each patient's unique circumstances 1.