Psychiatric Review of Systems: A Structured Approach
The psychiatric review of systems is a mandatory component of the initial psychiatric evaluation that systematically screens for symptoms across major psychiatric domains, with particular emphasis on anxiety symptoms, panic attacks, sleep abnormalities, and impulsivity. 1
Core Components Required by APA Guidelines
The American Psychiatric Association mandates that every initial psychiatric evaluation include a comprehensive psychiatric review of systems as part of the history of present illness. 1 This is not optional—it represents a fundamental standard of care for proper psychiatric assessment. 2
Essential Screening Domains
Anxiety and Panic Symptoms
- Systematically assess for anxiety symptoms and panic attacks in every patient. 1, 3
- This screening must occur regardless of the presenting complaint. 2
Sleep Disturbances
- Evaluate both past and current sleep abnormalities, including specific assessment for sleep apnea. 1, 3
- Sleep pathology frequently underlies or exacerbates psychiatric presentations. 2
Impulsivity Assessment
- Direct evaluation of impulsive behaviors and thoughts is required. 1
- This assessment informs both diagnosis and safety planning. 2
Practical Implementation Strategy
Use a Mnemonic-Based Approach The psychiatric review of systems can be efficiently conducted using a systematic mnemonic covering major psychiatric categories: depression, personality disorders, substance abuse, anxiety disorders, somatization, eating disorders, cognitive disorders, and psychotic disorders. 4 For each category, begin with an initial screening question, then pursue detailed diagnostic questions only when the screen is positive. 4
Employ Effective Interviewing Techniques
- Transitioning: Move smoothly between topics rather than abruptly changing subjects. 4
- Normalization: Phrase questions to convey that certain behaviors are understandable (e.g., "Many people in your situation have trouble sleeping—how has your sleep been?"). 4
- Symptom assumption: Frame questions to imply the behavior is expected (e.g., "How often do you drink alcohol?" rather than "Do you drink?"). 4
Critical Pitfall to Avoid
Do not rely solely on fully structured diagnostic interviews or checklists without clinical judgment. While structured formats increase symptom detection compared to unstructured interviews, 5 they cannot replace thorough clinical examination and may generate false positives, particularly in patients with medical comorbidities. 6 In one study, standardized interviews diagnosed major depression in 15.3% of cardiology patients, but expert clinical examination confirmed the diagnosis in only one patient—most had other conditions or were not mentally ill. 6
Integration with Broader Assessment
The psychiatric review of systems functions as one component within the comprehensive evaluation framework. 1 Information should be gathered through multiple methods: face-to-face interview, medical record review, physical examination, diagnostic testing, and collateral sources. 1 The evaluation may require several meetings depending on complexity, clinical setting, and patient cooperation. 1, 3
Time Efficiency A structured psychiatric review of systems can typically be completed in approximately 30 minutes as part of the broader diagnostic interview. 5 This rapid yet thorough approach can be readily incorporated into standard history-taking. 4
Documentation Requirements
All findings from the psychiatric review of systems must be clearly documented with date and time, authenticated by the evaluating clinician. 3 This documentation serves both clinical and certification purposes, as comprehensive assessment across all required domains is necessary for proper psychiatric certification. 2