What is the recommended approach for an initial psychiatric intake?

Initial Psychiatric Intake Assessment

A comprehensive initial psychiatric intake must systematically assess suicide and violence risk, complete a mental status examination, obtain detailed psychiatric and substance use histories, and engage the patient in collaborative treatment planning with documented preferences. 1, 2

Essential Risk Assessment (Highest Priority)

Every initial evaluation must begin with formal assessment of immediate safety concerns:

• Current suicidal ideation including active or passive thoughts of death, specific plans, access to lethal means, past attempts with details of method and lethality, and patient's intended actions if symptoms worsen 1, 2
• Current aggressive or homicidal ideation including thoughts of physical or sexual violence toward specific individuals, history of violent behaviors, access to weapons, and psychotic symptoms driving violence 1, 2
• Document a formal estimate of both suicide risk and aggressive behavior risk with specific influencing factors in every evaluation 1, 2

Structured History Components

Chief Complaint and History of Present Illness

• Document the patient's own words regarding the presenting problem and circumstances leading to evaluation 1
• Chronology of symptom development with specific attention to anxiety, panic attacks, sleep patterns, and impulsivity 1
• Psychiatric review of systems covering mood, anxiety, psychosis, cognitive changes, and behavioral symptoms 1, 3

Psychiatric History

• All past and current psychiatric diagnoses with details of previous hospitalizations, treatment responses, and adherence patterns 1, 2
• Prior psychotic episodes, aggressive behaviors (including homicide, domestic violence, threats), and suicidal attempts with context, method, damage, lethality, and intent 1, 2

Substance Use History

• Comprehensive assessment of tobacco, alcohol, and illicit drug use including misuse of prescribed or over-the-counter medications 1, 2
• Current or recent substance use disorders as these significantly impact diagnosis and treatment 1, 2

Medical History

• Allergies, drug sensitivities, and all current medications (prescribed, non-prescribed, supplements) 1, 2
• Past and current medical illnesses with specific attention to cardiopulmonary, endocrinological, and infectious diseases (STDs, HIV, tuberculosis, hepatitis C) 1, 2
• Primary care relationship status 1, 2

Family and Social History

• Psychiatric disorders in biological relatives and family history of suicidal or violent behaviors, especially relevant for patients with suicidal ideation 1, 2
• Psychosocial stressors including financial, housing, legal, occupational, and relationship problems 1, 2
• Trauma history and exposure to violence 1, 2

Mental Status Examination

Systematic assessment of:

• Appearance, behavior, and nutritional status 1, 2
• Speech fluency and articulation 1, 2
• Mood and affect 1, 2
• Thought process (logical, tangential, circumstantial) and thought content 1, 2
• Perception, cognition, and level of hopelessness 2
• Coordination, gait, and involuntary movements 2

Physical Examination

• Height, weight, BMI, and vital signs should be measured and documented 1

Collaborative Treatment Planning

Engage the patient in shared decision-making:

• Ask directly about treatment-related preferences and document these preferences 1, 2
• Explain the differential diagnosis and discuss risks of untreated illness 2
• Review all treatment options with their benefits and risks 2
• Document the rationale for treatment selection including specific factors that influenced the choice 1, 2

Special Considerations for Treatment Initiation

• If psychosis is present for a week or more with distress or functional impairment, antipsychotic treatment should be offered 4
• Earlier initiation is appropriate for severe distress or safety concerns to self or others 4
• Initial antipsychotic choice should be collaborative based on side-effect and efficacy profiles, with consideration of dose scheduling and long-acting formulations 4

Documentation Requirements

Every initial evaluation must include:

• Date, time, and source of information (patient, family, medical records) 1
• Documented estimate of suicide risk with influencing factors 1, 2
• Documented estimate of aggressive behavior risk with influencing factors 1, 2
• Treatment plan with specific rationale for medication or intervention choices 1, 2
• Authentication by the evaluating clinician 1

Critical Caveats

Common pitfalls to avoid:

• Do not use no-suicide contracts—instead, develop safety plans for patients with suicidal ideation 1
• For patients with aggression, conduct specific assessment of triggers and response to interventions 1
• Clinical judgment supersedes rigid adherence to these guidelines and must be tailored to clinical urgency, individual circumstances, available resources, and patient's ability to participate 2
• Structured interviews increase symptom detection compared to unstructured approaches, but beware that standardized tools may miss nuanced differential diagnoses, particularly with somatic comorbidity 5, 6