What approach should be taken during a psychiatric interview for a new patient to assess their mental health and develop an appropriate treatment plan?

Psychiatric First Intake Interview Approach

Conduct a comprehensive, structured psychiatric evaluation that systematically assesses mental status, suicide and violence risk, psychiatric and medical history, substance use, psychosocial stressors, and functional impairment, while establishing therapeutic rapport and collaborating with the patient on treatment planning. 1

Essential Assessment Domains

Initial Documentation and Chief Complaint

• Document patient demographics, date/time of evaluation, and information sources (patient, family, records) 2
• Record the patient's chief complaint in their own words and circumstances leading to the visit 2
• Establish the chronology of symptom development and current level of impairment 2

Mental Status Examination

Systematically assess and document the following observable features:

• Appearance and behavior: General presentation, nutritional status, coordination, gait, and involuntary movements 1
• Speech: Evaluate fluency and articulation 1, 2
• Mood and affect: Assess both subjective mood state and observed emotional expression 1, 2
• Thought process: Determine if logical, tangential, circumstantial, or disorganized 2
• Thought content: Screen for delusions, obsessions, preoccupations 1
• Perceptual disturbances: Assess for hallucinations across sensory modalities 1
• Cognition and sensorium: Evaluate orientation, attention, memory, and executive function 1
• Insight and judgment: Determine patient's understanding of their condition and decision-making capacity 2

Critical Risk Assessment

This is mandatory and must be thoroughly documented:

• Suicide risk evaluation 1, 2:

  • Current suicidal ideation, plans, intent, and access to lethal means (especially firearms)
  • History of prior suicide attempts with details on context, method, lethality, and intent
  • Protective factors including reasons for living, sense of responsibility to others, religious beliefs
  • Patient's intended course of action if symptoms worsen
  • Quality and strength of therapeutic alliance

• Violence risk evaluation 1, 2:

  • Current aggressive or homicidal ideation, plans, and intent
  • History of violent behaviors (homicide, domestic violence, workplace violence, threats)
  • Motivations for aggression and specific triggers
  • Access to weapons
  • History of impulsivity 2

• Document a formal estimate of suicide and violence risk with specific influencing factors 1, 2

Comprehensive Psychiatric History

• Past and current psychiatric diagnoses 2, 3
• Prior psychiatric hospitalizations and emergency department visits 3
• Previous treatments (medications with doses/duration, psychotherapy type/duration) and response to each 3
• Treatment adherence patterns for past and current interventions 3
• History of psychotic symptoms or aggressive ideation 3
• Prior intentional self-injury without suicidal intent 3

Psychiatric Review of Systems

Systematically screen for symptoms across diagnostic categories 2, 3:

• Mood symptoms: Depression, mania, mood lability
• Anxiety symptoms: Generalized anxiety, panic attacks, phobias, obsessions/compulsions 2, 3
• Sleep disturbances: Insomnia, hypersomnia, sleep apnea 2, 3
• Psychotic symptoms: Hallucinations, delusions, disorganized thinking
• Impulsivity and behavioral dyscontrol 2, 3

Substance Use Assessment

• Current and lifetime use of tobacco, alcohol, cannabis, stimulants, opioids, and other substances 2, 3
• Misuse of prescribed medications, over-the-counter drugs, or supplements 2, 3
• Current or recent substance use disorders with severity 3
• Impact of substance use on psychiatric symptoms and functioning 3

Medical History and Physical Examination

• Medical conditions: Current and past illnesses, hospitalizations, surgeries 2, 3
• Neurological history: Head injuries, seizures, neurocognitive disorders 3
• Current medications: All prescribed, over-the-counter, and supplements with side effects 2, 3
• Allergies and drug sensitivities 2, 3
• Relationship with primary care provider 2, 3
• Physical examination findings: Vital signs, height, weight, BMI 2
• Specific systems: Cardiopulmonary status, endocrine function, infectious diseases (HIV, hepatitis C, tuberculosis, STDs) 2
• Sensory function: Sight and hearing 1

Family History

• Psychiatric disorders in biological relatives 2, 3
• For patients with suicidal ideation: Family history of suicide attempts or completions 2, 3
• For patients with aggressive ideation: Family history of violent behaviors 3

Psychosocial and Developmental History

• Current stressors: Financial problems, housing instability, legal issues, occupational difficulties, relationship conflicts 2, 3
• Trauma history: Physical, sexual, or emotional abuse; exposure to violence 2, 3
• Legal consequences of past aggressive behaviors 3
• Cultural factors related to the patient's social environment and need for interpreter 3
• Developmental history: Educational attainment, occupational functioning, relationship patterns 1

Special Considerations for Specific Populations

Children and Adolescents with Intellectual Disability

When assessing youth with intellectual or developmental disabilities 1:

• Adapt interview techniques: Simplify questions, allow extra processing time, avoid leading questions, monitor for comprehension to prevent rote responses or echolalia 1
• Use knowledgeable informants: Gather observational information from caregivers across multiple settings 1
• Consider developmental level: Compare behaviors to developmental age rather than chronological age to avoid pathologizing developmentally appropriate behaviors 1
• Assess environmental factors: Changes in routine, educational placement appropriateness, caregiver stress, and sleep disturbances (2.8 times more common in this population) 1
• Screen for trauma: This population has elevated risk for bullying, abuse, and maltreatment 1
• Evaluate adaptive functioning: Daily living skills, sensory sensitivities, and need for support 1

Collaborative Treatment Planning

Patient Engagement and Shared Decision-Making

• Ask about treatment preferences before making recommendations 1, 2
• Explain clearly 1:
  • The differential diagnosis being considered
  • Risks of untreated illness
  • Available treatment options
  • Benefits and risks of each treatment approach
• Collaborate with the patient on treatment decisions rather than imposing a unilateral plan 1

Documentation Requirements

• Diagnostic formulation: Based on comprehensive assessment data 2
• Treatment plan with explicit rationale: Document specific factors influencing treatment selection 1, 2
• Risk estimates: Formal documentation of suicide and violence risk with contributing factors 1, 2
• Rationale for clinical tests if ordered 1
• Patient's treatment preferences 2
• Date, time, and clinician authentication 2

Measurement-Based Care

Consider incorporating quantitative measures of symptoms, functioning, and quality of life 1. While this is a suggested rather than required component, validated instruments can objectify baseline severity and facilitate outcome tracking.

Common Pitfalls to Avoid

• Relying solely on structured interviews without clinical judgment: Research demonstrates that fully structured interviews like the DISC may generate excessive false-positive diagnoses (47% vs 18% with expert judgment-based interviews), particularly for specific phobias 4. Standardized interviews cannot replace thorough clinical examination and may miss important differential diagnoses, especially with somatic comorbidity 5, 6

• Neglecting cultural factors: Failure to consider cultural context can lead to misdiagnosis 3

• Using no-suicide contracts: These are ineffective; instead, develop collaborative safety plans 2

• Diagnostic overshadowing: In patients with intellectual disabilities or medical comorbidities, avoid attributing all symptoms to the known condition 1

• Inadequate collateral information: Multiple informants across settings are essential for accurate assessment, particularly for children and patients with cognitive impairment 1

• Rushing the evaluation: The assessment may require several meetings to complete adequately, depending on complexity and patient cooperation 3