What questions should be asked during an initial psychiatric evaluation?

Initial Psychiatric Evaluation Questions

Every initial psychiatric evaluation must systematically assess suicide and violence risk, complete a mental status examination, obtain substance use history, and document collaborative treatment planning with patient preferences. 1

Immediate Risk Assessment (First Priority)

Suicide Risk Evaluation:

• Ask directly: "Are you having thoughts of killing yourself or wishing you were dead?" 1
• If positive, assess specific suicide plans and access to lethal means (firearms, medications, etc.) 1
• Document all past suicide attempts with details about method, medical damage, lethality, and intent 1, 2
• Ask: "What would you do if these feelings got worse?" 1
• Document a formal estimate of suicide risk with specific influencing factors 1, 2

Violence Risk Evaluation:

• Ask: "Are you having thoughts of hurting or killing someone else?" 1
• Assess thoughts of physical or sexual aggression toward specific individuals 1
• Document history of violent behaviors including homicide, domestic violence, and threats 1, 2
• Evaluate access to weapons 1
• Assess for psychotic symptoms that may drive violence 1
• Document a formal estimate of aggressive behavior risk with influencing factors 1, 2

Mental Status Examination

Systematically evaluate and document:

• General appearance, nutritional status, coordination, and gait 1
• Involuntary movements or abnormalities of motor tone 1
• Sight and hearing 1
• Speech fluency and articulation 1, 2
• Mood and level of anxiety 1
• Thought content (suicidal/homicidal ideation, delusions) and thought process (logical vs. tangential vs. circumstantial) 1, 2
• Perception (hallucinations—auditory hallucinations suggest primary psychiatric disorder, visual hallucinations suggest medical cause) 1, 3
• Cognition and level of hopelessness 1

Psychiatric History

Current and Past Diagnoses:

• Identify all past and current psychiatric diagnoses 1, 2
• Document all previous psychiatric hospitalizations 1
• Assess response to past treatments and treatment adherence patterns 1
• Document prior psychotic or aggressive episodes 1, 2

Symptom Review:

• Depression symptoms (mood, anhedonia, sleep, appetite, energy, concentration, guilt, psychomotor changes) 4
• Anxiety symptoms and panic attacks 2, 4
• Psychotic symptoms (hallucinations, delusions, disorganized speech or behavior) 3, 4
• Sleep patterns and abnormalities 2
• Impulsivity 2

Substance Use Assessment

Ask about:

• Tobacco, alcohol, and illicit drug use (illicit drugs are the most common medical cause of acute psychosis) 1, 2, 3
• Misuse of prescribed or over-the-counter medications 1, 2
• Current or recent substance use disorders 1, 2

Medical History and Physical Factors

Essential Medical Information:

• All allergies and drug sensitivities 1, 2
• Complete list of current medications (prescribed, over-the-counter, supplements) 1, 2
• Past and current medical illnesses 1, 2
• Recent head injury or trauma, seizures, cerebrovascular disease, new or worsening headaches (subacute onset suggests oncologic cause) 3
• Cardiopulmonary, endocrinological, and infectious disease status (HIV, hepatitis C, tuberculosis, STDs) 1, 2
• Relationship with primary care provider 1, 2

Vital Signs and Physical Examination:

• Height, weight, BMI 2
• Vital signs (tachycardia or severe hypertension may indicate drug toxicity or thyrotoxicosis; fever may suggest encephalitis or porphyria) 3
• Cognitive changes and abnormal vital signs suggest medical cause of psychosis 3

Family History

• Psychiatric disorders in biological relatives 1, 2
• Family history of suicidal or violent behaviors (especially critical for patients with suicidal ideation) 1, 2

Psychosocial Context and Trauma

Psychosocial Stressors:

• Financial, housing, legal, occupational, and relationship problems 1, 2
• History of trauma or exposure to violence 1, 2
• Cultural factors affecting presentation and treatment 1

Collateral Information:

• Obtain history from family members to establish presentation and course of illness 3
• Document source of information (patient, family, medical records) 2

Collaborative Treatment Planning

Shared Decision-Making:

• Ask the patient directly: "What are your preferences for treatment?" 1
• Explain the differential diagnosis 1
• Discuss risks of untreated illness 1
• Review all treatment options with their benefits and risks 1
• Document the rationale for treatment selection with specific factors that influenced the choice 1
• Document patient's treatment preferences 1, 2

Critical Documentation Requirements

Every initial evaluation must include:

• Estimated suicide risk with influencing factors 1, 2
• Estimated risk of aggressive behavior with influencing factors 1, 2
• Treatment rationale with specific justification 1
• Rationale for any clinical tests ordered 1
• Date and time of evaluation 2

Common Pitfalls to Avoid

Mistaking Psychosocial Reactions for Biological Illness:

• Do not attribute behavioral and emotional reactions to psychosocial stressors as symptoms of underlying biological illness 5
• For example, irritability in a child recovering from depression facing academic challenges may require psychosocial interventions rather than medication adjustments 5

Inadequate Assessment of Medical Causes:

• Always consider medical causes before attributing psychosis to primary psychiatric disorder 3
• Cognitive changes, abnormal vital signs, and visual hallucinations point toward medical etiology 3

Tailoring the Evaluation:

• Clinical judgment supersedes rigid adherence to these guidelines 1
• Tailor the evaluation to clinical context and urgency, individual patient circumstances, available time and resources, and patient's ability to participate 1