What are the steps for conducting a comprehensive psychiatric interview and assessment, including history of present illness, past psychiatric and medical history, substance use, mental status examination, risk assessment, formulation, and treatment planning?

Conducting a Comprehensive Psychiatric Interview and Assessment

The American Psychiatric Association recommends a systematic psychiatric evaluation that includes identifying information, chief complaint, comprehensive history of present illness with psychiatric review of systems, complete psychiatric and substance use history, medical history, family history, personal/social history, mental status examination, physical examination findings, risk assessment, and diagnostic formulation with treatment plan. 1, 2

Initial Assessment Framework

History of Present Illness

• Document the reason for presentation, onset and duration of symptoms, precipitating factors, and functional impairment across work, social, and personal domains 1
• Characterize the temporal pattern of symptoms: episodic versus chronic, frequency, duration, and any periods of remission 1
• Assess prior treatment responses, including specific medications tried, doses, duration, adherence, and reasons for discontinuation 2, 3
• Identify any antidepressant-induced mood elevation or agitation, as this strongly suggests underlying bipolar disorder 4

Past Psychiatric History

• Document all prior psychiatric diagnoses, including those that may have been incorrect, with dates of onset 2, 3
• Record history of psychiatric hospitalizations and emergency department visits, including dates, reasons, and outcomes 2
• Obtain complete suicidal history: prior suicidal ideation, specific plans, intent, attempts (including aborted or interrupted attempts), method, lethality, and circumstances 2, 3
• Document prior psychotic experiences, aggressive behaviors, homicidal ideation, and any history of violence 2, 3

Substance Use History

• Assess current and past use of tobacco, alcohol, cannabis, stimulants, opioids, hallucinogens, and benzodiazepines 2
• Document misuse of prescribed medications and over-the-counter medications 2
• Obtain toxicology screening when substance-induced mood disorder is suspected, assessing the temporal relationship between substance use and psychiatric symptoms 4, 3
• Critical pitfall: Overlooking substance use as a contributor to psychiatric symptoms leads to incomplete treatment 2

Medical History

• Review cardiovascular disease, cerebrovascular disease or stroke, neurologic structural abnormalities, head injury with loss of consciousness, sleep disorders, thyroid disease, vitamin B12 deficiency, and metabolic syndrome 1
• Document current medications, medication allergies, and personal/family history of medical problems 3
• Perform physical examination with vital signs, height, weight, BMI, and particular attention to neurological findings 3
• Four groups require particularly careful medical evaluation: the elderly, those with substance abuse, patients without prior psychiatric history, and those of lower socioeconomic level 3

Family History

• Obtain detailed family psychiatric history, particularly mood disorders, bipolar disorder, psychotic disorders, substance use disorders, and completed suicides 1, 2
• First-degree relatives of individuals with bipolar disorder have a four- to sixfold increased risk of developing the condition 4
• Document patterns of family interactions, parenting styles, and any history of maltreatment or trauma 1

Personal and Social History

• Assess developmental history, educational attainment, occupational functioning, and relationship history 1
• Document current living situation, social supports, financial stressors, and cultural/religious background 1
• Critical pitfall: Neglecting to assess trauma history can miss important etiological factors 2

Mental Status Examination

• Document appearance (fastidious or disheveled), eye contact, engagement level, and any signs of anxiety such as tremor or fidgetiness 1
• Assess speech: rate (pressured or poverty), volume, and coherence 1
• Evaluate mood (patient's subjective report) and affect (observed emotional expression, range, appropriateness, and stability) 1
• Examine thought process (linear, tangential, circumstantial, flight of ideas) and thought content (worry, rumination, delusions, obsessions) 1
• Test cognition: orientation, attention, concentration, memory, and insight into illness 1
• Observe for psychomotor changes: agitation, retardation, or catatonic features 1

Risk Assessment

Suicide Risk

• Assess current suicidal ideation: both active ("I want to kill myself") and passive ("I wish I were dead") thoughts 2, 3
• Document specific plans, intent to act, and access to lethal means (firearms, medications, other methods) 2, 3
• Identify protective factors: reasons for living, social supports, religious beliefs, responsibility to dependents 2
• The American Psychiatric Association recommends developing collaborative safety plans with specific coping strategies and crisis resources instead of using "no-suicide contracts" 2

Violence Risk

• Assess current homicidal or aggressive ideation, including specific targets 2, 3
• Document history of violent behavior, domestic violence, and access to weapons 2, 3
• Evaluate impulsivity, substance use, and command hallucinations directing violence 2

Special Considerations for Intoxicated Patients

• The patient's cognitive abilities, rather than a specific blood alcohol level, should be the basis on which clinicians begin the psychiatric assessment 1
• Consider using a period of observation to determine if psychiatric symptoms resolve as intoxication resolves 1
• Alcohol intoxication can mimic or alter psychiatric symptoms, and suicidality often clears as blood alcohol concentration decreases 1

Diagnostic Formulation

• Organize information using a biopsychosocial framework: biological factors (genetics, medical conditions), psychological factors (cognitive patterns, coping mechanisms), and social factors (relationships, stressors, cultural context) 1
• Structure the formulation around predisposing factors (vulnerabilities), precipitating factors (triggers), perpetuating factors (maintaining factors), and protective factors (strengths) 1
• Use a life chart to map the longitudinal course of symptoms, documenting when specific symptom clusters began, their duration, and any periods of remission 4
• Differentiate primary psychiatric disorders from substance-induced disorders, medical conditions, and medication side effects 1, 4

Treatment Planning

• Develop specific interventions including pharmacological and non-pharmacological treatments with clear rationale 2
• Incorporate patient's treatment preferences, goals, and personal/sociocultural values to enhance the therapeutic alliance 1, 2
• Explain the range of potentially effective treatments according to the cognitive, linguistic, and cultural level of the patient and family 1
• Address informed consent: diagnosis, nature and purpose of proposed treatment, attendant risks and benefits, alternative treatments and their risks and benefits, and risks and benefits of declining treatment 1
• Determine appropriate level of care based on diagnosis, symptom severity, comorbid conditions, risk to self or others, prior illness course, available supports, and treatment alliance 1

Follow-Up Assessment

• Provide a focused update on changes since the last evaluation, current symptoms, and mental status 2
• Review treatment response, medication adherence, and side effects 2
• Update risk assessment at each visit, as safety risks can change over time 1, 2
• Revise the treatment plan based on patient response and updated assessment 2
• Critical pitfall: Failing to review previous comprehensive documentation before follow-up visits wastes resources and burdens patients 2

Critical Pitfalls to Avoid

• Performing routine laboratory testing without clinical indication in psychiatric patients with normal vital signs and non-contributory examinations is not evidence-based 2
• Diagnostic overshadowing can prevent identification of new medical or psychiatric conditions 2
• Differentiating psychiatric symptoms from normal developmental phenomena in children and adolescents is essential to avoid pathologizing developmentally appropriate behavior 3
• Consider cross-cultural issues that may influence the expression or interpretation of symptoms and treatment response 4, 3