What is the recommended structure for a psychiatric interview with a 20‑year‑old male patient, including consent, demographics, presenting problem, history, mental status examination, risk assessment, and treatment planning?

Psychiatric Interview Structure for a 20-Year-Old Male Patient

A comprehensive psychiatric interview for a 20-year-old male should follow a standardized format that includes identifying information, chief complaint, history of present illness, psychiatric and substance use history, medical and family history, personal/social history, mental status examination, physical examination findings, risk assessment, and treatment planning with documented informed consent. 1

Consent and Confidentiality

Begin by introducing yourself and explaining the purpose, structure, and limits of confidentiality before proceeding with the interview. 2 Specifically state that information will remain confidential unless there is risk of harm to self or others, which must be disclosed for safety reasons. 3, 2 Document that the patient had an opportunity to ask questions and understood the nature of the assessment. 3

For a 20-year-old, obtain consent directly from the patient as he is an adult. 3 The consent discussion should cover:

• The purpose of the evaluation 3
• How information will be used 3
• Limits of confidentiality regarding safety concerns 3, 2
• Who will have access to the information 3

Demographics and Identifying Information

Document the following basic information at the outset: 1

• Full name, age (20 years), gender (male), date of birth 1
• Date and time of the current evaluation 1
• Source(s) of information (patient, family members, prior medical records, collateral contacts) 1
• Current living situation and who accompanied the patient 1

Chief Complaint and Reason for Evaluation

Record the patient's chief complaint in his own words verbatim. 1 Ask directly: "What brings you here today?" or "What's been going on that led to this appointment?" Document the exact phrasing he uses. 1

Assess the circumstances that led to this evaluation, including whether it was self-initiated, family-prompted, mandated by legal/academic authorities, or following an emergency event. 1

History of Present Illness

Obtain a detailed chronological account of symptom development: 1

Mood and Affect:

• Depressive symptoms: sadness, anhedonia, guilt, worthlessness, hopelessness 1
• Manic symptoms: elevated mood, decreased need for sleep, increased energy, impulsivity, grandiosity 1
• Duration, frequency, and severity of mood changes 1

Anxiety Symptoms:

• Generalized worry, panic attacks (with specific triggers and physical symptoms), social anxiety, specific phobias 1
• Use validated scales like the SCARED or Spence Children's Anxiety Scale for systematic assessment 2

Psychotic Symptoms:

• Hallucinations (auditory, visual, tactile—specify content and command nature) 1
• Delusions (paranoid, grandiose, referential—assess conviction level) 1
• Disorganized thinking or behavior 1

Sleep Patterns:

• Insomnia, hypersomnia, sleep-wake cycle disruption 1
• Snoring and upper airway obstruction symptoms to screen for sleep apnea 3

Impulsivity and Behavioral Control:

• Reckless behaviors, difficulty with impulse control, aggression 1

Functional Impairment:

• Impact on academic performance, work, relationships, self-care 1

Psychiatric History

Document all past and current psychiatric diagnoses, including who made the diagnosis and when. 1 Specifically assess:

Prior Suicidal Behavior:

• Past suicidal ideation, plans, and attempts 1
• For each attempt: context/precipitants, method used, medical damage sustained, perceived lethality, intent to die, rescue circumstances 1
• This is critical for risk stratification 1

Prior Aggressive Behavior:

• History of homicidal ideation, domestic violence, physical altercations, threats, weapon use 1
• Triggers and patterns of aggressive behavior 4

Prior Psychotic Episodes:

• Previous psychotic symptoms and their treatment response 1

Treatment History:

• All prior psychiatric medications (names, doses, duration, response, side effects, reasons for discontinuation) 3
• Psychotherapy (type, duration, perceived benefit) 3
• Psychiatric hospitalizations (dates, reasons, length of stay, treatments received) 3
• ECT or other somatic treatments 3

Substance Use History

Systematically assess use of all substances: 1

• Tobacco (cigarettes, vaping—frequency and quantity) 1
• Alcohol (frequency, quantity, binge drinking, blackouts) 1
• Cannabis (frequency, potency, method of use) 1
• Stimulants (cocaine, methamphetamine, prescription stimulants) 1
• Opioids (heroin, prescription opioids) 1
• Hallucinogens, sedatives, inhalants 1
• Misuse of prescribed or over-the-counter medications 1

For each substance, determine: age of first use, pattern of use, periods of abstinence, withdrawal symptoms, impact on functioning, and current or recent substance use disorders. 1

Medical History

Obtain a comprehensive medical history: 1

• Current medications (prescribed, over-the-counter, supplements—with doses) 1
• Allergies and adverse drug reactions (specify type of reaction) 1
• Past and current medical illnesses 1
• Hospitalizations and surgeries 1
• Cardiopulmonary conditions 1
• Endocrine disorders (diabetes, thyroid disease) 1
• Infectious diseases (HIV, hepatitis C, tuberculosis, sexually transmitted infections) 1
• Neurological conditions (seizures, head injuries, loss of consciousness) 3
• Relationship with primary care provider 1

Note that certain medications (lithium, valproic acid, clozapine) can cause psychiatric symptoms as side effects. 3

Family History

Assess psychiatric disorders in biological relatives (parents, siblings, grandparents, aunts, uncles): 1

• Specific diagnoses (depression, bipolar disorder, schizophrenia, anxiety disorders, substance use disorders) 1
• Psychiatric hospitalizations and treatments 1

For patients with suicidal ideation, specifically assess family history of suicide attempts and completions. 1 This is a critical risk factor. 1

Personal and Social History

Developmental History:

• Pregnancy and birth complications 3
• Developmental milestones (walking, talking, toilet training) 3
• Early childhood behavior and temperament 3

Educational History:

• Academic performance, grade retention, special education services 3
• Behavioral problems at school 3
• Current enrollment status and performance 1

Occupational History:

• Employment status, job stability, work performance 1

Relationship History:

• Current relationship status, quality of relationships 1
• Sexual orientation and gender identity 1
• History of intimate partner violence 1

Trauma History:

• Physical, sexual, or emotional abuse 1
• Neglect 1
• Witnessing violence 1
• Other traumatic events 1

When assessing trauma, consider cultural factors and use appropriate interview techniques, including consideration of interviewer characteristics that may influence disclosure. 2

Current Psychosocial Stressors:

• Financial problems 1
• Housing instability 1
• Legal issues 1
• Relationship conflicts 1

Social Support:

• Living situation and household composition 1
• Quality of family relationships 1
• Peer relationships 1

Mental Status Examination

Conduct a systematic mental status examination: 1

Appearance and Behavior:

• Grooming, hygiene, dress 1
• Eye contact, psychomotor activity (agitation, retardation) 1
• Cooperation with interview 1

Speech:

• Rate, volume, fluency, articulation 1
• Pressured, slowed, or normal 1

Mood and Affect:

• Subjective mood (patient's description) 1
• Objective affect (your observation of emotional expression) 1
• Range, appropriateness, stability of affect 1

Thought Process:

• Logical, goal-directed, tangential, circumstantial, loose associations, flight of ideas, thought blocking 1

Thought Content:

• Delusions, obsessions, preoccupations 1
• Suicidal ideation (current and past) 1
• Homicidal ideation 1

Perceptual Disturbances:

• Hallucinations (auditory, visual, tactile, olfactory, gustatory) 1
• Illusions, depersonalization, derealization 1

Cognition:

• Orientation (person, place, time, situation) 1
• Attention and concentration 1
• Memory (immediate, recent, remote) 1
• Fund of knowledge 1

Insight and Judgment:

• Awareness of illness 1
• Understanding of need for treatment 1
• Decision-making capacity 1

Physical Examination

Document vital signs and basic physical measurements: 1

• Height, weight, body mass index (BMI) 1
• Blood pressure, heart rate, respiratory rate, temperature 1

Note any relevant physical examination findings, particularly those that may indicate medical causes of psychiatric symptoms or side effects of medications. 1

Risk Assessment

This is a critical component that must never be omitted. 2

Suicide Risk Assessment:

• Current suicidal ideation (frequency, intensity, duration) 1
• Specific plan (method, access to means, timeline) 1
• Intent to act on thoughts 1
• Protective factors (reasons for living, social support, future orientation) 1
• Risk factors (prior attempts, family history, substance use, psychiatric symptoms, access to lethal means, recent losses, hopelessness) 1
• Document a clear estimate of suicide risk level (low, moderate, high) with specific factors influencing this assessment. 1

Homicide/Violence Risk Assessment:

• Current aggressive or homicidal ideation 1
• Specific targets or plans 1
• History of violence 1
• Psychotic symptoms driving aggressive thoughts 4
• Substance use 4
• Access to weapons 1

Use safety planning rather than no-suicide contracts, as contracts are not effective. 1 Safety planning involves identifying warning signs, coping strategies, people to contact, and means restriction. 1

Diagnostic Formulation

Synthesize all information into a diagnostic impression using DSM-5 criteria. 1 Consider:

• Primary psychiatric diagnosis 1
• Comorbid psychiatric conditions 1
• Medical conditions affecting mental health 1
• Psychosocial stressors 1
• Level of functioning 1

Be aware that misdiagnosis is common, especially at illness onset, and periodic diagnostic reassessment is necessary. 3 Educate the patient about diagnostic uncertainty when appropriate. 3

Treatment Planning

Develop a comprehensive treatment plan with clear rationale: 1

Immediate Interventions:

• Safety measures if risk is present 1
• Crisis resources and emergency contacts 1

Pharmacological Treatment:

• If medication is recommended, conduct a thorough informed consent discussion covering: 3
  • Target symptoms being treated 3
  • Expected benefits and timeline for response 3
  • Common and serious side effects 3
  • Risks of not treating 3
  • Alternative treatments (both medication and non-medication options) 3
  • Monitoring plan (frequency of follow-up, assessment methods) 3
  • What to do if problems develop 3

Psychosocial Interventions:

• Specific type of psychotherapy recommended (CBT, DBT, interpersonal therapy, family therapy) 3
• Frequency and duration 3

Level of Care:

• Outpatient, intensive outpatient, partial hospitalization, inpatient 1
• Rationale for level of care based on symptom severity, risk, and functional impairment 1

Patient Preferences:

• Incorporate the patient's treatment preferences into the plan. 1 This enhances engagement and adherence. 1

Follow-up:

• Specific timeline for next appointment 1
• Parameters for earlier contact if needed 1

Documentation

All sections must be clearly documented with date, time, and authentication by the evaluating clinician. 1 The documentation should be thorough enough to support clinical decision-making and meet medical-legal standards. 3

Common Pitfalls to Avoid

Do not fail to assess safety. 2 Suicidal ideation, self-harm, and harm to others must always be evaluated. 2

Do not ignore discrepant information from multiple sources. 2 When interviewing a 20-year-old, consider obtaining collateral information from family members (with patient consent), as patients may underreport certain symptoms while family members provide different perspectives. 2

Do not rush the interview. 2 While efficiency is important, premature termination prevents systematic history gathering. 2

Do not assume consent is a one-time event. 3 Ongoing consent discussions are needed as treatment evolves, particularly when adding medications or changing treatment approaches. 3

Do not neglect cultural factors. 2 Consider how cultural background influences symptom presentation, help-seeking behavior, and treatment preferences. 2