How should I perform an initial psychiatric assessment?

How to Perform an Initial Psychiatric Assessment

Conduct a systematic evaluation that includes identifying information, chief complaint, comprehensive psychiatric and medical histories, substance use assessment, mental status examination, physical examination with vital signs, risk assessment, and a documented treatment plan—all while obtaining informed consent and explaining confidentiality limits at the outset. 1

Consent and Confidentiality Framework

• Begin by explaining confidentiality limits explicitly: all information remains confidential except when there is risk of harm to the patient or others, at which point disclosure is legally required for safety. 1
• Confirm the patient understands the assessment's purpose and provide an opportunity to ask questions before proceeding. 1
• Document the source of information (patient, family, medical records, collateral contacts) at the start of your evaluation. 1

Core Assessment Domains

Identifying Information and Chief Complaint

• Record patient demographics (name, age, gender, date of birth), date and time of evaluation. 1
• Document the chief complaint in the patient's own words regarding the presenting problem. 1
• Capture the circumstances that led to the current evaluation or hospitalization. 1

History of Present Illness

• Obtain a chronological account of symptom development, including onset, duration, progression, and any precipitating factors. 1
• Conduct a psychiatric review of systems covering mood symptoms (depression, mania), anxiety and panic attacks, psychotic symptoms, sleep disturbances, impulsivity, and changes in appetite or weight. 1
• Quantify the percentage of time the patient is preoccupied with psychiatric symptoms and assess resulting psychosocial impairment. 2

Psychiatric History

• Identify all past and current psychiatric diagnoses, recognizing that misdiagnosis at illness onset is common and periodic reassessment is necessary. 1
• Document all prior psychiatric treatments in detail: medication names, dosages, duration, therapeutic response, side effects, and reasons for discontinuation. 1
• Record prior psychotherapy (type, duration, perceived benefit) and any somatic treatments such as electroconvulsive therapy. 1
• Assess history of psychiatric hospitalizations (dates, reasons, length of stay, treatments received). 1

Substance Use History

• Evaluate use of tobacco, alcohol, and illicit substances, including patterns, frequency, and quantity. 1
• Screen for misuse of prescribed or over-the-counter medications, as this is frequently overlooked. 1
• Identify current or recent substance use disorders and their impact on psychiatric presentation. 1

Medical History and Review of Systems

• Document allergies, drug sensitivities, and all current medications (prescribed, non-prescribed, supplements). 1
• Conduct a comprehensive review of systems, including cardiopulmonary status, endocrinological disease, and infectious diseases (STDs, HIV, tuberculosis, hepatitis C). 2, 1
• Screen specifically for sleep-related breathing problems (snoring, upper-airway obstruction) that may indicate obstructive sleep apnea, which can exacerbate psychiatric symptoms. 1
• Perform a focused neurological review assessing for seizures, head injuries, or loss of consciousness. 1
• Assess primary care relationship and continuity of medical care. 1

Family History

• Evaluate psychiatric disorders in biological relatives, as family history significantly influences diagnosis and treatment planning. 1
• For patients with suicidal ideation, specifically assess history of suicidal behaviors in relatives, as this increases risk. 1

Personal, Social, and Developmental History

• Identify current psychosocial stressors (financial, housing, legal, occupational, relationship problems). 1
• Assess trauma history comprehensively. 1
• For younger adults, inquire about prenatal and birth complications, early developmental milestones (walking, talking, toilet training), early childhood behavior and temperament. 1
• Document academic history including performance, grade retention, and special education services. 1

Physical and Mental Status Examination

Physical Examination

• Measure and record: height, weight, BMI (or percent median BMI for children/adolescents), vital signs including temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure. 2, 1
• Assess physical appearance for signs of malnutrition or purging behaviors. 2

Mental Status Examination

• Evaluate appearance and behavior, speech (fluency and articulation), mood and affect. 1
• Assess thought process (logical, tangential, circumstantial, flight of ideas) and thought content (delusions, obsessions, suicidal or homicidal ideation). 1
• Examine cognition, insight, and judgment. 1

Laboratory and Diagnostic Testing

• Obtain a complete blood count and comprehensive metabolic panel including electrolytes, liver enzymes, and renal function tests in all patients. 2
• Perform an electrocardiogram in patients with restrictive eating disorders, severe purging behavior, or those taking medications known to prolong QTc intervals. 2

Risk Assessment

• Evaluate current suicidal ideation, plans, intent, and access to means at every assessment. 1
• Document prior suicidal attempts including context, method, damage, lethality, and intent. 1
• Assess current aggressive or homicidal ideation, particularly in patients with a history of violence. 1
• Document prior aggressive behaviors (homicide, domestic violence, threats) and prior psychotic ideas. 1
• Provide a documented estimate of suicide risk with specific influencing factors (protective and risk factors). 1
• Use safety planning rather than no-suicide contracts for patients with suicidal ideation. 1

Diagnostic Formulation and Treatment Planning

• Develop a diagnostic formulation based on the comprehensive assessment, acknowledging when uncertainty exists and educating patients about the provisional nature of diagnoses. 1
• Create a documented, comprehensive, culturally appropriate, and person-centered treatment plan that incorporates medical, psychiatric, psychological, and nutritional expertise, commonly via a coordinated multidisciplinary team. 2
• Consider the patient's treatment preferences in the plan. 1
• Determine appropriate level of care (outpatient, intensive outpatient, partial hospitalization, inpatient) based on symptom severity, risk, and functional impairment. 1

Special Considerations

Avoiding Diagnostic Pitfalls

• Do not attribute behavioral or emotional reactions stemming from psychosocial stressors to underlying biological illness, as this leads to unnecessary medical interventions and overlooks needed psychosocial support. 3
• Be aware that certain psychotropic agents (lithium, valproic acid, clozapine) can produce psychiatric side effects that may be mistaken for primary symptoms. 1

Cultural and Demographic Factors

• Recognize that patient gender, ethnicity, and socioeconomic status can unconsciously influence clinical assessments, including perceived dangerousness, treatment recommendations, and reporting decisions. 4
• Be mindful that patients from certain ethnic backgrounds may have different pathways to care and may be less likely to be referred by general practitioners. 5

Documentation Requirements

• All sections must be clearly documented with date, time, and authentication by the evaluating clinician to satisfy clinical decision-making requirements and medical-legal standards. 1
• Ensure documentation is complete, organized, and accessible to the treatment team. 1