presentation mental health interview

• Last edited on February 1, 2024

The Psychiatric Interview

Table of contents, general tips, subspecialty, the psychiatric review of systems, obsessions and compulsions, medications, substance use history, past medical history, family history, personality traits/disorders, legal/forensic history, closing the interview, mental status examination (mse), the rule of parsimony.

The Psychiatric Interview involves a balance of being empathetic, asking the right questions, and thinking about the diagnostic criteria carefully for psychiatric disorders. Remember, everyone has a different way of interviewing, but every question you ask should have a purpose . Are you trying to elicit symptoms? Understand someone's life history? Understand their safety risks? Just as a good surgeon makes no unnecessary incisions on the patient during a surgery, a good psychiatrist should ask no unnecessary questions during the interview. This does not mean that your interview be devoid of substance or empathy, but that you make every question count . Below is a template to guide you.

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• Ask neutral questions early (e.g. - age, workplace, medical history, medications)
• Ask “threatening/challenging” questions later (e.g. - psychotic symptoms, suicide/homicidal thoughts, substance use, trauma, cognitive testing questions)
• Be careful of using leading questions and piggybacking multiple symptoms along. (e.g. - “How's your sleep, appetite, and mood?”; ask each individual item separately)
• Occam's Razor should be in the back of your mind.
• Open-ended questions are questions that cannot be answered with a simple “yes” or “no” response (e.g. - “Tell me about your childhood.”)
• Closed-ended questions can be answered from multiple choices or a “yes” or “no” response (e.g. - “On a scale of 1 to 10, how would you rate your mood?”)

Emergency Room Interviewing Tips

• They may tell you “It's not OK!” (because it really isn't “OK” for them right now), or tell you “No, you don't understand!” (because you really don't actually understand everything that is happening. How could you? You just met them today!)
• Watch out for these verbal “tics”!
• e.g. - “I can see you are very upset/very angry/pissed off, etc…”
• e.g. - “I can't even pretend to understand what you're going through right now, but I will do my best to listen and try to understand.”
• “Why here, and why now?” (the reason they came to the ER or reason for the crisis event)
• “What can we do for you? What were you hoping we could do for you?”
• e.g. - “Not making a decision is also a decision in and of itself.”
• Show empathy!
• Identify your patient's strengths and coping skills throughout the interview

If assessing a child, adolescent, or older adult, the interview and assessment will be significantly different. See the pages above.

Ask the pertinent social history upfront: this allows you to frame the interview and understand your patient's social situation.

• Relationship status and children (if any)
• Disability/welfare status
• Occupation/Education
• Living situation (where? with whom?)
• Family/siblings
• Health care providers: GP, psychiatrist, specialists, etc.

History of Presenting Illness

• Start with close ended questions, do not ask leading questions. Make them direct!
• Who brought you here? Who sent you here?
• Allow your patients to tell you the story. Doctors have a bad habit of interrupting patients within the first few minutes of meeting a patient. [1]
• Anything further in the past should be considered as past psychiatric history

Always Establish the Chronology of Events

• “How do you feel now?”, “How do you feel compared to your well self?”, “When did you last feel 'normal/well'?”
• Always compare the patient's current symptoms to their baseline
• Are there any acute stressors presently?
• What are their coping strategies?
• Key questions on a psychiatric review of systems includes asking questions about mood (both depression and mania ), sleep , anxiety , psychosis , obsessions and compulsions , dissociative symptoms , trauma history , body image disturbances , eating disorders , and somatic / pain disorders .
• It will be difficult to get through all these areas in a one-time assessment, and the clinician should use their clinical judgment to determine which questions will be the most helpful and high yield.
• An example of a relatively comprehensive psychiatric review of systems is detailed below, but is by no means exhaustive. Some individuals early on may find using a checklist helpful to keep themselves organized.
• “Tell me about your mood right now,” “How's your mood right now?”
• On a scale of 0 to 10 (0 = worst you've ever felt, and 10 = best mood you ever had)
• When someone says they are “depressed,” it is important to clarify what they mean by that, don't just take it at face value
• If someone says they've “always been depressed,” try to get them to describe what their earliest memory of being depressed was like

Substance-induced mood/anxiety disorder?

“Now I'm going to ask you about some other symptoms people might feel when they're depressed.”:

• “Tell me about your sleep”
• Ask about sleep hygiene (screen time)
• How long are you asleep?
• What time do you fall asleep?
• What time do you get up?
• Are there night time awakenings?
• Are you told you snore at night? (think about sleep apnea , which can cause depressive symptoms)
• Do you ever experience nightmares? (could be a sleep disorder or a trauma disorder )
• Interest (Anhedonia)
• ADHD screen may be applicable here
• How much weight loss?
• What is their ideal weight?
• What specifically makes this ideal?
• Are they pre-occupied with their weight
• Current weight and highest weight
• Compensatory behaviour: medications, purging, laxatives, diuretics
• Psychomotor Slowing
• Suicide (leave this for later, unless your patient brings it up)

Always ask about anxiety and depression at the same time since these symptoms often overlap and are “co-morbid.” Key questions to ask include:

• Find your worry is difficult to control?
• Do you easily blanking out or have difficulty concentrating?
• Easily fatigued?
• Sleep changes (difficulty falling or staying asleep, or restless, unsatisfying sleep)?
• Feel keyed up, on edge, or restless?
• Feel irritable, or others comment on it?
• Experience muscle tension when you are worried?
• Would you describe yourself as a worrier?

“Now I'm going to ask you about some symptoms when people feel the opposite of depressed.”

• “Found if easy to jump from one idea to another?” (more of a physical observation in the patient)
• Have your friends or family recently commented on this?
• Ever get the feeling you have superpowers, or invincible?
• “Racing thoughts in your head?” (more of the patient's subjective experience)
• “Have you been doing a lot more at work? Sexual indiscretion when you normally wouldn't? Having sexual relations with strangers?”
• “Decreased to the point where you don't have to sleep for days?”, more specifically, are not sleeping because you have so much energy ?
• “Talking more rapidly?”

Key questions to ask about bipolar symptoms and course of illness:

• Do you spend most of your time feeling depressed or manic?
• Do you tend to get psychotic symptoms when you have depressive or manic symptoms? (think: either depression with psychotic features , or mania with psychotic features)
• Was there a period of time (>2 weeks) where you did not feel depressed/manic, but still had psychotic symptoms? (think schizoaffective disorder )
• When was your first manic/depressive episode? (The index event is important, this informs you: what is the natural history of the illness in the person? Do they tend to have a depressive or manic presentation?)

In patients with a history of multiple manic and depressive episodes, it can often be overwhelming and not practical to ask about the course of each specific episode. It is useful to obtain in broad strokes the following details instead:

Key Features of a Good Bipolar Disorder History

• “Do you ever feel things are not real?
• “Do you worry that people might be against you or after you?”
• “Do the voices ever command you do to things?”
• “Do you ever things other people don't see?”
• “Are the voices outside or inside your head?” (auditory hallucinations are more likely to be heard “outside,” and often patients will look for the voice)
• “Do you ever feel that thoughts are being put into your head?” (thought insertion)
• “Do you ever feel that thoughts are being taken out of your head?” (thought withdrawal)
• “Do you ever feel that your thoughts are being broadcasting so that other people know what you are thinking?” (thought broadcasting)
• “Do you feel like there are special messages for you?”
• Ask about hallucinations types, are they: auditory, visual, tactile, or olfactory? - this may indicate brain pathology or lesions!

Substance-induced psychosis?

Most individuals with OCD will have both obsessions and compulsions. High sensitivity screening questions and a good OCD history includes the following:

• e.g. - worries about dirt/germs, or thoughts of bad things happening
• e.g. - repeatedly washing hands, cleaning, checking doors or work over and over, rearranging things to get it just right , or repeating thoughts in your mind to feel better?
• e.g. - interfering with school, work, or seeing friends?

The Relationship Between Obsessions and Compulsions

• Compulsions are usually performed in response to an obsession (e.g. - obsession about contamination → compulsion of hand washing rituals; obsession about a situation being incorrect → compulsion of repeating rituals until it feels “just right”)
• For individuals with OCD, compulsions reduce the distress triggered by the obsession, or prevent a feared event from occurring (e.g. - getting sick, hurting someone)
• It is important to note that compulsions are not connected in a realistic way to the feared event (e.g. - arranging items in a certain colour to prevent harm to a loved one) or are significantly excessive (e.g. - washing hands for 30 minutes at a time due to fears of contamination)
• Compulsions that are performed are not pleasurable! Rather, they allow the individual to experience relief from their anxiety or distress

Asking the question

• “Some people might think of suicide when their mood is low, has this ever crossed your mind?”
• “You're going through the loss of a loved one, has your own death or suicide ever crossed your mind?
• Always ask about the index suicide attempt (when, how, why?)
• Are there any self-harm behaviours that might put their safety at risk? Could this lead to an “inadvertent suicide”?
• Did they carry out their suicide attempt(s) with the expressed intent to die? (Sometimes a “suicide attempt” is not actually an attempt, but an accidental overdose - it is important to clarify this with your patient)

Current safety

• Is there any plan?
• Is there access to the means of death? (firearms, medications, poisons, etc.)
• Do they plan on doing this immediately?
• What are the chronic, acute, and imminent risk factors that might lead to suicide?
• Are there any threats to others due to psychotic symptoms?
• Are there any threats to specific individuals?
• “If you were to leave the hospital now, would you want to hurt anyone?”
• “If you saw [person they wanted to hurt] on the street, what would you do? Would you defend yourself? Would you want to hurt/kill them?”
• Are there any symptoms that cause dangerous driving? If patients have suicidal idea, homicidal ideation, mania, or psychosis, this is a critical safety question to ask
• Has their license ever been revoked?
• What medications are they on now?
• Have they been on any psychiatric medications? Now? In the past? What doses?
• Patients often forget about this, and it is important to prompt them. Certain supplements (e.g. - St. John's wort ) can have significant drug-drug interactions.
• Do they have any allergies to medications? Any specific reactions to psychiatric medications?
• What age? How many packs per day? Ever use nicotine replacement therapy?
• What age? What kind? IV/PO? Naloxone?
• What age? How much? History of blackouts? Have you ever been a binge drinker? Alcohol withdrawal? Seizures?
• “Ever feel you need to cut down your drinking?”
• “Have people annoyed you by criticizing your drinking?”
• “Have you ever felt bad or guilty about your drinking?”
• “Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover ( eye-opener )?”
• What age? How much? What specific effects from the cannabis do they like or not like? Do they get paranoia?
• What age? How much? What effects?
• How much caffeine do they use? What time of day? How many cups?

Substance-induced Psychiatric Symptoms?

Various medical conditions can relate to psychiatric symptoms, and can also have medication interactions. In brief, you should always ask:

• Any history of concussions or head injuries ?
• Any history of seizures ?
• Thyroid disease or disorders ?
• History of surgeries

Past Psychiatric History

• How many life-time hospital admissions?
• How many total depressive episodes?
• How many total manic episodes?
• How many total psychotic episodes?
• By staying general, but detailed enough to get broad strokes of a person's history, you can avoid getting bogged down in too much detail.
• Have they ever had ECT or neurostimulation?
• If they aren't sure, you can specifically ask the patient if they observed any unusual behaviours or symptoms in that family member
• Any family members die by suicide (or unexplained deaths)?
• Any family members with problematic alcohol or substance use?
• Any family members hospitalized for psychiatric reasons?
• Any family members with neurodegenerative disorders and dementias (for geriatric patients)

Social History

• Location raised
• Any issues with development/birth?
• Were you raised by your parents?
• Are your parents still together?
• Parent's occupation and finances
• Relationship with mother and father?
• Relationship with your siblings?
• Would you say you generally had a happy childhood? (individuals with a generally unhappy childhood are more likely to be dysthymic)
• What was school like for you?
• How would you describe yourself as a child?
• Bullying at school?
• Do you have any religious affiliation?
• “How did you do academically?”, “What is your highest level of education?”
• “Do you live by yourself/with others?”, “House, condo, etc.?”
• “What kind of jobs did you have?”
• Friends? Family? Co-workers?

While obtaining your social history, this is a good time to touch on any possible history of trauma.

• It is good to have a non-threatening opener, such as: “Stressful life experiences can affect your health, and it can be helpful for us as healthcare providers to understand this. You can skip these questions if you don't want to answer them, and they are non-mandatory.”
• “Have you ever experienced anything in your life that you would consider traumatic?,”
• Or more point-blank, “Have you ever experienced any physical, emotional, or sexual abuse?”

This is a good time to screen for things like borderline personality disorder :

• Ask about self-esteem, sense of self, impulsivity
• “Are you by nature an impulsive person?”
• “Do you feel that you have a poor sense of self?”
• “Is it hard for you when people in your life leave you?”
• “Do you frequently feel empty inside?”
• “Do you ever harm yourself such as cutting or burning?”
• Remember, you cannot diagnose someone with a personality disorder while they are having a primary mental disorder going on (e.g. - depression, psychosis, mania, etc.)
• Being able to tease out personality disorders can help you differentiate between diagnoses (i.e. - cluster B traits vs. bipolar disorder)
• “Any issues with the law? Or being in jail?”
• Past arrests, incarceration, court dates, murder, assault, violence?
• “Did you have any thoughts on how we might be able to help you today?”
• “Did we go through the main concerns that you hoped to talk about today?”
• Thank the patient for their time and sharing a “snippet” of their life with you today

During the interview, you should pay attention to the mental status examination (MSE). The MSE is a systematic way of describing a patient's mental state at the time you were doing a psychiatric assessment.

Diagnosis and Biopsychosocial Formulation

Now that you have finished gathering information, the next steps will be to establish a diagnosis and to formulate the patient.

Even though the DSM II was published in 1968 (!) the following excerpt is sage advice even (and especially) today.

A Tip From the DSM-II...

• Systematic Psychiatric Evaluation: A Step-by-Step Guide to Applying The Perspectives of Psychiatry
• Essentials of Psychiatric Diagnosis, Revised Edition: Responding to the Challenge of DSM-5® Revised Edition

For Clinicians

• 14 Tips for the Diagnostic Interview of Mental Disorders - Dr. Allen Frances
• Maria Yang: The Social History
• R.S. Manley. Psychiatric Interview, History, and Mental Status Examination. Chapter 7.1
• The Hub (Psychiatry)
• Psychiatry: a Resource Guide for Residents and Researchers

Home > Blog > Mental Status Exam (MSE) Cheat Sheet & Checklist

Mental Status Exam (MSE) Cheat Sheet & Checklist

Salwa Zeineddine

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As helping professionals, our primary aim is to gain a thorough understanding of those who seek our guidance.

There exist various respectful avenues for cultivating knowledge about an individual's experiences and circumstances, whether through brief check-ins or more extended discussions.

Often, a carefully organized interview allows for in-depth learning about how someone functions and behaves in their daily life.

One of the most widely used formats for evaluation in psychology, psychiatry, and related domains is the mental status examination (MSE) .

Conducting a mental status examination provides a thoughtful lens into an individual's presentation at a specific time, illuminating strengths as well as struggles.

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In this blog, we aim at Mentalyc to describe the standard components of the mental status examination process while offering suggestions for carrying it out respectfully and insightfully. Several templates, checklists and descriptors are also included to support comprehensive examinations.

Setting the Stage: What is a Mental Status Exam?

In mental health, professionals do not rely on intrusive physical examination techniques like palpation or auscultation. Instead, they focus on being expert observers, keenly noting both positive and negative findings to gain insights into an individual's cognitive, emotional, and behavioral functioning. One way to achieve that is the Mental Status Examination (MSE).

Originally developed for use in psychiatry and clinical psychology, the MSE has also found its application in other helping professions like social work and coaching. It serves as a valuable tool to document and evaluate an individual's mental state at a specific point in time.

The MSE typically involves a structured interview and systematic behavioral observations. While there may be variations in the specific forms used by different practitioners, there are core domains that should be covered in every MSE, which we aim to tackle in this blog.

MSEs are an integral part of mental health assessments and clinical contacts . They offer a holistic assessment of a patient's cognitive and behavioral functioning, based on both the clinician's observations and the client's subjective descriptions.

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Think of the MSE as a psychiatrist's version of a physical exam , but focused on mental health. It allows behavioral health professionals to create a comprehensive picture of an individual's present moment, capturing their mental state at that specific time, identifying any areas of concern, and recognizing any potential for interventions.

Key Principles in the Approach to the Mental Status Exam (MSE)

When conducting a Mental Status Examination (MSE), it is essential to adhere to certain key principles to ensure a comprehensive and accurate assessment of an individual's mental state. These principles help create a conducive environment for the patient, promote open communication, and consider various factors that may influence the assessment process. Here’s the secret recipe from Mentalyc!

Welcome and Establish Comfort:

Begin the MSE by warmly welcoming the patient and clearly stating the purpose of the meeting. Make them feel comfortable and at ease, as this can contribute to their willingness to share openly. Acknowledge any concerns or distress they may have and assure them that their privacy will be maintained throughout the assessment.

Maintain Privacy and Respect:

Privacy is crucial during the MSE. Ensure that the assessment takes place in a private and confidential setting. Encourage open conversation by actively listening and showing respect for the patient's thoughts, feelings, and experiences. Validate their concerns and distress, creating a safe space for them to express themselves.

Documentation:

When documenting the MSE, it is important to write down the patient's words exactly as they are expressed. This helps prevent misinterpretation and ensures accuracy in capturing the patient's thoughts and experiences. Pay attention to the order in which the patient expresses their words, as this can provide valuable insights into their mental state.

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Consider individual factors:.

Take into account the patient's age, culture, ethnicity, language, and level of premorbid functioning. These factors can influence the way individuals express themselves and may require additional considerations during the assessment process. For example, if the patient speaks a different language, it may be necessary to involve an interpreter to ensure fairness and accuracy in the assessment.

Consider Physical Health:

Recognize that physical health problems can impact an individual's mental state. Be mindful of any physical health conditions or medications that may influence the patient's cognitive, emotional, or behavioral functioning. Consider how these factors may contribute to their overall mental well-being.

Distinguish MSE from the MMSE:

It is important not to confuse the Mental Status Examination (MSE) with the Mini-Mental State Examination (MMSE). While the MMSE is a brief neuropsychological screening test for cognitive impairment and suspected dementia, the MSE encompasses a broader assessment of various aspects of mental functioning. However, the MMSE can be used as a more detailed cognitive assessment within the MSE.

Now, Let’s Delve into the Content of the MSE

The MSE includes ten key aspects that should be evaluated: appearance, behavior, speech, mood, affect, thoughts, perception, cognition, insight, and judgment. These domains provide a comprehensive understanding of an individual's mental state and contribute to the formulation of a working diagnosis.

I. Appearance

Observing a patient's appearance and clothing can provide initial clues about their mental state. However, it is essential to recognize that a well-groomed appearance does not always indicate good mental health. Here are some key points to consider:

Grooming: While a patient may appear well-groomed, it is important to inquire further about their personal care. Ask if they find attending to their personal hygiene difficult, if they need prompting, or if they require physical assistance. This helps uncover any potential challenges they may be facing in maintaining their personal care.

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Clothing Choice: Assess whether the patient has dressed appropriately for the season, setting, and occasion. Additionally, consider if their clothing reflects their mood. Bright, dark, or dull clothing choices may provide insights into their emotional state.

Cleanliness and Hygiene: Note whether the patient's clothes are clean and in wearable condition. This can indicate their ability to maintain basic hygiene and take care of their belongings.

Assess whether the patient has recently stopped looking after themselves or if there has been a decline in their self-care routines. This may indicate a deterioration in their mental health or the presence of other underlying issues.

Also inquire if the patient needs help or prompting with personal hygiene tasks. This can shed light on their ability to independently manage their self-care.

Posture and Gait: O bserving a patient's posture and gait can provide additional information about their mental and physical well-being. Assess whether the patient's posture is closed, slouched, or open. Closed or slouched postures may indicate a lack of confidence or emotional distress. Additionally, look for any signs of postural instability, which may suggest neurological or physical issues.

Furthermore, observe the patient's gait and note any abnormalities. Their gait may be brisk, slow, hesitant, propulsive, shuffling, ataxic, or uncoordinated. These observations can provide insights into potential motor or neurological impairments.

Additionally, be vigilant for signs of alcohol abuse and withdrawal symptoms such as tremors, tachycardia, pallor, perspiration, and neurological signs like ataxia, nystagmus, ophthalmoplegia, dysarthria, or peripheral neuropathy.

Common Descriptors: Clean, Shaven, Neat, Unshaven, Disheveled, Hair Brushed, Fashionable, Dirty, Body odor, Bizarre, Inappropriate, etc.

II. Behavior

By carefully observing a patient's non-verbal communication, clinicians can gain valuable insights into their current mental state. These observations, along with other components of the assessment, contribute to a comprehensive understanding of the patient's mental health.

Attitude: Observe the patient's attitude, which can range from cooperative to hostile, open to secretive, evasive to suspicious, apathetic to distracted, and defensive. This provides insights into their current mental state and level of engagement.

Gestures: Gestures play a crucial role in non-verbal communication. They can indicate language comprehension, sensory integration, and motor behavior. Pay attention to gestures as they can provide clues about semantic retrieval, learning, and communicative ability.

Mannerisms: Mannerisms, such as unusual repetitions, compulsions, or rituals, can be symptomatic of various psychiatric disorders. Take note of any repetitive behaviors or actions that may be indicative of an underlying condition.

Eye Contact and Body Language: Assess the patient's ability to maintain eye contact. Additionally, observe their posture, which can be open, closed, engaged, poor, or distracted. Eye contact and body language offer insights into their level of comfort, engagement, and emotional state.

Facial Expressions: Facial expressions can reveal a wide range of emotions, including happiness, anxiety, sadness, alertness, anger, distrust, suspicion, and tearfulness. Pay attention to the patient's facial expressions as they provide valuable information about their emotional state.

Psychomotor Activity: Observe the patient's level of psychomotor activity. This includes assessing for rapid talking, pacing around the room, tremors, foot tapping, psychomotor slowing (which may indicate depression), or elation. These observations can indicate underlying psychological or neurological conditions.

Disinhibited Behavior: Disinhibited behavior refers to a disregard for social conventions, affecting motor, instinctual, emotional, cognitive, and perceptual aspects. Look for signs of disinhibition or impulsivity, as they can be indicative of certain mental health conditions.

Abnormal Movements: Abnormal movements may indicate underlying organic conditions or medication-related side effects. If the patient is on antipsychotic medications, a thorough examination for extrapyramidal side effects should be conducted. These movements can include orobuccal dyskinetic movements, tics, akathisia, Parkinsonian tremor, choreiform movements, dystonia, or catatonic features.

Common Descriptors: Avoidant, Tension, Decreased activity, Limp, Agitation, Restless, TICS, Grimacing, Lip pursing, Tongue writhing, Chewing, Lip smacking, Evasive, Guarded, Passive, Sullen, Withdrawn, Demanding, Hostile, Overly friendly, Relaxed, Open, Shy, Playful, Candid, etc.

I II. Speech

Here are some key aspects to consider:

Paralinguistic Features: Pay attention to paralinguistic features such as volume, rhythm, prosody, intonation, pitch, phonation, articulation, quantity, rate, and latency of speech. These features provide insights into the patient's emotional state and overall communication style.

Rate and Flow: Assess the rate and flow of the patient's speech. Is it within the normal range, rapid (which may indicate mania), or slow (which may indicate depression)? Note if there is a paucity of content, characterized by a lack of meaningful information, which can be seen in depression or as a negative symptom of schizophrenia. Additionally, observe if the patient provides short monosyllabic answers to questions or exhibits pressure of speech, which is characterized by a rapid and pressured speech pattern often seen in mania.

Quantity: Evaluate the quantity of speech. Is the patient talkative, spontaneous, and expansive in their speech? Or do they exhibit paucity or poverty of speech, with limited verbal output? These observations can provide insights into the patient's thought processes and overall mental state.

Tone: Dull and monotonous speech may be indicative of depression, while normal prosody refers to the usual intonation and lilt in speech. Note if the patient's speech is loud, whispered, or tremulous, as these variations can provide additional information about their emotional state.

Fluency and Rhythm: Assess the fluency and rhythm of the patient's speech. Is their speech slurred, clear, hesitant, or articulate? Note if there are any signs of aphasia, which is a language disorder that affects the ability to articulate and comprehend speech.

Route: Pay attention to the route of the patient's speech. Circumstantial speech, characterized by excessive and unnecessary detail, may indicate obsessive traits or anxiety. Tangential speech, on the other hand, involves veering off-topic and may be seen in individuals experiencing mania.

Other Common Descriptors: Dysarthric, Slurred, Monotone, Soft, Loud, etc.

Observe and describe the patient's pervasive emotional state. Is their mood elated, dysthymic (chronically low mood), euthymic (within the normal range), apathetic, blunted (reduced emotional expression), or irritable? Note any signs of depression.

Mood Changes: Assess if the patient's mood changes throughout the meeting or evaluation. Do they experience fluctuations in their emotional state? Note any triggers or patterns that may contribute to these mood changes.

Encourage the patient to describe how they have been feeling recently. Ask open-ended questions to allow them to express their emotions in their own words. Note their exact words and verbatim to accurately capture their subjective experience.

Ask the patient if they have been feeling irritable, angry, depressed, discouraged, or unmotivated recently. Encourage them to elaborate on these emotions and their intensity. This helps to gain a deeper understanding of their emotional state and any associated distress.

Other Common Descriptors: Depressed, Irritable, Sad, Angry, Fantastic, etc.

Affect refers to a patient's moment-to-moment expression of emotions, which can be observed through their posture, movements, body language, facial expressions, and tone of voice. It is important to note that in this section, no questions are asked, and the assessment is purely observational.

Here are some descriptors to consider when assessing a patient's affect:

Intensity: Evaluate the intensity of the patient's affect. Is it within the normal range, blunted (reduced emotional expression), or flat (absence of emotional expression)? This observation provides insights into the patient's emotional responsiveness.

Quality: Assess the quality of the patient's affect. Does their affect appear sad, agitated, hostile, or any other specific emotional quality?

Fluctuation: Observe if the patient's affect is labile, meaning it easily fluctuates or changes in response to stimuli. Labile affect may indicate emotional instability or difficulty regulating emotions.

Range: Evaluate the range of the patient's affect. Is it restricted, meaning limited in the variety and intensity of emotions expressed? Or is it expansive, with a wide range of emotions displayed? A normal range of affect indicates a healthy emotional expression.

Congruence: Determine if the patient's affect is congruent or incongruent with their verbal content or the situation at hand. Congruent affect means that the patient's emotional expression aligns with their words and the context. Incongruent affect refers to a mismatch between the patient's emotional expression and their verbal or situational cues.

VI. Thoughts

Content of Thought: Ask the patient what has been on their mind recently. Inquire if they have any worries or concerns.

Explore if they have ever felt that life isn't worth living.

Ask if things seem unreal or distorted to them.

Assess if they have any thoughts that they can't get out of their head. Assess for suicidal and homicidal ideation, conducting a thorough risk assessment.

Observe for the presence of delusions, which are false beliefs that are firmly sustained despite evidence to the contrary.

Look for ideas of reference and delusions of reference, where the patient believes that events, objects, or other people have a particular and unusual significance.

Stream of Thought: Observe the quantity and speed of the patient's thoughts. Are their thoughts blocked or pressured? Do they experience poverty of thought? Note if the patient's thoughts are logical and linked together, or if they are tangential, replying to questions in an oblique or irrelevant way. Look for signs of thought possession, such as thought insertion, thought withdrawal, or thought broadcasting.

Form of Thought: Note if their thoughts are organized and linked together, or if they exhibit word salad, where speech or thinking is incomprehensible due to a lack of logical or meaningful connection.

Look for signs of derailment, where their ideas slip off one track onto another unrelated or obliquely related track.

Pay attention to clang associations, where the sound of a word, rather than its meaning, guides subsequent associations.

Observe if the patient's speech is pressured, increased in amount, accelerated, and difficult to interrupt.

Note if there is a reduction in the quantity of thought, known as poverty of thought.

Look for signs of blocking, which is a sudden interruption of thought or speech.

Observe if the patient refuses to speak, known as mutism.

Note if the patient engages in echolalia, which is the meaningless repetition of the examiner's words.

Pay attention to the use of neologisms, which are new words formed by the patient to express their ideas.

Common Descriptors: Blocking, Tangential, Word salad, Impoverished, Incoherent, Circumstantial, Loose, Rapid, Distractible, Perseverative, Flight of ideas, etc.

VII. Perception

Perception is the process by which we become aware of the stimuli presented to our body through the sensory organs. It involves the interpretation and processing of sensory information to make sense of the world around us. However, in certain cases, perception can be altered, leading to the presence of hallucinations and illusions.

Hallucinations can be defined as perceptions that occur in the absence of any external stimulus. They are sensory experiences that are not based on real sensory input. Hallucinations can affect any of the senses, including sight, hearing, taste, smell, and touch. Common types of hallucinations include seeing things that are not there (visual hallucinations), hearing voices (auditory hallucinations), or feeling sensations that are not present (tactile hallucinations). Hallucinations can be a symptom of various medical and psychiatric conditions, such as schizophrenia, substance abuse, or certain neurological disorders.

Illusions, on the other hand, are misinterpretations of real sensory stimuli. They occur when the brain incorrectly perceives or interprets sensory information. Illusions can occur in any of the senses and can be influenced by various factors, such as lighting conditions, cognitive biases, or prior experiences. For example, an optical illusion may cause us to perceive an image differently than it actually is, or a misinterpretation of a sound may lead to a false perception of its source.

When assessing a patient's perception, it is crucial to inquire about the presence of hallucinations and illusions. Questions to consider may include:

Have you experienced any sensory perceptions that others around you do not seem to perceive?

Do you ever see, hear, smell, taste, or feel things that are not actually present? Have you noticed any misinterpretations of sensory stimuli, where you perceive something differently than it actually is?

Common Descriptors: Tactile hallucinations, Derealization, Auditory hallucinations, Olfactory hallucinations, Depersonalization, Visual hallucinations, Illusions, etc.

VIII. Cognition

The cognition section focuses on assessing various aspects of cognitive functioning, including orientation, attention, memory, alertness, and visuospatial functioning. It provides valuable insights into the patient's awareness of self, environment, higher cortical functioning, frontal functioning, and language abilities.

Orientation refers to the patient's awareness of time, place, and person. It assesses their ability to accurately answer questions such as the current time, date of birth, age, and their current location. Questions like "What is the date today?" or "Can you tell me where we are right now?" help evaluate the patient's orientation to time and place.

Awareness of the current setting is another important aspect of cognition. It involves assessing the patient's understanding of the situation they are in. Questions like "What is your full name?" or "How would you describe the situation we're in?" can help determine if the patient has a clear awareness of their current setting.

The section may also include the administration of a mini-mental status examination (MMSE). The MMSE is a brief screening tool used to assess cognitive impairment. It evaluates various cognitive domains, including orientation, registration (immediate memory), attention and calculation, recall (short-term memory), etc.

IX. Insight and Judgment

To gain insight into the patient's understanding of their mental health problem, it is essential to gather information directly from their perspective. This can be achieved through open and empathetic communication, allowing the patient to express their thoughts, feelings, and beliefs about their mental health condition.

Insight and judgment are closely related, as insight refers to the patient's awareness and understanding of their mental health condition, while judgment pertains to their ability to make sound decisions and solve problems effectively. Both aspects provide valuable information for treatment planning and intervention strategies.

Common Descriptors: Good, Fair, Poor, etc.

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Our doors are always open, welcoming you with open arms. Whether you reach out to us through a message or a call, we are just a moment away!

References:

• Kaplan and Saddock’s Synopsis of Psychiatry 10th Ed. Chapt. 7 – Clinical Examination of the Psychiatric Patient

All examples of mental health documentation are fictional and for informational purposes only.

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Psychiatric Interview Skills Guide

Supplied by the University of Sheffield

Introduction

Good doctor-patient communication is essential for a good doctor-patient relationship. The interview is particularly important in psychiatry, as this discipline relies less on physical examination and investigations and more on history and behavioural assessment.

The aim of this resource is to provide you with a basic framework to be used as a guide when interviewing different types of psychiatric patients. It also provides some useful links for additional information.

The focus is on the common psychiatric presentations you should be familiar with and will encounter during your placement in psychiatry. It is not an exhaustive list, but hopefully it will help you develop your psychiatric assessment skills and also serve as a resource to be drawn upon when preparing for observed cases and examinations.

We really hope you enjoy your psychiatry placement!

• General Interview skills
• The self harm / suicidal patient
• The psychotic patient
• The anxious patient
• The cognitively impaired patient
• The patient with an alcohol problem

Useful Resources

The Royal college of psychiatrists website has lots of useful resources to offer students. There is a ‘Clinical Skills Series’ with videos showing common psychiatric scenarios which you may find beneficial.

It is free and you can register as a ‘student associate’ by following this link:

http://www.rcpsych.ac.uk/discoverpsychiatry/studentassociates/resources/psychiatryinpractice.aspx

Another excellent resource is the CETL learning centre. There are numerous videos and interactive scenarios which can help you learn about common psychiatric scenarios. 

http://www.cetl.org.uk/learning/index.html

(Click on Tutorial link, scroll down to communication in mental health assessment)

http://www.cetl.org.uk/learning/tutorials.html

General Interview Skills

The following are general communication skills that can be applied to any doctor-patient interview:

Beginning the interview

Introduce yourself

Good afternoon Mr Jones. My name is Tom Brown….I’m a student doctor working with Dr X.

Check the patient’s name

Explain the purpose of the interview

    I would like to talk to you today to find out a bit more about your mood.

Put the patient at ease

     Is that OK with you?…..If at any time you do feel uncomfortable, please tell

    me…

Information Gathering

Use appropriate body language

Look relaxed and interested. Make good eye contact.

Ask open questions

Particularly useful in the early stages of the interview:

How have you been feeling lately?

            What can I do for you?

Clarify terms that you do not understand, are vague or ambiguous

You said a moment ago that you were feeling ‘out of sorts’. What exactly do you mean by that?

Express empathy

You must have been devastated when your wife died so suddenly.

That must have been a terrible time for you…

Facilitate communication

Facilitation conveys to the patient that you are listening to what they are saying and may be:

Verbal: Yes, I see,  OK…right….     Go on 

Non-verbal: Nodding one’s head

Mirror the patient’s feelings

The patient is usually helped to put feelings into words if the doctor acts as a sort of mirror in which the patient’s feelings are revealed. The following comments are examples of mirroring:

Your eyes began to water when you spoke about that.

            You looked upset when you mentioned your son

Use pauses appropriately

Sometimes when patients are expressing very painful feelings, they may need to be given the space to do this. Resist the temptation to always interrupt a silence with a new question and suppress what the patient may be struggling to say.

Rounding off the interview

So let me summarise, you’ve told me that you have been feeling low and been unable to sleep for the last three weeks since you were diagnosed with breast cancer. Your mood has got progressively worse and two days go you took an overdose because you were feeling suicidal. Is that right?

Ask if there are any questions

Is there anything you would like to ask? Do you have any questions?

Thank the patient

The Self Harm / Suicidal Patient

One is often asked to see patients who have harmed themselves (eg. by self cutting or overdose). In this situation, one has to get a detailed HISTORY of the self-harm attempt and also assess the current SUICIDE RISK .

When taking a history of, for example, an overdose, the following details are important:

Objective (observed)

• Exactly what was taken?
• Where and when was it taken?
• Was anyone else present?
• Were any precautions taken to avoid discovery?
• Was there a suicide note?
• Was there any other act in anticipation of death? (eg. making a will)
• Was action taken to alert possible helpers after taking the overdose?

Subjective  (patients perception)

• What was the patient’s stated intent?
• What was the patient’s estimate of lethality of the substances taken?
• Evidence of recent / psychiatric illness, notably symptoms of depression or psychosis.
• Is there a past history of psychiatric illness or self harm?
• Is there any evidence of drug or alcohol abuse ?
• Recent precipitating life event?
• Any family history of mental illness
• Social support at home?

When assessing the current suicide risk the following things are important things to ask about:

Assessment of history

Seriousness of attempt

Previous self harm

Presence of mental illness (eg., depression)

Use of drugs / alcohol

Identification of support person

Assessment of patient’s thoughts / mental state

Anything changed?

Regrets about attempt

Current intent (ie, any suicidal thoughts / plans)

Any reasons for stopping repeat

Feelings re future

Screening questions for depression

How have you been feeling in your spirits / mood?                   

Have you been rather weepy / crying a lot recently?

Have you been sleeping?

What is your energy like?

What is your interest in things like?

Can you concentrate OK?

What is your appetite like?

How is your weight doing?

Do you find your mood changes throughout the day?

Do you find yourself waking up earlier than normal?

Have you noticed any change in your sex drive recently?

If evidence of low mood, try to establish how low?

Have you been feeling hopeless/guilty/worthless ?

Sometimes when people feel so low they do not want to go on any more. Have you felt like that?

Any thoughts of harming yourself?

Any thoughts of ending your life?

How does the future look?

The Psychotic Patient

Assessing a patient who has lost touch with reality can be difficult and daunting at first. It is useful to have some screening questions for common psychotic symptoms to utilise particularly when a patient may be guarded or lacking insight.

Screening questions for psychotic symptoms

Have you been having any strange experiences recently?

Auditory hallucinations

Do you ever seem to hear noises or voices even when there is nobody about?

Have you been hearing voices? What are they like?

Visual hallucinations

Do you ever seem to see things other people cannot?

Have you had any visions or seen things other people could not see?

Thought insertion

Do you ever have the feeling that thoughts are being put into your mind that are not your own?

Thought withdrawal

Do you ever feel that your thoughts are being taken out of your mind?

Thought broadcast

Do you ever feel that your thoughts are not private to yourself; as though they are being broadcast so others can know what you are thinking?

Thought echo

Does a thought in your mind ever seem to be repeated over again, like an echo?

Do you ever hear your thoughts echoed out aloud?

Passivity phenomena

Sometimes when people are unwell, they feel that they are no longer in control of their actions; it is as though they are being made to do things by someone else / an external force. Have you ever had this feeling?

Have you ever felt that your emotions / feelings are being controlled by an external force?

Delusions of persecution

Do you feel that your life is in danger or somebody is after you / wants to kill you?

Does anyone seem to be trying to harm you?

How sure are you about this?

Does there seem to be a plot or conspiracy behind this?

The Anxious Patient

An anxiety disorder is characterised by an intense, excessive state of apprehension and fear.

There are two common types of anxiety disorder:

• Generalised anxiety disorder – anxiety symptoms are pervasive and persistent
• Panic disorder – anxiety symptoms are episodic, occurring out of the blue

Screening questions for anxiety

Have you been worrying a lot recently?

Have you felt tense, keyed-up, and on edge?

Are you able to relax?

Have you been irritable?

How is your sleep?

Any difficulty falling asleep?

Any difficulty concentrating?

Any headaches, neckaches or back ache? 

Any dizziness, sweating?   (AUTONOMIC ANXIETY)

Any palpitations?

Any breathlessness?

Any tingling / pins and needles anywhere?

Any nausea, diarrheoa or vomiting?

Any problems passing water?

Are these symptoms there all the time or do they come as attacks with periods of feeling well in between?

The Patient with Cognitive Impairment

It is important to be able to assess a patient’s cognitive state confidently.

The Mini Mental State Examination (MMSE) is a widely used screening tool for cognitive function (see below). You should practice using it with patients you see. However, if time is very limited, the cognitive state examination needs to be more focused on the essentials – orientation, attention, concentration, memory (see later).

Mini Mental State Examination

Instructions for Administration of Mini Mental State Examination

Orientation

Ask the date. Then ask specifically for parts omitted, for example, ‘Can you also tell me what season it is?’ Score 1 point for each correct.

Ask in turn, ‘Can you tell me the name of this place?’ (town, country, etc). Score 1 point for each correct.

Registration

Ask the patient if you may test his or her memory. Then say the names of three unrelated objects, clearly and slowly, about one second for each. After you have said all three, ask him or her to repeat them.

This first repetition determines the score (0-3) but keep saying them until he or she can repeat all three, up to six trials. If he or she does not eventually learn all three, recall cannot be meaningfully tested.

Attention and calculation

Ask the patient to begin with 100 and count backwards by 7. Stop after five subtractions (93, 86, 79, 72, 65). Score the total number of correct answers. If the patient cannot or will not perform this task, ask him or her to spell the word ‘world’ backwards. The score is the number of letters in correct order, eg dlrow 5, dlowr 3.

Ask the patient if he or she can recall the three words you previously asked him or her to remember. Score 0-3.

Naming: Show the patient a wrist-watch and ask him or her what it is. Repeat for pencil. Score 0-2.

Repetition: Ask the patient to repeat the sentence after you. Allow only one trial. Score 0 or 1.

Three-stage command: Give the patient a piece of plain blank paper and repeat the command. Score 1 point for each part correctly executed.

Reading: On a blank piece of paper, print the sentence ‘Close your eyes’ in letters large enough for the patient to see clearly. Ask him or her to read it and do what it says. Score 1 point only if he or she actually closes his eyes.

Writing: Give the patient a blank piece of paper and ask him or her to write a sentence for you. Do not dictate a sentence, it is to be written spontaneously. It must contain a subject and verb and be sensible. Correct grammar and punctuation are not necessary.

Copying: On a clean piece of paper, draw intersecting pentagons (as below), each side about one inch and ask him or her to copy it exactly as it is. All ten angles must be present and two must intersect to score 1 point. Tremor and rotation are ignored.

Essential Cognitive State Examination

Time                What day/time is it? (without looking at clock)

Person             Do you remember what I said my job is?

Place                 Do you know where you are?

3 items  (eg. ball, flag, tree)

Name and address (eg. John Brown, 15 Regent St, Glasgow)

Attention & Concentration

Spell WORLD backwards

ie. Recall of three items or Name and address at 5 minutes 

eg. Past personal events, major public events in lifetime (eg. dates of World War II)

eg. News, name of Prime Minister

The Patient with an Alcohol Problem

Problems with alcohol such as MISUSE or DEPENDENCE may exist in isolation or co-exist with other psychiatric or physical disorders. It is important not only to be able to clarify whether a problem exists but also what type of problem it is.

CAGE may help in initial screening:

C      Have you ever felt you ought to C UT down on your drinking?

A      Have people A NNOYED you by criticising your drinking?

G      Have you ever felt bad or G UILTY about your drinking?

E      Have you had a drink first thing in the morning to steady your nerves or

        Get rid of a hangover ( E YE OPENER)?

If you get positive replies to any TWO of these questions, it is worth taking a proper ‘drinking history’.

Taking a Drinking History

Start by asking the patient to describe a typical drinking day (Begin with the morning and proceed through the day) establishing what is drunk and when:

• Establish if the first drink of the day is taken to combat withdrawal symptoms
• Does the patient drink without getting drunk, or in bouts – usually at lunchtime and the evening?
• How much is drunk at each session?
• Does a single drink always lead to many more, and the person generally become drunk? If so, has this led to blackouts or falls?
• Establish whether drinking takes place alone, and whether the person drinks only in response to certain moods or situations.

Screening for alcohol dependence syndrome

Has alcohol become the most important thing in your life?

Would you say you devote more time to drinking than to other things in your life?

Do you find that you have to drink more alcohol now to get the same level of satisfaction that you used to get with fewer drinks?

Have you noticed any change in the effect that alcohol has?

What happens if you don’t have a drink?

Sometimes, if people don’t drink for a while, they start feeling shaky, sweaty and anxious. Does this ever happen to you?

RELIEF DRINKING

If this does happen, do you find a drink will calm you down?

Do you ever find yourself craving alcohol?

NARROWING OF REPERTOIRE

What do you drink?

Do you find that you always drink the same things?

STEREOTYPED DRINKING PATTERN

Do you tend to drink at a set time / place / alone or with others? Does it vary?

REINSTATEMENT AFTER ABSTINENCE

Have you ever managed to stay off alcohol?

What has been your longest period of abstinence?

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20 Mental Health Professional Interview Questions and Answers

Common Mental Health Professional interview questions, how to answer them, and sample answers from a certified career coach.

Mental health professionals play an important role in providing support and resources to individuals struggling with mental illness. If you’re applying for a job as a mental health professional, it’s essential that you prepare for the interview process.

From questions about your experience with different types of clients to inquiries about how you handle difficult situations, the hiring manager will likely ask many questions designed to gauge your proficiency in this field. To help you get ready for the big day, here are some common mental health professional interview questions—with advice on how to answer each one.

• What is your experience with providing mental health services to individuals from diverse backgrounds?
• Describe a time when you had to manage a crisis situation in a mental health setting.
• Explain the concept of therapeutic alliance and its importance in mental health treatment.
• How do you assess for suicidal ideation in a patient?
• Have you ever dealt with a patient with a personality disorder? If so, what was your approach?
• Outline your experience working with patients with dual diagnoses (e.g. substance abuse and mental illness).
• Give an example of a time when you had to advocate for a patient’s rights in a hospital setting.
• What strategies do you use to build trust with clients who are reluctant to open up about their feelings?
• Describe a patient case you have worked on that required a multidisciplinary approach.
• Explain the difference between pharmacotherapy and psychotherapy in the context of mental health treatment.
• How do you handle patients who are not compliant with their treatment plan?
• What techniques do you use to help clients identify and address negative thought patterns?
• Explain your understanding of the different types of psychotherapies and when they are most effective.
• How do you ensure that all clients receive equitable access to mental health services?
• Describe a situation in which you had to communicate difficult news to a patient or family member.
• What is your opinion on the role of technology in mental health care?
• How do you stay informed about new developments in the field of mental health?
• What would you do if a client refused to accept your diagnosis or recommendations?
• How do you handle ethical dilemmas that arise during the course of your work?
• What strategies do you use to maintain professional boundaries with clients?

1. What is your experience with providing mental health services to individuals from diverse backgrounds?

Mental health services have to be tailored to each individual, and that means understanding and being sensitive to the culture, language, and values of the person you’re working with. This question gives you the opportunity to demonstrate your understanding and experience with different cultural backgrounds and how you’d approach the job if hired.

How to Answer:

You should be prepared to discuss the different populations you’ve worked with, what challenges they faced, and how you addressed those issues. If you haven’t had a lot of direct experience working with diverse populations, talk about any cultural competency training or courses you’ve taken that have helped you gain an understanding of different cultures. You can also mention any research you’ve done on your own in order to better understand the needs of different communities.

Example: “I’ve had the privilege of working with individuals from a variety of backgrounds, including African American, Hispanic, Asian, and Native American communities. I understand that each person has their own unique set of experiences and needs, so I strive to create an environment where everyone feels respected and heard. I also take time to research the cultural norms and values of different communities in order to provide more culturally competent care. In addition, I have taken several courses on multicultural counseling, which has helped me gain a better understanding of how to work effectively with clients from diverse backgrounds.”

2. Describe a time when you had to manage a crisis situation in a mental health setting.

Mental health professionals must be prepared to handle emergency situations that require quick thinking and problem-solving. This question is designed to test your ability to stay calm in a crisis and assess a situation quickly in order to provide the best possible care for the patient. Interviewers want to make sure you have the skills to handle difficult and emotionally charged situations.

To answer this question, focus on a specific situation you’ve encountered in the past and explain how you handled it. Talk about what steps you took to assess the situation, how you managed your emotions while still providing care for the patient, and the outcome of the situation. Make sure to emphasize any positive outcomes that resulted from your actions. Finally, talk about what you learned from the experience and how it has helped you become a better mental health professional.

Example: “I was once consulted on a case of a patient who had been in and out of psychiatric hospitals for years due to severe depression. The patient had become increasingly isolated and mistrustful of mental health professionals, so it was important to build a strong therapeutic alliance with them. I used active listening to show that I was really hearing what the patient was saying, as well as empathy and validation to let them know that their feelings were valid and understood. This allowed us to develop a trusting relationship which ultimately led to successful treatment and discharge from the hospital.”

3. Explain the concept of therapeutic alliance and its importance in mental health treatment.

Therapeutic alliance is the mutual trust and understanding between a patient and therapist that is essential for successful mental health treatment. It is a key concept in mental health, as it can help ensure a patient is comfortable and willing to share their innermost thoughts, as well as help a therapist better understand the patient and their needs. This question is asked to demonstrate that you have a thorough understanding of the concept and its importance in mental health treatment.

You should explain that therapeutic alliance is the relationship between a therapist and patient based on trust, understanding, and respect. It is essential for successful mental health treatment as it helps create an environment in which the patient feels comfortable enough to open up about their thoughts and feelings, allowing the therapist to better understand them and provide more effective treatment. You can also mention how communication techniques such as active listening, empathy, and validation are important components of building a strong therapeutic alliance.

Example: “Therapeutic alliance is the relationship between a therapist and patient based on trust, understanding, and respect. It is essential for successful mental health treatment as it helps create an environment in which the patient feels comfortable enough to open up about their thoughts and feelings, allowing the therapist to better understand them and provide more effective treatment. Communication techniques such as active listening, empathy, and validation are important components of building a strong therapeutic alliance that can help ensure positive outcomes for the patient.”

4. How do you assess for suicidal ideation in a patient?

Mental health professionals are responsible for helping individuals identify and address any mental health issues they may be facing. This question helps to determine the candidate’s ability to assess for potential risks, such as suicidal ideation, and to provide appropriate support to the patient. It also showcases their understanding of risk assessment protocols and their ability to communicate effectively with patients to ensure their safety.

Your answer should focus on your experience with assessing for suicidal ideation, as well as any protocols or techniques you use to identify and address potential risks. For example, you could discuss how you would ask questions about the patient’s feelings and thoughts, assess their behavior, and look for signs of depression or other mental health issues that may increase the risk of suicide. Additionally, explain what steps you take to ensure the safety of the patient, such as providing referrals to additional resources or connecting them with a support system.

Example: “When assessing for suicidal ideation in a patient, I start by asking questions about their feelings and thoughts to get an understanding of how they’re thinking. This also helps me assess their behavior and look for signs of depression or other mental health issues that may increase the risk of suicide. I then provide referrals to additional resources such as counseling services or support groups, and work with them to create a safety plan if needed. Ultimately, my goal is to make sure the patient feels heard and supported throughout the process.”

5. Have you ever dealt with a patient with a personality disorder? If so, what was your approach?

Personality disorders can involve a range of cognitive, behavioral, and emotional difficulties. The interviewer wants to know that you have experience working with these types of clients and that you understand their particular needs. They will also want to know that you have a plan for how to best help them and that you have the skills and resources to do so.

Start by talking about any experience you have had with clients who have a personality disorder. If you don’t have direct experience, mention any relevant coursework or research that you have done on the topic. Then, explain how you would approach working with such a client. Talk about your understanding of their needs and how you would create an individualized treatment plan to help them. Finally, emphasize any resources or tools you have available to assist in the process.

Example: “I have worked with a few clients who were diagnosed with a personality disorder. My approach is to focus on developing an individualized treatment plan that takes into account their unique needs and circumstances. I believe in taking a collaborative approach, working closely with the client to explore different strategies for managing their symptoms. I also make sure to draw on my knowledge of available resources, such as support groups or community-based programs, which can be incredibly helpful for individuals living with a personality disorder.”

6. Outline your experience working with patients with dual diagnoses (e.g. substance abuse and mental illness).

Mental health professionals often work with patients who suffer from a range of conditions, such as substance abuse and mental illness. Interviewers want to know that you understand the challenges associated with dual diagnosis, and that you have experience working with such patients. They are looking for evidence that you can identify and diagnose the underlying issues, as well as provide treatment and support.

Start by describing your experience working with patients who have dual diagnoses. Talk about any specialized training you’ve received, as well as the techniques and interventions you use to help such patients. Be sure to mention any success stories or cases where you were able to make a positive impact in the lives of these patients. Finally, explain why you are passionate about working with this population and how it has shaped your approach to mental health treatment.

Example: “I have had a great deal of experience working with patients who suffer from dual diagnoses, such as substance abuse and mental illness. Through my work I’ve developed a deep understanding of the challenges associated with this population and how to provide effective treatment. In particular, I specialize in cognitive-behavioral therapies that focus on helping patients identify and modify their thought patterns and behaviors in order to cope better with their condition. I am passionate about providing care for these individuals because I believe there is hope for them, despite their difficult circumstances. My goal is to help them recognize their strengths and build on them so they can lead more fulfilling lives.”

7. Give an example of a time when you had to advocate for a patient’s rights in a hospital setting.

Mental health professionals are expected to have a deep understanding of patient rights and to advocate for those rights when necessary. This question helps the interviewer gauge your knowledge of the legal and ethical boundaries of the profession and your ability to remain professional in a challenging situation. It also shows that you understand the importance of advocating for the best interests of patients.

Begin your answer by providing a brief overview of the situation. Then, explain what you did to advocate for the patient’s rights and how it impacted the outcome. Be sure to focus on any positive outcomes that resulted from your efforts. Finally, discuss any lessons learned or changes you would make if faced with a similar situation in the future.

Example: “I recently worked with a patient who was admitted to the hospital for suicidal ideation. During my initial assessment, I noticed that the attending physician had not obtained informed consent from the patient before administering medication. This was in violation of the patient’s rights and could have resulted in serious legal repercussions. So, I immediately brought the situation to the attention of the physician and discussed why it was important to obtain informed consent. The physician agreed and we were able to get the patient’s permission to administer the medication without any further complications or delays. From this experience, I learned the importance of advocating for patients’ rights and how it can positively impact their care. Going forward, I will always prioritize obtaining informed consent and ensure that all physicians are aware of the need to do so as well.”

8. What strategies do you use to build trust with clients who are reluctant to open up about their feelings?

Mental health professionals need to be patient, empathetic, and trustworthy in order to help their clients. Building trust is an important part of the therapeutic process and can take time and effort. This question is specifically targeted towards understanding how you, as an individual, approach the problem of building trust with clients, and how you’re able to create a safe space for them to open up.

Your answer should focus on the strategies you use to build trust with clients. You can talk about your approach to creating a safe space for clients, such as setting boundaries and providing them with reassurance that their conversations will remain confidential. Additionally, you can discuss how you actively listen to clients and provide validation of their feelings in order to create an atmosphere of understanding and support. Finally, you can mention any techniques you have used in the past to help clients open up, such as using creative activities or role-playing exercises.

Example: “I believe that trust is the foundation of any successful therapy session. When I’m working with a client who is hesitant to open up, I try to create a safe and comfortable environment. I do this by setting clear boundaries and providing reassurance that our conversations will remain confidential. I also actively listen to their concerns and provide validation of their feelings. I find that this helps to build a strong relationship of trust between us. Additionally, I have found that creative activities or role-playing exercises can be a helpful tool for clients who are reluctant to open up. By engaging in these activities, clients are able to express their feelings in a more comfortable and less intimidating way.”

9. Describe a patient case you have worked on that required a multidisciplinary approach.

Mental health professionals often work with other professionals, including psychiatrists, psychologists, social workers, and counselors, to provide the best level of care to their patients. By asking this question, the interviewer is looking to determine if you are comfortable collaborating with other professionals and can handle complex cases that require a team approach.

To answer this question, you should discuss a patient case that required collaboration with other professionals. Describe the problem and how you worked together to develop a treatment plan. Focus on your role in the treatment process and highlight any successes you had in working together with other professionals. Additionally, mention any challenges you faced while developing the treatment plan and how you overcame them. Finally, explain what you learned from the experience and how it has helped shape your approach to multidisciplinary care.

Example: “I recently worked on a case involving a patient who was suffering from severe anxiety and panic attacks. I collaborated with a psychiatrist and a psychologist to develop a comprehensive treatment plan that included medication, cognitive behavioral therapy, and lifestyle changes. We also worked with the patient’s family to provide education and resources. Despite the complexity of the case, we were able to develop a successful treatment plan and the patient was able to make significant progress in managing their anxiety. This experience taught me the importance of collaboration and communication when working with a team of professionals. I now understand that it’s essential to have a clear, unified plan of action when treating complex mental health cases.”

10. Explain the difference between pharmacotherapy and psychotherapy in the context of mental health treatment.

Mental health professionals need to understand both pharmacotherapy (medication) and psychotherapy (talk therapy) to provide effective treatment. This question will allow the interviewer to gauge your knowledge of both forms of treatment and how you might apply them in a practical setting. It’s also a good way to determine whether you’re up-to-date on the latest mental health research and treatments.

Start by explaining that pharmacotherapy involves the use of medication to treat mental illnesses, while psychotherapy is a form of talk therapy used to help patients understand their thoughts and feelings. Then explain how both forms of treatment can be used in combination or separately depending on the patient’s needs. You should also mention any experience you have with either form of treatment and how it has helped your clients in the past.

Example: “Pharmacotherapy is the use of medications to treat mental health conditions. It can help reduce symptoms and improve overall functioning. Psychotherapy, on the other hand, is a form of talk therapy that helps patients explore their thoughts, feelings, and behaviors in order to gain insight and develop new coping strategies. Both forms of treatment can be used together or separately depending on the patient’s individual needs. Personally, I have experience in both pharmacotherapy and psychotherapy, and I’ve found that they can be very effective when used together in treating mental health conditions.”

11. How do you handle patients who are not compliant with their treatment plan?

Mental health professionals must be able to help patients who may not be compliant with their treatment plans. This question allows the interviewer to assess how you approach difficult conversations and how you might handle a situation in which the patient is not willing to comply with their treatment.

Start by discussing your approach to patient compliance. Explain that you focus on understanding the root cause of why a patient might not be following their treatment plan and then work with them to develop an alternative solution or course of action that is more beneficial for them. Talk about how you use empathy and active listening to build trust with patients, so they are willing to open up and discuss their reluctance to comply. Finally, explain how you use evidence-based strategies to help motivate patients to follow through with their commitments.

Example: “When a patient is not compliant with their treatment plan, I focus on understanding the root cause of why they may not be following through. I use active listening to build trust and empathy with the patient, so they feel comfortable enough to talk about their reluctance to comply. Then I use evidence-based strategies to help motivate them to follow through with their commitments. I also work with them to develop an alternative solution that might be more beneficial for them and their situation. My goal is to always create a positive and supportive environment in which the patient feels heard, respected, and empowered to take control of their own mental health journey.”

12. What techniques do you use to help clients identify and address negative thought patterns?

Mental health professionals help their clients recognize and address the thoughts and behaviors that might be contributing to their difficulties. This question is a way for the interviewer to assess your understanding of evidence-based treatment techniques that you can apply to clients in different situations. It also gives them an idea of your ability to tailor techniques to the individual, rather than applying a one-size-fits-all approach.

You should be prepared to discuss a range of evidence-based techniques that you have experience using. Depending on the type of mental health professional you are, this could include cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), acceptance and commitment therapy (ACT), or other approaches. You can also talk about how you use these techniques in combination with one another to create an individualized treatment plan for each client. Additionally, it’s important to highlight your ability to help clients identify and challenge their negative thought patterns in order to develop healthier coping strategies.

Example: “I use a variety of evidence-based techniques to help my clients identify and address negative thought patterns. My primary approach is cognitive behavioral therapy (CBT), which focuses on helping clients identify and challenge thoughts that are contributing to their distress. I also use acceptance and commitment therapy (ACT) to help clients accept their thoughts and feelings without judgment and develop healthier coping strategies. Additionally, I draw on dialectical behavior therapy (DBT) to help clients better regulate their emotions. I tailor my approach to each client’s individual needs, and strive to create an individualized treatment plan that will best help them reach their goals.”

13. Explain your understanding of the different types of psychotherapies and when they are most effective.

Mental health professionals need to have a deep understanding of the different types of psychotherapies they might use in order to effectively help their clients. An interviewer may ask this question to gauge your understanding of the different approaches and how you might apply them in different situations. It also shows how familiar you are with the field, and demonstrates your ability to think critically and analyze different treatments.

Start by explaining the different types of psychotherapies, such as cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and acceptance and commitment therapy (ACT). Then explain how each approach can be used to treat certain mental health issues. For example, CBT is often used to help people with anxiety or depression, while DBT can be useful for those struggling with self-destructive behaviors. Finally, discuss when it might be most appropriate to use a particular type of therapy, depending on the client’s needs.

Example: “I understand that there are a variety of psychotherapies, each of which has its own unique approach to treating mental health issues. Cognitive Behavioral Therapy (CBT) is a type of talk therapy that helps people identify and address negative thinking patterns that can lead to anxiety and depression. Dialectical Behavior Therapy (DBT) is a type of therapy that focuses on helping people learn to regulate their emotions, and can be particularly helpful for those struggling with self-destructive behaviors. Acceptance and Commitment Therapy (ACT) is a form of therapy that helps people accept their thoughts and feelings while still taking action towards their goals. All of these therapies can be effective in treating different mental health issues, but it is important to assess a client’s needs and determine which approach is best suited for them.”

14. How do you ensure that all clients receive equitable access to mental health services?

Mental health professionals provide a vital service to those in need, and it is important that they are able to identify and address any areas of inequity within the system. By asking this question, an interviewer is looking for evidence that you are aware of and understand the importance of providing equitable access to mental health services for all clients. This could be accomplished through understanding and addressing any systemic issues, as well as through individualized care plans that are tailored to the specific needs of each client.

To answer this question, you can discuss the steps that you have taken in previous roles to ensure equitable access. This could include things such as advocating for greater diversity in hiring practices, ensuring that language and cultural barriers are addressed, or providing resources to clients who might not otherwise be able to access services. Additionally, you should be prepared to discuss how you would evaluate a client’s individual needs and develop care plans accordingly.

Example: “I believe that all clients should have equitable access to the mental health services that I provide. In my previous role, I worked with a diverse range of clients from different backgrounds and with different needs. I am committed to understanding each client’s individual needs and developing care plans that are tailored to those needs. I also believe in advocating for greater diversity in hiring practices and providing resources to those who might not otherwise be able to access services. By understanding and addressing any systemic issues, I am confident that I can ensure that all clients receive the best possible care.”

15. Describe a situation in which you had to communicate difficult news to a patient or family member.

Mental health professionals must have a strong sense of empathy and understanding when it comes to their patients’ needs. This question gives the interviewer insight into how you handle difficult conversations and how you prioritize patient care and comfort. It also provides an opportunity to demonstrate your ability to remain calm, patient, and compassionate in the face of difficult conversations.

To answer this question, you should explain the situation in detail. Describe how you prepared for the conversation and your approach to communicating difficult news. Talk about what emotions you were feeling during the conversation and how you managed them so that they didn’t interfere with your ability to communicate effectively. Finally, discuss how the patient or family member responded and how you followed up afterwards to ensure their needs were met.

Example: “I recently had to communicate difficult news to a patient and their family. I was aware that this would be a difficult conversation and so I took the time to prepare in advance. I read through the patient’s medical records and made sure I was familiar with their current condition. I then rehearsed the conversation in my mind and thought through the best way to communicate the news. When it came time to have the conversation, I was calm and direct, but also empathetic. I could tell that the patient and their family were upset, but I was able to provide them with reassurance and support. I followed up with the patient afterwards to ensure they were getting the care they needed and to answer any additional questions they had.”

16. What is your opinion on the role of technology in mental health care?

Technology has been playing an increasingly important role in mental health care, from providing online resources for self-help to using telehealth services for remote therapy sessions. The interviewer wants to know your opinion on the matter and if you have any experience with related technologies. This can help them gauge your understanding of the industry, as well as your potential interest in expanding your knowledge in this area.

This question is an opportunity to showcase your knowledge of mental health care and technology. Talk about the different ways that technology can be used in mental health care, such as online resources for self-help, telehealth services for remote therapy sessions, or even apps for tracking moods. You can also discuss the potential benefits and drawbacks of using these technologies, such as improved access to care for those who may not have access to traditional services but also a lack of personal connection between patient and therapist. Finally, if you have any experience with related technologies, be sure to mention it here.

Example: “I believe that technology can be a powerful tool in mental health care, particularly when it comes to providing access to care for those who may not have access to traditional services. Telehealth services can be incredibly helpful for remote therapy sessions, and I’m familiar with a few apps that help people track their moods and self-monitor their mental health. That said, I believe there is still a need for personal connection between patient and therapist, and technology can’t always provide that. I’m committed to using modern tools and technology in my practice, but I’m also aware of the potential drawbacks and am careful to ensure that my clients are getting the most out of their therapy sessions.”

17. How do you stay informed about new developments in the field of mental health?

Mental health is an ever-evolving field, and it’s important to stay up to date on research, treatments, and best practices. Your interviewer wants to make sure you’re aware of the latest developments in the field and are prepared to use them to provide the best care to your clients.

This question is an opportunity to demonstrate your commitment to professional development and staying informed. Talk about any conferences, workshops, or online courses you’ve taken to stay up to date on the latest developments in mental health. You can also mention if you read industry publications or follow certain professionals on social media for updates. Additionally, talk about how you use this information to inform your practice and provide better care to your clients.

Example: “I take my professional development very seriously and make a point to stay informed of the latest developments in the field of mental health. I attend conferences and workshops whenever possible, and I also take online courses and read industry publications regularly. Additionally, I follow certain professionals and organizations on social media to stay up to date on the latest research and treatments. I make sure to apply this knowledge to my practice to ensure that I’m providing the best care to my clients.”

18. What would you do if a client refused to accept your diagnosis or recommendations?

Mental health professionals work with a wide variety of people, many of whom don’t always agree with the diagnosis or treatment plan. This question is designed to test the ability of the potential hire to handle these types of situations. The interviewer wants to know that you can be sensitive to the client’s feelings while still remaining professional and staying true to your professional opinion.

The best approach to this question is to demonstrate that you can remain professional and empathetic in the face of opposition. You should explain how you would listen to the client’s concerns, acknowledge their feelings, and work with them to come up with a plan that they are comfortable with. Additionally, you should emphasize your ability to collaborate with other professionals when necessary and be open to different opinions. Finally, it’s important to show that while you understand the importance of respecting the client’s wishes, you will always prioritize their safety and well-being first.

Example: “If a client refused to accept my diagnosis or recommendations, I would start by listening to their concerns and trying to understand where they are coming from. I would then explain my diagnosis and recommendations in more detail, and discuss other options. I would be sure to explain the potential risks of not following my recommendations, while still being respectful of the client’s wishes. If necessary, I would also discuss the situation with other mental health professionals and collaborate to find the best course of action. Ultimately, my goal would be to ensure the client’s safety and well-being while also taking their wishes into consideration.”

19. How do you handle ethical dilemmas that arise during the course of your work?

Mental health professionals are expected to abide by a strict code of ethics and practice, and to be able to navigate the ethical dilemmas that can arise in their work. Interviewers want to make sure that you have the moral and ethical compass to make the right decisions, even in difficult and challenging circumstances.

Start by talking about the code of ethics you abide by, and how it informs your work. Talk about a time when you faced an ethical dilemma in your practice and how you managed it. If you haven’t had to face such a situation yet, discuss what kind of approach you would take if presented with one. Make sure to emphasize that you are committed to upholding the highest standards of professional conduct and care for all of your patients.

Example: “As a mental health professional, I take the ethical aspects of my work very seriously. I adhere to the code of ethics set out by my profession and strive to make sure that all of my patients are treated with respect and dignity. I understand that ethical dilemmas can arise in any profession and I am prepared to handle such situations in an ethical and responsible manner. For example, when I was faced with a situation in which a patient asked me to break confidentiality, I discussed the implications of such a decision with the patient and explained why it was not in their best interests. I also consulted with other professionals in my field to make sure I was making the best decision for the patient.”

20. What strategies do you use to maintain professional boundaries with clients?

This question is important because it shows that you understand the importance of establishing and maintaining professional boundaries with clients. Mental health professionals have to be able to build a trusting relationship with their clients, while at the same time maintaining a level of professionalism that is respectful and appropriate. This requires a good sense of judgment and self-awareness, which is why this question is so important.

When answering this question, you should focus on strategies that you have used in the past to maintain professional boundaries. Examples of these strategies include setting clear expectations with clients at the beginning of your relationship, not sharing personal information with clients, and avoiding any physical contact or other forms of intimacy. You should also emphasize how you strive to create an environment where clients feel safe and respected.

Example: “I strive to create a relationship with my clients that is based on trust and respect. To ensure this, I always set clear expectations at the beginning of our relationship and I make sure that they understand the boundaries of our professional relationship. I also strive to keep my personal life separate from my professional life and I never share any personal details or stories with clients. In addition, I always maintain a professional distance and avoid any physical contact or other forms of intimacy. By following these strategies, I am able to create an environment where clients feel safe and respected, which is essential for successful therapy.”

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Psychiatric Interview

• Author: Lorin M Scher, MD, FACLP; Chief Editor: David Bienenfeld, MD  more...
• Sections Psychiatric Interview
• Identification and Chief Symptom
• History of Present Illness
• Psychiatric Review of Symptoms
• Psychiatric History
• Suicide and Violence Risk Assessment
• Medical History
• Family History
• Social History
• Substance Use and Abuse
• Mental Status Examination
• Plan and Documentation
• Special Considerations

The following text provides an overview of the basic components and key concepts of the psychiatric interview. It is the authors' intention to also provide additional hints in how to effectively obtain information during that interview. This format is most appropriate for new patient interviews but can also be of value for existing patients whose psychiatric history has never been fully explored.

Each interview will be unique; for example, the length and depth of the interview with an acutely psychotic inpatient varies considerably from that of an outpatient struggling with many years of anxiety. Regardless, the essential goals for data collection within a psychiatric interview remain similar, and a consistently applied format is valuable. The clinician and patient benefit from the improved relationship and diagnostic accuracy that a thorough assessment provides.

Documentation is as important as the information collected. An example template for recording information that also serves as an interview template is demonstrated in Table 1, below.

Table 1. SIGECAPS Mnemonic (Open Table in a new window)

An open-ended question provides the patient with flexibility in opening the interview, balanced against the clinician’s practical need to obtain relevant information. “What brings you to (see me/the hospital) today?” can have a wide variety of answers. Occasionally, a patient is unable to state clearly why he or she has actually come to visit. This frequently occurs in psychosis and cognitive impairment but may also be seen with intellectual disabilities or even depression with severe vegetative symptoms. A passive-aggressive or outright hostile chief symptom is an early sign of resistance to the interview, which can later be explored.

Exploring and expanding on the chief symptom is a reliable, patient-centered way to build rapport and begin gathering information. Recording a direct quote from the patient is best. Although recording “depression” is certainly acceptable, more descriptive phrases, such as “unable to stop crying for the past 3 days,” is more memorable to a reader.

The history of present illness is the most important component of a modern diagnostic interview, yet it is approached differently depending on how the illness is defined. A longitudinal view of illness emphasizes obtaining a history of the course of the illness. Another approach involves looking only at the immediate events preceding the patient’s arrival for treatment; ie, a history of the patient's present illness episode.

Obtaining both is ideal; however, certain patient presentations make this a challenging task. If a patient is too disorganized (thought disordered) or otherwise impaired to participate fully, more emphasis should be placed on the current episode. If someone is presenting as a stable outpatient with an unclear diagnosis, the course of illness helps to clarify future treatment.

Although the depth may vary, every history of present illness should attempt to elicit information on certain topics. How the patient was functioning prior to his or her illness, current symptoms, if and when prior episodes occurred, and precipitating factors are a few that are particularly high yield. Remember that nearly every diagnosis from the Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revision ( DSM-IV-TR ), requires the impairment of social, occupational, or academic functioning. [ 1 ] Without a firm knowledge of where the patient was with regard to these domains, assessing the impact of the symptoms on his or her life is more difficult.

Briefly looking at the recent or chronic stresses that the patient may be experiencing is also important; these may contribute to the illness or its severity. Any sort of transition, such as medical illness, a new relationship, a new job, or a recent loss, can be a stressor that precipitates or exacerbates a mental illness.

However, not all patients are necessarily able to elaborate on precipitating factors. Moreover, illnesses may occur spontaneously, so not "willing" a cause on every aspect of a patient’s suffering is important. Even so, helping the patient to relate the stressors in his or her life to the symptoms of mental illness can be informational and therapeutic.

The psychiatric review of symptoms seeks to reveal issues that the patient may have not brought up when describing the history of his or her present illness.

As in the rest of medicine, patients likely do not share an identical view with their physician of what constitutes an illness. Experiences that a practitioner would call pathologic may be experienced by the patient as "ego-syntonic." That is, they are not recognized as intrinsically different from how the patient would expect to act or feel. A person with bipolar disorder may not, for example, feel that the euphoric symptoms of mania represent anything wrong. If a significant positive response does occur during the review, it can be moved to the history of present illness when the practitioner is documenting his or her findings. The questions described below are also appropriate for delving deeper into a patient’s initial complaint.

Many practitioners are familiar with the SIGECAPS mnemonic. Depressive disorders can also be easily assessed with 2 questions, one regarding depressed or irritable mood and another regarding anhedonia. [ 2 ] When asked "What sort of things do you like to do for fun?" the anhedonic patient often answers "nothing" or discusses activities that he or she used to do for pleasure.

Follow-up questions regarding guilt, decreases in energy level, concentration, and appetite are assessed if needed and are important to assess longitudinally. Psychomotor retardation or agitation can be screened for by asking "Have you or someone else noticed anything different about how you move?" Suicidality should also be addressed with all patients, but especially those with a positive depression screen.

A discussion of depression should be followed with one of mania . Given that manic episodes often do not feel pathologic to a patient, it can be challenging to collect this history. DIGFAST is a common mnemonic used in mania screening. (See Table 2, below).

Table 2. DIGFAST Mnemonic (Open Table in a new window)

Distractibility can be witnessed by the interviewer, by friends or family, or by the patients themselves. Increased risk taking can have many forms, but sex, spending, and substance use are common and are thus high-yield areas to explore.

Grandiosity can vary from just feeling superior to a true psychosis; a sensitive screen asks the patient if he or she has or has had any special abilities. Flight of ideas can be approached as a sort of internal distractibility.

Inquiring about sleep is one of the easiest ways to pick up a manic episode in the absence of substance abuse. If the answer to "What’s the longest period of time you’ve gone without sleeping but not feeling tired the next day?" is anything longer than 2 days, further assessment is warranted. Pressured speech should be immediately apparent in a person currently in a manic episode and easily recallable by friends or family members.

Frank psychosis is not often missed during a psychiatric interview, but an in-depth screen may be necessary to pick up prodromal symptoms or uncommon presentations. Asking all patients if they "ever see or hear things that other people don’t" is appropriate. This should be asked in the most normalizing manner possible. Terms such as hallucinations or delusions can have either very little or an extremely stigmatized meaning attached to them and should be avoided. Delusions can be difficult to elicit from a patient if ego-syntonic and not spontaneously offered.

Persecutory delusions are common, [ 3 ] and asking "are you ever concerned that other people may want to harm you?" is unlikely to offend a patient. Positive responses may be completely rational in clients suffering real abuse or engaged in criminal behavior, and sensitive follow-up questions are key to not misclassifying their symptoms.

Blunting of affect and disorganization of thought are not likely to be volunteered by a patient. Friends and family members of the patient can provide helpful details here as well.

The presence of anxiety suggests many diagnoses to consider. A concrete place to start is in the concept of panic. If the patient identifies panic attacks, determine what a "panic attack" means to this particular patient. Open questions such as "what does your body feel like when you are having one of these panic attacks?" may lead to expected cardiac, pulmonary, gastrointestinal (GI), or neurologic symptoms and give the interviewer more confidence in a diagnosis of panic disorder.

Similarly, the question "What are you thinking or feeling during these episodes?" can elicit diagnostic symptoms without suggesting them. Questions such as "Do you ever feel the need to count the number of certain objects in a room?," "How often do you find yourself checking and then repeatedly rechecking locks or switches?," and "Do you spend excessive time cleaning or organizing?" can identify some of the more common presentations of obsessive-compulsive disorder .

Cleaning and organization can also be assessed. Obsessive-compulsive disorder is often more ego-dystonic than obsessive compulsive personality disorder, and this is a helpful point to assess for diagnostic accuracy.

Trauma-related anxiety can be discussed without stressfully detailing the entire event. First, determine if the patient has ever been involved in an event in which either the patient or someone else was facing potential death or serious injury. If this first question has a positive response, then asking "Do you often have thoughts, feelings, or dreams about this event?" and "How have these thoughts or feelings affected your life?" is appropriate.

This is usually enough to begin a discussion of avoidant or hyperarousal symptoms of posttraumatic stress disorder (PTSD). The emotionally numbing aspect of PTSD may require a somewhat subtle approach to elicit; eg, the practitioner may address it by asking a question such as "How do you think your feelings are different from those of other people?"

Cognitive symptoms should also be addressed. Many patients by middle age will endorse some memory problems, but this most often represents a normal decline in cognitive function. [ 4 ] A positive answer to "Do you find that you’ve become more forgetful recently?" is followed by a specific assessment of attention, memory, and executive functioning if needed. Family members are often considerably more useful at providing information in this realm than the patient. If any concerns are noted, cognition can be formally assessed.

The psychiatric history provides perspective regarding the history of a patient's present illness and current symptoms by contrasting these findings with past treatment and illness episodes. "Have you ever been diagnosed with a mental illness in the past?" is an appropriately broad place to start, but a negative answer should not end this section of the interview. Stigma may be significant regarding mental illness, [ 5 ] and this may play a role in the patient’s acceptance of a diagnosis, as well as the depth in which previous practitioners discussed the diagnosis.

A good follow-up question regardless of the answer to the first is "Have you ever seen a mental health provider such as a psychiatrist, psychologist, or social worker before?" If so, ask about the past providers. "What sort of things have these providers done for you?" gives an open-ended opportunity to question the patient about his or her medication and psychotherapeutic history.

The adequacy, efficacy, and timing of treatment must be examined in depth. The timing of past trials is crucial to assess if treatments were individual or adjuvant to one another and help to appropriately assign intended or adverse effects. Neither therapy nor medications are likely to be effective with only brief trials, and failing to assess this can block a patient’s access to a beneficial therapy.

Psychiatric hospitalizations are discrete events that should also be assessed in detail. Most patients remember these emotionally charged events in detail. [ 6 ] Evaluate how severe the patient’s illness was, potential stressors, and the location and duration of past hospitalizations. Collateral information regarding all past psychiatric history is valuable, including hospital summaries, clinic records, and family reports.

A suicide and violence risk assessment is an important part of any psychiatric interview, but it is often forgotten if the patient does not endorse or appear depressed. Not only does it provide immediately apparent information on the severity of the patient’s illness, it also has the benefit of protecting the patient and the community. Because no empirically validated and reliable suicide assessment instruments exist, a clinical interview focusing on current presentation, psychiatric illness, history of homicidal/suicidal behavior, psychosocial stressors/strengths, and individual strengths/vulnerabilities is the current criterion standard of assessment. [ 7 ]

If the patient appears overly anxious or withholding, asking if he or she has had serious thoughts of death and dying can start a stepwise approach toward exploring suicidality. Many patients welcome the chance to get "right to the point" and seek relief from these distressing thoughts.

Suicidality or violence should be examined in detail. This includes obtaining a history of suicide attempts and of prior violent acts in general. The patient’s mental state at the time should be looked into, with some focus on past stresses in order to put the present into context. If no previous behaviors existed, but suicidal or violent thoughts occurred in the past or exist in the present, it may be appropriate to ask "What stopped you?" Similar questions should be asked of any current suicidal or violent ideation.

Suicidal and violent ideations are not simple "yes or no" concepts. Instead, both of these phenomena exist on continuums. The patient’s acute risk examines where he or she is at the time of the interview. It is increased by the extent of his or her ideation, clearly expressed intent (ie, moving from passive to active ideation), the development/practicality of any plans, and, finally, the extent of other current symptoms of mental illness. [ 8 ] .

The nature of the acute risk is such that it can fluctuate rapidly, even over the course of an interview. Conversely, the patient’s chronic risk is set largely before the interview has begun.

Large studies on the epidemiology of suicide and violence indicate that women are more likely to attempt suicide and that men are more likely to complete suicide. Persons in their teens and elderly are most likely amongst age groups. Anxiety, insomnia, agitation, previous suicide attempts, alcohol use, depression, anhedonia, and a lack of a social support system are all known to increase the risk of suicide. [ 9 , 10 ]

Assessing the risk for violent behaviors toward others is less well studied, but having grown up around violence, a history of violence, current habitation in a violent neighborhood, and any sort of substance abuse problem raises the chronic risk. [ 11 ]

All mental illness is biologic, and the separation of mental and physical illness with regards to etiology (eg, "it's not organic, it's psychiatric") or legitimacy (eg, "it's all in the patient's head") is a false dichotomy. The designations of "medical" and "mental" illness have practical value only in that they allow a practitioner to subdivide illness for the sake of staying organized. A medical history obtained in psychiatry, while not structurally different from that obtained in other specialties, does have some important focuses.

Seizures , [ 12 ] head injuries, [ 13 ] human immunodeficiency virus ( HIV ), [ 14 ] and other medical illnesses predispose patients to mental illness. Some chronic mental illnesses, such as schizophrenia, are associated with reduced access to and use of medical care. [ 15 ] Pharmacologic treatment can cause such medical illnesses as metabolic abnormalities, movement disorders, and sexual dysfunction. Alternatively, a medical illness may in fact be the cause of a mental illness, such as is the case with delirium. Medical illnesses are likely to be an additional stressor in a person’s life. They should be examined in at least some detail to create as much of a comprehensive view of the patient as can be obtained in an initial evaluation.

"Do you have any medical problems?" is a straightforward question to begin this portion of the interview, but it is not likely to be sufficient. Medications, major surgeries, allergies, and the name of the patient's current primary care provider should be directly collected. The length of questioning beyond these topics can vary immensely by practitioner, time limitations, and setting. Consulting in the hospital setting, a complete medical history may already be available prior to seeing the patient. In a psychiatric office setting, a checkbox questionnaire before the interview may be more appropriate. Collateral information will again be helpful in providing additional details.

The patient’s family history aids in the diagnosis of the patient, as well as providing a degree of context to his or her developmental history. Mental illnesses have variable degrees of hereditability, many quite strong. Having a parent with bipolar disorder, for example, raises the patient’s risk of developing the same disorder by at least 7-fold. [ 16 ]

Certain illnesses, such as those with psychotic features, may appear very similar on initial presentation, and a family history can help to guide accurate diagnosis and treatment, since the patient’s symptoms can be longitudinally observed. The second role that a family history plays is as a component of the social history. The transmissibility of mental illness is not entirely genetic, and the environmental factors can be identified. Having grown up with a severely depressed parent, for example, may have created distorted thinking or biases that affect functioning in the present.

The family history should cover topics similar to those of the psychiatric review of systems; namely, depression, mania, psychosis, and anxiety in first degree relatives. An assessment of seizures, metabolic disorders, early death and suicide, or violence is also likely to be useful. Of particular importance is the use and effectiveness of any medications, as this can be a guide in treatment of the patient. Severity, including hospitalizations, is also important to determine with regard to family members, as it may provide some information concerning prognosis.

Patients may not have the same level of knowledge about family members as they might about themselves, and definitive diagnoses or treatment history may be elusive. Of note, patients may not clearly recognize mental illness in family members, and a discussion of relevant symptoms in lay language may be more useful than asking about specific illnesses.

The social history occasionally degrades into a simple inventory of vices. A harried physician may take the time to ask only about sex, drugs, and abuse, with a brief assessment of housing and finances. To say that this gives an incomplete view of the patient would be an understatement. The social history should provide a longitudinal view of the patient’s life, as do the psychiatric and medical histories, but with a more holistic view.

Pathologic and adaptive events are assessed. The depth of this portion of the interview may be limited by time and goals. Much more is to be gained from a thorough medical history review with a hospitalized, delirious patient, for instance. For some patients, a detailed history may need to occur over multiple, sequential outpatient visits. Some forms of psychotherapy may be able to be thought of as extended social histories, as disordered relationships and past traumas are examined and explored. Strong working relationships are built by patients knowing that their doctor is interested in them and not just in their pathology.

Developmental history and parental relationships

A logical place to begin is the patient's developmental history. This could start with questions about drug exposures in utero and other prenatal history but will most often begin with birth. These questions and early childhood developmental milestones may not be well known to the patient. It is helpful to have additional information from family members to help determine if current symptoms may actually represent developmental disorder.

Discuss the relationship of the patient to his or her parents and their relative presence or absence in the patient’s life. Abuse is a complicated topic. Given that what a patient views as abuse may differ significantly from what a clinician considers to be abuse, asking "Were you ever physically, sexually, or emotionally abused growing up?" is a nonjudgmental and empathetic approach that will be accepted by most patients. A positive answer to any of these should be examined in detail. This is also a good time to inquire about any current abuse, especially in patients with a positive history.

Academic and occupational histories

Academic and occupational histories provide a smooth transition from early childhood to adolescent and adult life. Questions may involve what subjects the patient enjoyed in school and how well he or she got along with teachers and peers, queries that help to establish whether learning/conduct disorders are present and that aid in illuminating the patient's interpersonal skills and personality structure. At a minimum, assess for the patient's last competed grade level. The stresses that led to an early termination of education may relate directly to mental illness and could continue to impair the patient. [ 17 ]

Occupational history should ideally follow the patient from his or her first job to the present. Periods of disability and function, as well as of failure and triumph, are often remembered based on their relationships to school and work. Periods of incarceration and military service should also be detailed. Goals for future education, occupation, or other opportunities for growth should also be explored.

Adult relationships

Adult relationships are an important aspect of the patient's social history as well. A feel for the depth and length of multiple types of relationships should be obtained; eg, boss, coworker, and family. Sexual history is a challenging topic for the patient and the interviewer. More than many areas of the interview, this portion calls for questions that are neither judgmental nor overtly supportive, in order not to burden the patient with the clinician’s emotions in addition to his or her own.

The patient should be given the option to decline answering. Intimacy, sexual attraction, and sexual action are separate, although often related, topics. They should be explored equally with questions sensitive to the possibility that "men, women, or both" are involved, and this is a straightforward way of phrasing such queries. Asking directly about marriage, although common, can unfortunately indicate a bias toward heteronormativity and lead to a patient withholding otherwise pertinent information. Instead of using this interview shortcut, asking about "long-term relationships" can provide much more information.

Sources of emotional support

Other sources of support in the patient’s life should be explored in the context of a social history. This includes faith or religious tradition, as well as family or other communities. It is rarely sufficient to simply ask, "Do you belong to any particular religion?" Using a broader term such as "spirituality" or "faith tradition" gives a patient more flexibility in answering the question without concern for the clinician’s biases. If time permits, a religious or spiritual history from childhood onward is helpful to establish how a patient’s spiritual worldview developed.

Asking "Does your (religion/faith/community) help you with life?" may provide a wealth of information on the patient’s current support or lack thereof. Remember that not all experiences the patient has had are necessarily positive. As with the entirety of the interview, an open and nonjudgmental interview technique is crucial to collecting a full picture.

Acquiring a list of substances used, as well as determining the quantities used and the periods of time over which they were used, is important, but more important is the role that these substances play in the patient’s overall life. Use of vernacular may be appropriate for some patients and may yield more accurate information, but an interviewer should ask for clarification if the patient begins to use terminology that is unfamiliar.

In addition to illicit drugs, prescription medication usage should be examined with a simple "do you ever find yourself using more of a medication than your doctor prescribes or using other people’s prescriptions?" The route and amount consumed are important for illicit and prescribed medications.

For alcohol in particular, the CAGE questionnaire [ 18 , 19 ] can be a quick screening tool (see Table 3, below). Two or more positive responses are likely to indicate some form of alcohol abuse. Beyond abuse, differentiating the presence of dependence is important. Tolerance, withdrawal, and loss of control in the amount or time of use can all be signs of dependence.

Table 3. CAGE Questions (Open Table in a new window)

The mental status examination is often and accurately described as the physical examination of psychiatry. It is of particular importance given the lack of clinically relevant lab or imaging studies for many psychiatric diagnoses, which are in fact syndromes of historical data and objectively observed symptoms.

The mental status examination begins upon first seeing the patient and noting his or her appearance. Apparent race/ethnicity, age, and gender are usually noted first. Attire and overall hygiene are noted next. Tattoos, make-up, jewelry, and any physical abnormalities are included and may be topics of further inquiry. Make every attempt to be descriptive and not interpretive to minimize subjectivity. For instance, "punk rock hair" is a less objective description than "purple hair styled into 2-inch spikes."

Behavior is the active component of the patient’s appearance and is described separately. A bare minimum includes describing any psychomotor agitation or retardation seen in the patient. Any abnormal movements should be noted. Examination and notation of facial movements are important for monitoring tardive dyskinesia. Compulsive movements, such as picking at the skin or rearranging items or clothing, can be helpful in a differential.

Specific behaviors are important to note because they can be side effects of psychiatric medications. These include muscle rigidity, an extrapyramidal symptom that, when severe and acute, may also point to the more serious neuroleptic malignant syndrome.

Movement disorder descriptions are as follows:

Choreiform - Jerky, irregular, not specifically repeated, and semi-purposeful

Athetoid - Writhing, more repetitive

Ballismus - Involuntary, rapid movement in one direction; often a punch or throw movement

Speech and thought can be difficult to separate objectively; after all, we only know what our patients are thinking based on what they tell us. For the purposes of a mental status examination, speech covers the motor and neurologic aspects of producing words, although process and content, discussed later, will refer to the informational and organizational components.

The relative or total absence of speech may be notable and indicate depression or severe psychotic disorders. Accents provide some information to be further examined in the social history. In mania, rapid or pressured speech may be noted. Mania may also present with increased tone or volume.

Poor articulation of words could point towards substance intoxication. Rhythm abnormalities may be most pronounced in Tourette syndrome, in which speech can be cluttered with repeated sounds or noises. Alterations in prosody can suggest affective disorders. Some commonly used terms to describe speech are defined as follows:

Rapid - Increased rate of speech

Pressure - A flow of speech that is difficult to interrupt; often related to, but not dependent on, an increased rate of speech

Prosody - The rhythm, stress, and intonation of speech

Speech latency - The delay between the question/statement of an interviewer and the response of the patient

Aphasia - Inability to speak

Mood and affect

Mood and affect are separated in the mental status examination. The mood is the internal, subjective aspect of the patient's emotional state and the affect is the external, objective aspect of the patient's emotional state. Many terms have been used to try to capture and convey these states. For example, mood is defined as follows:

Depressed - Low or sad mood

Anxious - Distress or unease, fears of misfortune or harm

Euphoric - Elevated, distorted levels of happiness

Affect is defined as follows:

Labile - More affective states evident than expected during the interview, with the changes occurring rapidly

Appropriate - Affect matches the individual's described mood

Inappropriate - Affect does not match the person's described mood

Euthymic - Emotional range is evident

Restricted/constricted - Emotional range is limited but not completely absent

Flat - No emotional range evident

The mood is most often obtained by asking the patient, "How are you feeling?" Use a direct quote from the patient when recording your finding. A thorough examination of mood includes questions regarding how long the patient has felt the way he or she does, how often his or her mood changes, and the patient’s view of the relative strength of the emotion, to determine the pervasive and most sustained emotion that the patient has been experiencing as opposed to each and every momentary feeling.

The examination of affect looks at stability and range (or constriction) of displayed emotion across the interview. An affect is compared to the stated mood and congruence (or lack thereof) noted. The appropriateness of a patient’s emotional appearance to the topics being discussed is also a part of the affective examination. A patient with limited affect or no affect may be described as blunted or flat, respectively.

Thought process

Thought process, defined as how a patient organizes his or her thoughts, becomes apparent over the course of the interview through dialog. Some examples of thought processes are as follows:

Loose associations - Ideas from the patient only indirectly related to what the interviewer was actually asking

Tangential - If responses begin to relate to a question but veer off into unrelated topics

Circumstantial - The response eventually does answer the question posed, but extensive and only vaguely related information is also included

Thought blocking/derailment - Thoughts are suddenly stopped (blocking), with speech then resuming after several seconds on a new topic (derailment)

Associations are a part of the thought process wherein a patient connects meaning to words and sentences. Loose associations such as "I’ve read that driving a car is more dangerous than flying in an airplane. The birds outside my window were loud this morning," are often associated with mania. Often, very loose associations have connections understood only by the patient.

Normal associations are referred to as tight. The overall thought process could be described as tangential, circumstantial, or goal directed. Flight of ideas is an extreme form of tangential thought process, in which not only the question posed, but also the patient’s own words, lead the patient onto separate topics, usually in quick succession. Thought blocking and derailment are thought-process disorders classically seen in schizophrenia.

Thought content

Thought content describes what the patient’s focus is during the interview. In a tightly structured interview with closed-ended questions, the content of the patient’s thoughts may be "question focused," with the patient having little opportunity or desire for spontaneity and discussing only what the interviewer brings up.

However, a more accurate view of the topics that are crossing the patient’s mind can be ascertained by simply letting the patient talk. Using the first 5 minutes of the interview in this way is of great benefit. Record any topics the patient identifies as significant or spends significant time on. Details of psychosis are defined as follows:

Delusions - Fixed, false beliefs

Hallucinations - Sensory perceptions of something that does not exist

Illusions - Sensory misrepresentations of real stimuli; eg, a hat across a dim room becomes an assassin

Any delusion should be detailed and categorized as bizarre and nonbizarre based on the possibility of it being accurate. Hallucinations are also included under thought content. Although a hallucination may not always be directly evident to a patient, many sufferers recognize some foreign aspect to the sensory experience and will reply affirmatively to the question "Do you ever see or hear things that other people don’t?" Ideally, hallucinations from all sensory domains should be queried. Finally, any active thoughts that the patient has about harming himself or herself or others should be directly investigated and noted in this section if such thoughts are currently present.

Insight and judgment

Insight and judgment can be assessed throughout the entirety of the interview. Insight in this context references the patient’s mental illness and the patient's awareness of it. If a patient presents with clear symptoms of a mental illness but rejects the diagnosis, he or she may be deemed to have poor insight. Judgment is narrowly defined as the active demonstration of insight, such as willingness to take medication or accept other treatments. A proxy measurement may be why or how the patient came to see the interviewer.

An incarcerated patient being brought in for treatment by the custody staff is less likely to have good judgment than an outpatient who scheduled his or her own appointment. Judgment more commonly is broadly defined by determining whether recent choices that patients have made were adaptive or maladaptive in maintaining or improving their level of functioning.

Insight and judgment may be limited by cognitive ability, which is assessed separately. This section of the examination often begins with a statement on the patient’s level of alertness and orientation to his or her name, location, date, and reason for being where he or she is. Concentration can be assessed through simple arithmetic or by spelling words backwards. Memory should be assessed in the short term, often through recall of number or word sequences, and in the long term, possibly through the recalling of important dates in the patient’s life as verified by a family member.

The patient’s general fund of knowledge should be assessed through questions about major national events or figures. Of note, the patient’s fund of knowledge will be heavily based on his or her educational background. A patient’s ability to understand abstract concepts may be tested through comparisons such as "How are an orange and an apple the same?" or through the use of proverbs, such as asking what "You can’t judge a book by its cover" means. Concrete answers, such as "Both have skins" or "You can’t tell what is in a book by looking at it," respectively, should be documented.

Finally, executive functioning should be examined with a question such as "If you heard a fire alarm going off in your house, what would you do?" These domains of cognition are often examined in more structured tests, such as the Folstein Mini-Mental Status Exam [ 20 ] or the Montreal Cognitive Assessment, [ 21 , 22 ] to provide an objective measure between interviewers and over time.

Please see the Medscape Reference topic History and Mental Status Examination for additional information on collecting the mental status examination.

The assessment is a summary of the entire interview, clearly combining history and examination into a differential diagnosis. Pertinent positives and negatives are included in order to support the listed diagnosis. If a specific diagnosis or specific diagnoses have not yet been reached, a list of possible diagnoses is discussed in brief, along with which diagnostic information is missing to finalize a diagnosis.

Do not hurry to a diagnosis if further investigation, information, or longitudinal assessment is needed; provisional diagnoses are common and accepted in the early stages of treatment. Including at least a few sentences on the current and historical stressors in the patient’s life that may be contributing to either the presence or the exacerbation of the current illness is also usually important.

The "biopsychosocial model," [ 23 ] while not a strict outline, encourages the examination of biologic, psychological, and social factors in the patient’s diagnosis and how they support or impede recovery. It facilitates a broader approach to treatment than a purely biomedical focus. Since its formulation, its use has spread to diseases with a classically medical focus, such as diabetes, [ 24 ] but it is most commonly used with psychiatric illnesses.

Within psychiatry, substance abuse and dependence are particularly well suited to an assessment in the biopsychosocial format. [ 25 ] For example, alcohol abuse can have biologic predispositions in the form of the genetic loading and may have biologic implications, such as hepatic cirrhosis. Having had parents with substance abuse problems is likely to have impacted the patient’s social functioning and how the patient relates to people as adults. The psychological stress of dealing with the current and past stresses in the patient’s life is likely to be contributing to the continuation of the patient’s substance abuse. Actions by the patient while intoxicated may have reduced the social support available to him or her, impeding recovery.

The plan addresses any intervention needed to improve a patient's symptoms or functioning, and considering the biopsychosocial assessment will help with its organization. Biologic consideration may include needed laboratory tests or imaging that will aid in accurate diagnosis or treatment monitoring. Any medications should also be described, noting dose, titration, potential length of treatment, and a description of what risks and benefits were discussed with the patient.

The psychological plan includes the nonpharmacologic treatment of psychiatric conditions. This may vary from something as simple as breathing exercises for anxiety to something as complex as long-term psychodynamic psychotherapy.

The social plan details how support networks, including friends and family, among others, will be used or shored up. Depending on the setting, legal filings may also be noted here, including any involuntary holds. Social planning further includes goals for the patient’s residence, work, education, or filing for disability, among many others.

Sources for additional information in any of the domains and how they may be reached should be described. Any remaining issues or questions that were not fully answered during the course of the psychiatric interview should be left in the plan as a reminder for either the interviewer or other clinicians at the patient’s next visit. The anticipated timing of this next visit can serve as an endpoint for the plan.

Documentation

Documentation of the interview is at least as important as the process of the interview itself. It provides a reference during follow-up visits for the interviewing clinician, and at least parts of it will likely be seen by other medical providers, such as the patient's primary care provider. Further, the write-up will serve as evidence of the patient interaction for billing purposes, and it can be an important source for at least the minimum degree of information required by any involved insurance programs.

The write-up should provide a summary of the all of the information collected. Providing every detail is obviously not possible, and this should not be a goal in general, as time constraints will likely be present for most readers in the future. Wording in all documentation should also reflect the possibility of being read by the patient in the future and thus avoid any judgmental language. An example template is demonstrated as follows:

Date of Evaluation:

Referred by:

Current Medication/s:

History of Present Illness:

Psychiatric Review of Symptoms:

Hospitalizations:

Medication Trials:

Suicide Attempts:

Family Psychiatric History:

Past Medical History:

Past Surgical History:

Relationship Status:

Employment:

Appearance:

Thought Process:

Thought Content:

Diagnostic Assessment:

Axis V: Current GAF =

Highest GAF Past Year:

Initial Treatment Plan

Medications:

Time to Return to Clinic:

Adolescent interview

An interview involving adolescents is not likely to have been initiated by the patient and will likely involve interacting with the entire family. From the outset, confidentiality must be discussed with everyone and firm ground rules laid out. The adolescent should feel comfortable speaking openly with the interviewer.

Everyone should understand that outside of the adolescent posing harm to himself/herself or others, the clinician will share information only at the patient’s discretion. Information sharing among all other parties should be encouraged, and the patient should be given the option to share himself/herself or to allow the interviewer to summarize findings.

Topics such as sexual activity and drug use covered during a one-to-one interview provide significant opportunities for behavioral counseling but also pose a risk of the patient becoming more withdrawn. If possible, they may be best discussed at interviews subsequent to the first meeting. They should be initially broached in reference to peers. For example, "Drug use can start happening in kids your age; do any of your friends use drugs?" This sort of question gives the interviewer an opening to more directly discuss the patient's own experiences with drugs (or sexual activity).

Interviews with adolescents often have specific focuses beyond symptoms control. Academic functioning is a common concern. Family members may be comforted by the knowledge that such challenges are common. For example, between 5-10% of a given population may suffer from dyslexia. [ 26 ] Parents have been shown in some studies to underreport or otherwise minimize psychiatric symptoms; [ 27 ] thus, it can be useful to obtain information directly from the patient’s teachers or other care providers.

Specific learning disabilities may need formal neuropsychiatric testing. However, as with the entirety of the psychiatric interview, further studies should be guided by the past; the collection of information on learning disabilities from the patient and caretaker requires a longitudinal approach that looks for a consistent pattern of difficulty over time and space. A fresh and unique view of the patient may help to narrow down diagnoses, since anything from conduct disorder to attention deficit hyperactivity disorder can have the same end result — poor school performance — but require dramatically different treatments.

Consult interview

A consultation evaluation to a general medical hospital or clinic is usually focused on a specific question. A clear description of the problem from the patient’s primary provider is a significant piece of information needed in formulating this question. In addition to any physicians involved in the patient’s care, additional information should be obtained from nursing and other ancillary staff.

A very thorough chart review is often required because the patient may be unable to provide a complete history due to his or her medical illness. A chart review and discussions with staff can also help to illuminate underlying issues that may not have been clearly stated in the original consult question. [ 28 ]

If interpersonal conflicts have been frequent, significant therapeutic benefit can often be obtained simply by giving the provider a space to discuss his or her concerns. Challenges with communication between staff members should be looked for.

Begin the interview with an assessment of the patient’s understanding as to why a psychiatrist was consulted. If the patient has any concerns about being seen for a psychiatric assessment, these should be addressed before any history is collected.

This interaction may be the patient’s first with a mental health professional, one that the patient may not have sought; the patient may also be under duress due to his or her medical illness. Greater flexibility should be allowed in the style and language of the interaction than would occur in a "traditional" interview for these reasons. [ 29 ] The content of the interaction, while not structurally dissimilar from that of other psychiatric interviews, will be more focused on the underlying medical illness as either a source of the psychiatric complaint or an exacerbation.

Delirium affects between 10-30% of all hospitalized patients; [ 30 ] thus, the ability of a patient to remain alert throughout the interview and a full cognitive evaluation should be documented.

Translated interview

Nearly 1 in 5 Americans speak a language other than English at home. [ 31 ] This can present a particular challenge for psychiatry given the length and depth of the interview required. A patient who is conversationally fluent and is able to otherwise navigate the medical system, may have more difficulties with the details of a psychiatric interview. Similarly, whereas the use of a multilingual staff member (untrained in translation) or a family member of the patient could be appropriate in other settings, the dual role may create additional confusion in this setting. A medical interpreter with experience in mental health care should be obtained.

Prior to beginning the interview, it may be helpful to speak separately with the interpreter to discuss any potential concerns or issues that may arise. For example, if the interpreter is not experienced in mental health and if the patient is already known, it may put the interpreter more at ease if he or she is informed ahead of time of known symptoms and what specific areas of thought content, language, or disorganization the clinician is interested in. It also gives the interpreter some opportunity to educate the interviewer on any cross-cultural issues that may impact the interview.

The goal is to interpret what the patient is saying as closely as possible but to recognize the difficulty that the interpreter may have in conveying feelings and thoughts that may not easily be communicated in English. Given this difficulty, the patient and provider should limit themselves to no more than 2-3 sentences at a time before pausing for interpretation.

After the interview, the clinician and interpreter can discuss some of the translation difficulties they encountered, as well as discuss any cultural issues that may have arisen. This is more appropriate than talking about the patient in his or her presence, regardless of the language used.

Geriatric interview

The number of Americans over age 65 years is expected to double to over 70 million by 2050. [ 32 ] Interviews with elderly patients need to cover the same material that they do with younger patients, but certain areas are likely to require more depth and detail. Physical symptoms are likely to take a larger role, and adequate time should be devoted not just to detailing them, but also to examining the role they play as a stressor in the patient’s life. Moreover, simply by virtue of having been alive longer, a geriatric patient will have a longer history, and time should be allotted to accommodate this.

The interviewer should be vigilant for minimization/dismissal of symptoms as "normal" aging. For example, a decline in sexual interest may be viewed by some elderly patients as normal or even expected; thus, these patients may not bring this up as a symptom to their physician. Simply raising the question may be enough normalization for the patient to realize that something is wrong. This realization, in turn, may allow the interviewer to begin to probe more deeply into the root cause of these symptoms, such as depression.

Caregivers can play an important role in the geriatric patient’s life and should not be excluded from the interview. Concerns that the caregiver has are particularly important in relation to cognitive disorders, which may not be readily apparent to the patient. Caregivers may be able to provide a more complete longitudinal view of the patient’s functioning as well.

In addition, discussing matters with a caregiver gives the interviewer the opportunity to assess and address caregiver burnout and fatigue, helping the caregiver and patient to function better together. The patient should also be given an opportunity to discuss their perspective on care giving with a review of potential neglect or abuse.

Crisis interview

An emergency psychiatric evaluation is often performed when a patient poses an immediate harm to himself/herself or others or when such a threat is thought to exist. The potential for danger can raise the anxiety level during what would already be a stressful interview. The maintenance of a quiet, safe environment should be foremost in mind before beginning the interview, emphasized to the patient from the onset. [ 7 ]

A description by the interviewer of his or her role and how he or she will be interacting with the patient in the future becomes even more important than in most interviews. Some patients may even require a dose of antipsychotic or anxiolytic medications before proceeding with the interview. Concern for the safety of the interviewer is as valid as it is for that of the patient. Often, an interview with a potentially assaultive person may best be accomplished with multiple interviewers.

If the assaultive person is restrained in any way, an important way to begin the interview is with the steps that the patient needs to take to have the restraints removed. If the patient is not restrained, the interviewer should at no time block the patient’s exit from the interview space or be situated in the interview space in such a way that he or she could easily become trapped.

Once the patient is deemed stable enough, the interview should focus on the relatively recent past and what led to the specific problem now being addressed. Clearly, something significant has taken place, and "what changed?" should be high on the list of questions to ask. [ 7 ]

Acute stressors may be medication changes or substance use or may be social in nature and are reasonable to ask about if the patient is not immediately forthcoming. Substances are also able to rapidly escalate psychiatric problems to the level of crises, becoming a combined biologic and social stressor.

In addition to the diagnostic and treatment considerations that are part of any interview, special consideration should be placed on the appropriate location for treatment when doing an emergency assessment. Interventions can range from hospitalization to more frequent follow-up visits, but should be an explicit part of the treatment plan.

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• Table 1. SIGECAPS Mnemonic
• Table 2. DIGFAST Mnemonic
• Table 3. CAGE Questions

Contributor Information and Disclosures

Lorin M Scher, MD, FACLP Clinical Professor of Psychiatry and Behavioral Sciences, Vice-Chair for Education, Roy T Brophy Endowed Chair, Director, Integrated Behavioral Health Services, Medical Director, Government and Community Relations, UC Davis Health Lorin M Scher, MD, FACLP is a member of the following medical societies: Academy of Consultation-Liaison Psychiatry, Alpha Omega Alpha , American Medical Association , American Psychiatric Association , Association of Directors of Medical Student Education in Psychiatry, California Medical Association , Central California Psychiatric Society, Sierra Sacramento Valley Medical Society Disclosure: Nothing to disclose.

Travis J Fisher, MD Assistant Professor, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin Travis J Fisher, MD is a member of the following medical societies: Academy of Psychosomatic Medicine , American Medical Association , American Psychiatric Association Disclosure: Nothing to disclose.

Scott M Summers, MD, PhD Resident Physician, Department of Psychiatry, University of California, Davis, School of Medicine Disclosure: Nothing to disclose.

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine David Bienenfeld, MD is a member of the following medical societies: American Medical Association , American Psychiatric Association , Association for Academic Psychiatry Disclosure: Nothing to disclose.

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• Brief Psychiatric Interviewing: Interview Tips
• Psychiatric Interviewing
• Screening & the Interview
• Interview tips
• Conclusion & References

Text adapted from "The art of the brief psychiatric interview in primary care" in  Psychiatry in primary care , by Jon Davine ,  (CAMH, 2019).

Help patients understand the mind–body connection

If a patient comes to you with somatic complaints that do not feel organic in origin but rather seem to be stress-based, you can help the patient understand the mind–body link. In your first interview, assure the patient that the complaints are “real” and “not all in your head.” Indicate that you will do the necessary physical work-up to look at possible physical origins of these complaints, but also explain that emotional factors may be a possible cause of the symptoms. You can use the examples of tension headache or butterflies in the stomach as illustrations of a pain that is “real” but due to emotional rather than organic underpinnings. This approach helps to build a collaborative relationship with the patient while shifting into a mind–body paradigm.

It is not recommended to do a full organic work-up first, and then weeks or months later bring up possible psychosocial issues if the organic work-up  is negative. Doing so may set up a paradigm that solidifies organic causes as primary, and psychological causes as secondary. Open up both pathways together as being equally valid.

Facilitate disclosure of painful events

Ask about your patient’s sexual life and past history of sexual abuse or sexual assault. The number of people who have been abused is distressingly high. Opening the door here is very important because patients may not offer the information themselves. Once you have opened that discussion, patients may often disclose abuse they have experienced. By asking these kinds of questions, you are giving the patient a “meta-message” about a few things: you are saying that you are aware of these issues, that you are fine with opening up discussion about them, and that you are comfortable dealing with issues that may arise out of this discussion. This meta-message will help people open up to you.

Follow the patient’s lead

Primary care practitioners may avoid bringing up certain topics, even though the topics are touched on by the patient, because they fear opening up a “Pandora’s box” of issues. However, it is always useful to capitalize on openings that patients naturally provide when they mention important subjects themselves. It does not matter when in the interview this happens—when the patient arrives, or when the patient is leaving, with a hand on the door. If something comes up near the end of the interview, you can always underline its importance for the patient and schedule another interview soon to continue the discussion. This “shelving” manoeuvre can be a good way to use patient initiative to obtain psychiatric data. Obviously, if the issue is urgent, for example, suicidal ideation, this discussion cannot be put off and you will have to extend the interview.

Practice active listening

Active listening includes being aware of the patient’s body language and speech and labeling things directly with the patient. For example, you might say, “I noticed that you have been talking more quietly as you tell me about your marriage.” This observation may prompt the patient to disclose more important information about the marriage. Summarize things back to the patient—this shows that you have been listening and gives the patient a chance to correct any wrong assumptions. Sometimes, simply repeating the last word a patient says may encourage the patient to say more. For example:

Patient: “I have been having trouble recently with my mother-in-law.” You: “Your mother-in-law?” Patient: “Yes, she has been so upset with me lately.”

No matter how busy you feel, it is essential to allow the patient time to speak. One study of internists showed that in 69 per cent of interviews, physicians interrupted their patients, on average, within the first 18 seconds of the encounter. These interruptions can get in the way of understanding  the patient’s problems and obtaining complete information. Silence is golden, and allowing the patient to speak for a minute or two will help useful information emerge.

Prioritize and shelve issues

When patients speak freely, a lot of issues may be presented at the beginning of the interview. Although this information can be useful, it can be somewhat daunting. A helpful strategy for dealing with multiple problems is called “prioritizing and shelving.” You and the patient prioritize the top one, two or three complaints to be dealt with that day, and “shelve” the less urgent complaints to be dealt with on another day. Your patient of course has a say in what issues are prioritized, but if you think that other problems are more urgent, those need to be considered as well. This “meshing of agendas” helps patients feel that they are being listened to and their complaints validated.

Allocate time for addressing mental health concerns

If possible, having a flexible schedule that accommodates certain patients can be useful. For example, if you know that a certain patient is coming  in to discuss mental health problems, you can schedule a slightly longer appointment to give you more latitude with that patient.

Take a careful personal history

Taking a personal history can help you know your patients in a longitudinal way, which in turn helps patients better understand the themes permeating their lives. Although there is not time to take a personal history with every patient, doing so is extremely useful for patients who are being actively treated for current mental health problems. Table 1 presents questions you can ask to gather the essential information. These questions elicit information that captures the enduring emotional patterns of a patient’s life. They also give clues to where these patterns may have originated.

Table 1 Key questions to ask in a personal history

In The Art of the Brief Psychiatric Interview in Primary Care

• Screening  
• Interview Tips

Psychiatric Interviewing Video Series

Dr. David Goldbloom, Senior Medical Advisor at CAMH, goes through a series of scenarios for primary care practitioners.

Active listening

Psychiatric interviewing scenarios for primary care practitioners

Asking items on a checklist

Asking about substance use, asking about trauma/sexual abuse, talking about involving family members, referring a patient, keep in touch with camh.

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