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Michael J. Vergare, M.D., Chair
Renée L. Binder, M.D.
Ian A. Cook, M.D.
Marc Galanter, M.D.
Francis G. Lu, M.D.
This practice guideline was approved in December
2005 and published in June 2006. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available.
This practice guideline was developed under the auspices of
the Steering Committee on Practice Guidelines. The development process
is detailed in a document available from the APA Department of Quality
Improvement and Psychiatric Services, the "APA Guideline Development
Process." Key features of this process include the following:
A comprehensive literature
Development of evidence tables
Initial drafting of the guideline by a work group that
included psychiatrists with clinical and research expertise in psychiatric
Production of multiple revised drafts with widespread
review (14 organizations and 64 individuals submitted
significant comments)
Approval by the APA Assembly and Board of Trustees
Planned revisions at regular intervals
Relevant literature was identified through a computerized
search of MEDLINE, using PubMed, for the period from 1994 to 2005.
The search strategy (psychiatric assessment OR psychiatric assessments
OR psychiatric emergencies OR psychiatric emergency OR psychiatric
evaluation OR psychiatric evaluations OR psychiatric histories OR
psychiatric history OR psychiatric interview OR psychiatric
interviewing OR psychiatric interviews OR psychological assessment
OR psychological assessments OR psychological evaluation OR psychological
interview OR mental status examination OR mental status examinations
OR psychiatric rating) OR (mental disorders/diagnosis AND [laboratory
findings OR laboratory techniques OR laboratory test OR laboratory
tests OR radiograph OR radiographic OR radiography OR x ray OR imaging
OR MRI OR tomography OR physical exam OR physical examination OR
interview OR interviewing OR history taking OR evaluation OR assessment])
yielded 19,429 references, of which 7,894 were published between
1994 and 2005 in English and had associated abstracts. An additional
search on history taking AND (psychiatric OR sexual OR occupational
OR social OR psychosocial) yielded 1,927 references, with 731 of
these published with abstracts in English between the years 1994
and 2005.
Additional, more limited searches were conducted by APA staff
and individual members of the Work Group on Psychiatric Evaluation
to address discrete issues outside of the primary guideline topic.
This document represents a synthesis of current scientific
knowledge and rational clinical practice on the psychiatric evaluation
of adults. It strives to be as free as possible of bias toward any
theoretical approach.
Psychiatric evaluations vary
according to their purpose. This guideline is intended primarily
for general, emergency, and consultation evaluations for clinical
purposes. It is applicable to evaluations conducted by a psychiatrist
with adult patients (age 18 or older), although sections may be
applicable to younger patients. Other types of psychiatric evaluations
(including forensic, child custody, and disability evaluations)
are not the focus of this guideline; however, the general recommendations
of this guideline may be applicable to other, more specialized evaluations.
The guideline presumes familiarity with basic principles
of psychiatric diagnosis and treatment planning as outlined in standard,
contemporary psychiatric textbooks (1–6) and taught in
psychiatry residency training programs. It was developed following
a review of contemporary references, and it emphasizes areas of
consensus in the field.
Recommendations of this guideline are intended to be consistent
with the care model endorsed in the Institute of Medicine report
the Quality Chasm
(7). This report notes that with
advancements in medical science, the emphasis of health care delivery
must shift to ongoing management of chronic conditions. The initial
psychiatric evaluation may set the stage for such ongoing care by
establishing initial treatment goals, gathering relevant baseline
data, establishing a plan for systematic follow-up assessment using
formal but practical and relevant measures, and ensuring longitudinal
While there is broad agreement that each element of the extensive
general evaluation described in this guideline may be relevant or
even crucial in a particular patient, the specific emphasis of an
evaluation will vary according to its purpose and the patient's
presenting problem. Consideration of the domains outlined in this
guideline is part of a general psychiatric evaluation, but the content,
process, and documentation must be determined by applying the professional
skill and judgment of the psychiatrist. The performance of a particular
set of clinical procedures does not ensure the adequacy of a psychiatric
evaluation, nor does their omission imply that the evaluation is
deficient. The particular emphasis or modifications applied by the
psychiatrist to the generic evaluation offered in this guideline should
be consonant with the aims of the evaluation, the setting of practice,
the patient's presenting problem, and the ever-evolving
knowledge base concerning clinical assessment and clinical inference.
Although documentation is an integral part of an evaluation, it
is important to emphasize that the scope and detail of clinically
appropriate documentation also will vary with the patient, setting,
clinical situation, and confidentiality issues. Because of the wide
variation in these factors, this guideline does not include recommendations
regarding the content or frequency of documentation. Such determinations
must be based on the specific circumstances of the evaluation.
To share feedback on this or other published APA practice
guidelines, a form is available at http://mx.psych.org/survey/reviewform.cfm.
The purpose and conduct of a psychiatric evaluation depend
on who requests the evaluation, why it is requested, and the expected
future role of the psychiatrist in the patient's care. The
outcome of the evaluation may or may not lead to a specific psychiatric
diagnosis. Three types of clinical psychiatric evaluations are discussed:
1) general psychiatric evaluation, 2) emergency evaluation, and
3) clinical consultation. In addition, general principles to guide
the conduct of evaluations for administrative or legal purposes
are reviewed. At times there may be a conflict between the need
to establish an effective working relationship with the patient
and the need to obtain comprehensive information efficiently. If
the psychiatrist expects to provide care directly to the patient, the
establishment of an effective working relationship with the patient
may take precedence over the comprehensiveness of the initial interview
or interviews (8). In such a case, emphasis may be placed on obtaining
information needed for immediate clinical recommendations and decisions
A general psychiatric evaluation has as its central component
an interview with the patient. The interview-based data are integrated
with information that may be obtained through other components of
the evaluation, such as a review of medical records, a physical examination,
diagnostic tests, and history from collateral sources. A general
evaluation usually is time intensive. The amount of time necessary
generally depends on the complexity of the problem and the patient's
ability and willingness to work cooperatively with the psychiatrist.
Language competence needs to be assessed early in the evaluation
so that the need for an interpreter can be determined. Several meetings
with the patient, and in many cases appropriate family or relational
network members, may be necessary. More focused evaluations of lesser
scope may be appropriate when the psychiatrist is called on to address a
specific, limited diagnostic or therapeutic issue.
The aims of a general psychiatric evaluation are 1) to establish
whether a mental disorder or other condition requiring the attention
of a psychiatrist is present; 2) to collect data sufficient to support
differential diagnosis and a comprehensive clinical formulation;
3) to collaborate with the patient to develop an initial treatment
plan that will foster treatment adherence, with particular consideration
of any immediate interventions that may be needed to address the
safety of the patient and othersor, if the evaluation
is a reassessment of a patient in long-term treatment,
to revise the plan of treatment in accordance with new perspectives
gained from the evaluation; and 4) to identify longer-term issues
(e.g., premorbid personality) that need to be considered in follow-up
In the course of any evaluation, it may be necessary to obtain
history from other individuals (e.g., family or others with whom
the patient resides; individuals referring the patient for assessment,
including other clinicians). Although the default position is to
maintain confidentiality unless the patient gives consent
to a specific intervention or communication, the psychiatrist is
justified in attenuating confidentiality to the extent needed to
address the safety of the patient and others (10, 11). In addition,
the psychiatrist can elicit and listen to information provided by
friends or family without disclosing information about the patient to
the informant.
More detailed recommendations for performing a general psychiatric
evaluation are provided in Section III.
The emergency psychiatric evaluation generally occurs in response
to thoughts, feelings, or urges to act that are intolerable to the
patient, or to behavior that prompts urgent action by others, such
as violent or self-injurious behavior, threats of harm to self or
others, failure to care for oneself, bizarre or confused behavior,
or intense expressions of distress. The aims and specific approaches to
the emergency evaluation have been reviewed elsewhere in detail
(11–15) and include the following:
Assess and enhance the
safety of the patient and others.
Establish a provisional diagnosis (or diagnoses) of
the mental disorder(s) most likely to be responsible for the current
emergency, including identification of any general medical condition(s)
or substance use that is causing or contributing to the patient's mental
Identify family or other involved persons who can give
information that will help the psychiatrist determine the accuracy
of reported history, particularly if the patient is cognitively
impaired, agitated, or psychotic and has difficulty communicating
a history of events. If the patient is to be discharged back to
family members or other caretaking persons, their ability to care
for the patient and their understanding of the patient's needs
must be addressed.
Identify any current treatment providers who can give
information relevant to the evaluation.
Identify social, environmental, and cultural factors
relevant to immediate treatment decisions.
Determine whether the patient is able and willing to
form an alliance that will support further assessment and treatment,
what precautions are needed if there is a substantial risk of harm
to self or others, and whether involuntary treatment is necessary.
Develop a specific plan for follow-up, including immediate
treatment and disposition; determine whether the patient requires
treatment in a hospital or other supervised setting and what follow-up
will be required if the patient is not placed in a supervised setting.
The emergency evaluation varies greatly in length and may
on occasion exceed several hours. Patients who will be discharged
to the community after an emergency evaluation may require more
extensive evaluation in the emergency setting than those who will
be hospitalized. For example, patients who have presented with intoxication
or who have received medications in the emergency department may
require additional observation to verify their stability for discharge.
In other individuals with significant symptoms but without apparent acute
risk to self or others, additional time may be needed to obtain
more detailed input from family, other involved caretaking
persons, and treatment providers; to verify that the proposed plan
of follow-up is viable; and to communicate with follow-up caregivers
about interventions or recommendations resulting from the emergency
When patients are agitated, psychotic, or uncooperative with
assessment, and when their clinical presentation appears to differ
from the stated factors prompting assessment, it may be especially
important to obtain history from other individuals (e.g., family
members, other professionals, police), keeping in mind principles
of confidentiality, as described in Section I.A above and in
Patients presenting for emergency psychiatric evaluation have
a high prevalence of combined general medical and psychiatric illness,
recent trauma, substance use and substance-related conditions,
and cognitive impairment (16–27). These diagnostic possibilities
deserve careful consideration. General medical and psychiatric evaluations
should be coordinated so that additional medical evaluation can
be requested or initiated by the psychiatrist on the basis of diagnostic
or therapeutic considerations arising from the psychiatric history and
interview. Although issues of confidentiality are sometimes raised,
in an emergency situation necessary information about the patient
can be communicated with the emergency medicine department staff.
In many emergency settings, patients initially are examined by a
nonpsychiatric physician to exclude acute general medical problems.
Such examinations usually are limited in scope and rarely are definitive
(18, 19, 28–30). Furthermore, psychiatrists and emergency
physicians sometimes have different viewpoints on the utility of
laboratory screening for substance use or medical disorders in psychiatric
emergency department patients (31, 32). Therefore, on the basis
of clinical judgment and the specific circumstances of the evaluation,
the psychiatrist may need to request or initiate further general
medical evaluation to address diagnostic concerns that emerge from
the psychiatric evaluation (12, 16, 18–27, 33–35).
Clinical consultations are evaluations requested by other
physicians or health care professionals, patients, families, or
others for the purpose of assisting in the diagnosis, treatment,
or management of an individual with a suspected mental disorder
or behavioral problem. These evaluations may be comprehensive or
may be focused on a relatively narrow question, such as the preferred
medication for treatment of a known mental disorder in a patient with
a particular general medical condition. Psychiatric evaluations
for consultative purposes use the same data sources as general evaluations.
Consideration is given to information from the referring source
on the specific problem leading to the consultation, the referring
source's aims for the consultation, information that the
psychiatrist may be able to obtain regarding the patient's
relationship with the primary clinician, and the resources and constraints
of those currently treating the patient. Also, in the case of a
consultation regarding a mental or behavioral problem in a patient
with a general medical illness, information about that illness,
its treatment, and its prognosis is relevant. The patient should
be informed that the purpose of the consultation is to advise the
party who requested it. Permission to report findings to others,
including family, needs to be clarified with the patient and other
concerned parties before the evaluation begins.
The aim of the consultative psychiatric evaluation is to provide
clear and specific answers to the questions posed by the party requesting
the consultation (36, 37). For example, the psychiatrist may be
asked to determine the patient's capacity to give consent
for treatment decisions. On other occasions, the psychiatrist may
be asked to assess a particular sign, symptom, or syndrome; provide
a diagnosis; and recommend evaluation, treatment, or disposition
at a level of specificity appropriate to the needs of the treating
In the course of the evaluation, the consultant may also identify
a diagnostic or therapeutic issue that was not raised in the request
for consultation but that is of concern to the patient or of relevance
to treatment outcome. For example, treatment adherence may be affected
by personality and countertransference issues that compromise the
patient's therapeutic alliance with the referring clinician.
If any conflicts between the patient and the primary clinician do
emerge as an issue, positive resolution of them should be encouraged in
a manner that respects the patient's relationship with
the primary clinician.
If agreed to by the patient, discussion of findings and recommendations
with the family or involved persons can assist with appropriate
follow-up and adherence with recommendations.
Other psychiatric consultations are directed toward the resolution
of specific legal, administrative, or other nonclinical questions.
While the details of these evaluations, such as forensic evaluations,
child custody evaluations, and disability evaluations, are beyond
the scope of this guideline, several general principles apply. First,
the evaluee usually is not the psychiatrist's patient,
and there are limits to confidentiality implicit in the aims of
the evaluation; accordingly, the aims of the evaluation and the
scope of disclosure should be addressed with the evaluee at the
start of the interview (38, 39). Second, questions about the evaluee's
legal status and legal representation should be resolved before
the assessment begins, if possible. Third, many such consultations
rely heavily, or even entirely, on documentary evidence or data
from collateral sources. The quality and potential biases of such
data should be taken into account.
The aims of these psychiatric consultations are 1) to answer
the requester's question to the extent possible with the
data obtainable and 2) to make a psychiatric diagnosis if it is relevant
to the question.
The scope, pace, and depth of inpatient evaluation depend
on the patient population served by the inpatient service, the goals
of the hospitalization, and the role of the inpatient unit within
the overall system of mental health services available to the patient
(40, 41).
In addition to providing a highly structured and contained
setting in which patient safety can be monitored and optimized,
the inpatient setting permits intensive and continuous observation
of signs and symptoms while the patient is being treated for psychiatric
and general medical conditions through the collaborative
efforts of the multidisciplinary treatment team (see also
). Particularly for individuals with complex psychiatric presentations or
multiple co-occurring disorders, the enhanced level of observation
in the inpatient environment may facilitate assessment of co-occurring
general medical conditions or evaluation for procedures such as
electroconvulsive therapy, may aid in resolving diagnostic dilemmas,
and may help in determining a patient's ability to function
safely and independently in a less restrictive setting (41, 42).
Inpatient settings provide enhanced opportunity to corroborate
clinical judgment and decision making, including discharge planning,
through access to information from multiple sources. These include
the multidisciplinary treatment team, family, friends, and individuals
involved in the care of the patient outside the hospital, as well
as prior hospitalization records.
From the outset, the inpatient evaluation should include assessment
of the patient's access to appropriate treatment following
hospitalization. The patient's living arrangements should
also be assessed to determine whether they will continue to be suitable
after discharge. If the posthospitalization disposition is not apparent,
the evaluation should identify both patient factors and community
resources that would be relevant to a viable disposition plan and
should identify the problems that could impede a suitable disposition.
Family involvement, when appropriate, can also be initiated, and
goals for inpatient family work can be identified.
Outpatient settings differ widely, from office-based practices
to community mental health centers to intensive outpatient or partial
hospital programs, among others. Nevertheless, evaluation in the
outpatient setting usually differs in intensity from inpatient evaluation
because of less frequent interviews and less immediate availability
of laboratory services and consultants from other medical specialties.
Also, the psychiatrist in the outpatient setting has substantially less
opportunity to directly observe the patient's behavior
and to implement protective interventions when necessary. For this
reason, during the period of evaluation it is important for the
psychiatrist to reassess whether the patient requires hospitalization
or more intensive outpatient care (e.g., greater visit frequency,
intensive outpatient or partial hospital programs, programs of assertive
community treatment). Unresolved questions about the patient's
general medical status may also require more rapid assessment in
a more structured setting. If the patient's presentation
is atypical (e.g., with respect to symptoms, symptom severity, or
age at onset), a more thorough medical workup may be required or
coordinated with the patient's primary care physician.
Patients who do not have a primary care physician may need assistance
in obtaining appropriate referrals. A decision to change the setting
for evaluation will depend on the patient's current mental
status and behavior as well as the patient's history of
psychiatric symptoms and treatment, the status of co-occurring general
medical conditions or substance use, and the availability of diagnostic
resources, therapeutic resources, and sociocultural supports.
Advantages of the outpatient setting include greater patient
autonomy and the potential for a more longitudinal perspective on
the patient's symptoms. However, the lack of continuous
direct observation of behavior limits the obtainable data on how
the patient's behavior appears to others. Consequently,
extended evaluation of the patient in the context of psychoeducational
or time-limited groups can complement and augment observations from one-to-one
interviews. With the patient's permission, involvement
of family or significant others as collateral sources in the evaluation
process also deserves consideration. It is also useful to be aware
that family and significant others may not be supportive of the
patient or of psychiatric treatment. If the patient states that
family systems issues, especially marital or partner issues, are
a problem, an evaluation session with the partner can provide valuable information
and clarify the systems issues. When substance use is suspected,
obtaining data from other involved persons (e.g., family, close
friends, staff), determining blood alcohol levels, or screening
for substances of abuse may be especially important.
Evaluations are also conducted in hospital emergency departments
(see Section I.B) and general medical (i.e., nonpsychiatric) settings,
such as inpatient units. The latter allow for some direct behavioral
observation by staff and for some safeguards against self-injurious or
other violent behavior by patients. However, the level of behavioral
observation and potential intervention against risky behavior in
these settings tends to be less than on psychiatric inpatient units.
In addition, psychiatric interviews on general medical-surgical
units are often compromised by interruptions and lack of privacy.
These problems sometimes can be mitigated by using a space on the
unit where the patient and the psychiatrist can meet privately.
Developing an ongoing relationship with staff on medical inpatient
units will increase the likelihood of obtaining accurate behavioral
data as well as of ensuring that staff implement recommendations.
If there is prominent hostility or anxiety in interactions between
the patient and hospital staff, the evaluating physician must consider
interfacing with others in the hospital system to determine its
If the patient has an unclear sensorium or other cognitive
impairments, it is critical to interview people in the patient's
relational network to see if these symptoms were present before
hospitalization or have developed since treatment was begun. In
interviewing family members, it is very useful to discuss their
beliefs about the patient's illness and prior treatment,
the patient's record of adherence to medication treatment,
and concerns about discharge planning. If family members do not
perceive themselves as allies in treatment, the patient's
treatment is likely to be compromised once he or she leaves the
hospital (43).
Documentation of psychiatric evaluations in general medical
charts should be sensitive to the standards of confidentiality of
the nonpsychiatric medical sector and the possibility that charts
may be read by persons who are not well informed about psychiatric
issues. Information written in general medical charts should be
confined to that necessary for the general medical team and should
be conveyed with a level of detail and specificity that will be
most helpful to the overall management of the patient. It is also
important that documentation be of sufficient detail to establish
a diagnosis and treatment plan.
Evaluations conducted in other settings, such as residential
treatment facilities, home care services, nursing homes, long-term
care facilities, schools, and prisons, are affected by a number
of factors: 1) the level of behavioral observations available and
the quality of those observations, 2) the availability
of privacy for conducting interviews, 3) the availability of general
medical evaluations and diagnostic tests, 4) resources to conduct
the evaluation safely, and 5) the degree of likelihood that information
written in facility records will be understood and kept confidential.
In light of these factors, it is necessary to consider whether
a particular setting permits an evaluation of adequate speed, safety,
accuracy, and confidentiality to meet the needs of the patient.
Factors of the setting that compromise the evaluation merit documentation.
General psychiatric evaluations involve a systematic consideration
of the broad domains described in this guideline and vary in scope
and intensity. Table 1 summarizes the domains. The intensity with
which each domain is assessed depends on the purpose of the evaluation
and the clinical situation. An evaluation of lesser scope may be
appropriate when its purpose is to answer a circumscribed question.
Such an evaluation may involve a particularly intense assessment of
one or more domains especially relevant to the reason for the evaluation.
Across all domains, evaluations are generally based on three
sources of information: 1) observation and interview of the patient;
2) information from others (e.g., family, significant others, case
managers, other clinicians [including the patient's
primary care physician]) that corroborates, refutes, or
elaborates on the patient's report; and 3) medical records.
An awareness of how people report current symptoms and events is
important to the clinical assessment process. In considering the
information obtained, the patient's current mental state
is relevant. Mistakes in comprehension, recall, and expression may
also lead to erroneous reporting of information (44).
The purpose of the evaluation influences the focus of the
examination and the form of documentation. The reason for the evaluation
usually includes (but may not be limited to) the chief complaint
of the patient. It should be elicited in sufficient detail, including
the patient's words, to permit an understanding of the
duration of the complaint and the patient's specific goals
for the evaluation. If the symptoms are of long standing, the reason
for seeking treatment at this specific time is relevant; if the
evaluation was occasioned by a hospitalization, the reason for the
hospitalization is also relevant. If the patient did not initiate
the evaluation, the reason another individual or entity may have
requested or required it should be noted. The opinions of other
parties, including family, can also assist in establishing a reason
for evaluation. Under some circumstances (e.g., with psychotic or
uncommunicative patients), input from others may be crucial.
Questions to Consider
Reason for the evaluation
What is the patient's chief complaint and
its duration?
What reason does the patient give for seeking evaluation
at this specific time?
What reasons are given by other involved parties (e.g.,
family, other health professionals) for seeking evaluation at this
specific time?
History of the present illness
What symptoms is the patient experiencing (e.g., worries; preoccupations;
changes in mood; suspicions; delusions or hallucinatory experiences;
recent changes in sleep, appetite, libido, concentration, memory,
or behavior, including suicidal or aggressive behaviors)?
What is the severity of the patient's symptoms?
Over what time course have these symptoms developed
or fluctuated?
Are associated features of specific psychiatric syndromes
(i.e., pertinent positive or negative factors) present or absent
during the present illness?
What factors does the patient believe are precipitating,
aggravating, or otherwise modifying the illness or are temporally
related to its course?
Did the patient receive prior treatment for this episode
of illness?
Are other clinicians who care for the patient available
to comment?
Past psychiatric history
What is the chronology of past episodes of mental illness,
regardless of whether such episodes were diagnosed or treated?
What are the patient's previous sources of
treatment, and what diagnoses were given?
With respect to somatic therapies (e.g., medications, electroconvulsive
therapy), what were the dose or treatment parameters,
efficacy, side effects, treatment duration, and adherence?
With respect to psychotherapy, what were the type,
frequency, duration, adherence, and patient's perception
of the therapeutic alliance and helpfulness of the psychotherapy?
Is there a history of psychiatric hospitalization?
Is there a history of suicide attempts or aggressive
Are past medical records available to consult?
History of alcohol and other substance use
What licit and illicit substances have been used, in
what quantity, how frequently, and with what pattern and route of
What functional, social, occupational, or legal consequences
or self-perceived benefits of use have occurred?
Has tolerance or withdrawal symptoms been noted?
Has substance use been associated with psychiatric
Are family members available who could provide corroborating information
about the patient's substance use and its consequences?
General medical history
What general medical illnesses are known, including hospitalizations,
procedures, treatments, and medications?
Are undiagnosed illnesses causing major distress or
functional impairment?
Does the patient engage in high-risk behaviors that
would predispose him or her to a medical illness?
Is the patient taking any prescribed or over-the-counter
medications, herbal products, supplements, and/or vitamins?
Has the patient experienced allergic reactions to or
severe adverse effects of medications?
Developmental, psychosocial, and sociocultural
What have been the most important events in the patient's
life, and what were the patient's responses to them?
What is the patient's history of formal education?
What are the patient's cultural, religious,
and spiritual beliefs, and how have these developed or changed over
Is there a history of parental loss or divorce; physical,
emotional, or sexual abuse; or exposure to other traumatic experiences?
What strategies for coping has the patient used successfully
during times of stress or adversity?
During childhood or adolescence, did the patient have
risk factors for any mental disorders?
What has been the patient's capacity to maintain
interpersonal relationships, and what is the patient's
history of marital and other significant relationships?
What is the patient's sexual history, including
sexual orientation, beliefs, and practices?
Does the patient have children?
What past or current psychosocial stressors have affected
the patient (including primary support group, social environment,
education, occupation, housing, economic status, and access to health
What is the patient's capacity for self-care?
What are the patient's sociocultural supports
(e.g., family, friends, work, and religious and other community
What are the patient's own interests, preferences,
and values with respect to health care?
Occupational and military history
What is the patient's occupation, and what
jobs has the patient held?
What is the quality of the patient's work
What work skills and strengths does the patient have?
Is the patient unable to work due to disability?
Regarding military service, what was the patient's
status (volunteer, recruit, or draftee), did the patient experience
combat, and did the patient suffer injury or trauma?
Is the patient preparing for or adjusting to retirement?
Legal history
Does the patient have any past or current involvement
with the legal system (e.g., warrants, arrests, detentions, convictions,
probation, parole)?
Do past or current legal problems relate to aggressive
behaviors or substance intoxication?
Has the patient had other significant interactions
with the court system (e.g., family court, workers' compensation
dispute, civil litigation, court-ordered psychiatric treatment)?
Is past or current legal involvement a significant
social stressor for the patient?
Family history
What information is available about general medical
and psychiatric illnesses, including substance use disorders, in
close relatives?
Is there a family history of suicide or violent behavior?
Are heritable illnesses present in family members that
relate to the patient's presenting symptoms?
Review of systems
Is the patient having difficulty with sleep, appetite,
eating patterns, or other vegetative symptoms, or with pain, neurological symptoms,
or other systemic symptoms?
Does the patient have symptoms that suggest an undiagnosed medical
illness that may be causing or contributing to psychiatric symptoms?
Is the patient experiencing side effects from medications
or other treatments?
Physical examination
What is the appropriate timing, scope, and intensity
of the exam for this patient, and who is the most appropriate examiner?
Upon examination, are there abnormalities in the patient's
general appearance, vital signs, neurological status, skin, or organ systems?
Is more detailed physical examination necessary to
assess the patient for specific diseases?
Mental status examination
What symptoms and signs of a mental disorder is the
patient currently exhibiting?
What are the patient's general appearance
and behavior?
What are the characteristics of the patient's
What are the patient's mood and affect, including
the stability, range, congruence, and appropriateness of affect?
Are the patient's thought processes coherent?
Are there recurrent or persistent themes in the patient's
thought processes?
Are there any abnormalities of the patient's
thought content (e.g., delusions, ideas of reference, overvalued
ideas, ruminations, obsessions, compulsions, phobias)?
Is the patient having thoughts, plans, or intentions
of harming self or others?
Is the patient experiencing perceptual disturbances
(e.g., hallucinations, illusions, derealization, depersonalization)?
What are the patient's sensorium and level
of cognitive function (e.g., orientation, attention, concentration,
registration, short- and long-term memory, fund of knowledge, level
of intelligence, drawing, abstract reasoning, language, and executive
What are the patient's level of insight, judgment,
and capacity for abstract reasoning?
What is the patient's motivation to change
his or her health risk behaviors?
Functional assessment
What are the patient's functional strengths,
and what is the disease severity?
To what degree can the patient perform physical activities
of daily living (e.g., eating, toileting, transferring, bathing,
To what degree can the patient perform instrumental
activities of daily living (e.g., driving, using public transportation,
taking medications as prescribed, shopping, managing finances, keeping house,
communicating by mail or telephone, caring for dependents)?
Would a formal assessment of functioning be useful
(e.g., to document deficits or aid continued monitoring)?
Diagnostic tests
What diagnostic tests are necessary to establish or
exclude a diagnosis, aid in the choice of treatment, or monitor
treatment effects or side effects?
Information derived from the interview process
Are symptoms minimized or exaggerated by the patient
or others?
Does the patient appear to provide accurate information?
Do particular questions evoke hesitation or signs of
Is the patient able to communicate about emotional
How does the patient respond to the psychiatrist's
comments and behaviors?
The history of the present problem or illness is a chronologically
organized history of recent exacerbations or remissions and current
symptoms or syndromes. These may involve descriptions of worries,
changes in mood, suspicions, preoccupations, delusions, or hallucinatory experiences
as well as recent changes in sleep, appetite, libido, concentration,
memory, or behavior, including suicidal or aggressive behaviors.
Information gathered on the pertinent positive and pertinent negative
features of the history of present illness will vary with the patient's
presenting symptoms or syndrome. Temporal features relating to the
onset or exacerbation of symptoms may also be relevant (e.g., onset
after use of exogenous hormones, herbal products, or licit or illicit
substances; variation in symptoms with the menstrual cycle; postpartum
onset). Also pertinent are factors that the patient and other informants
believe to be precipitating, aggravating, or otherwise modifying
the illness. Available details of previous treatments and the patient's
response to those treatments will be delineated as part of the history
of present illness. If the patient was or is in treatment with another
clinician, the effects of that relationship on the current illness,
including transference and countertransference issues, are considered.
Input from members of a clinical team who care for the patient can
be very helpful (Section IV.A.6). For patients seen on medical-surgical
units, it is important to consider the history of both the present
medical-surgical illness and the present psychiatric illness (45).
The past psychiatric history includes a chronological summary
of all past episodes of mental illness, including substance use
disorders, and treatment. The summary includes prior hospitalizations;
suicide attempts, aborted suicide attempts, or other self-destructive
behavior; psychiatric syndromes not formally diagnosed
at the time; previously established diagnoses; treatments offered;
and responses to and satisfaction with treatment. With respect to psychotherapy,
it is important to ascertain the type (e.g., psychodynamic, cognitive,
behavioral, supportive), format (e.g., group, individual, couple),
frequency, duration, patient's perception of the alliance,
and adherence. With respect to medications, the dose, efficacy, side
effects, treatment duration, and adherence are important to ascertain
while understanding that reporting errors are more likely to occur
when treatment involved more than one medication (46). With respect
to other somatic therapies such as electroconvulsive therapy, information
on the number of treatment sessions, treatment course
duration, technical parameters, efficacy, and side effects is similarly
useful to obtain. When past medical records are available and readily
accessible, it is important that they be consulted for ancillary
The chronological summary also delineates the most recent
periods of stability as well as episodes when the patient
was functionally impaired or seriously distressed by mental or behavioral symptoms,
even if no formal treatment occurred. Such episodes frequently can
be identified by asking the patient about the past use of psychotropic
medications prescribed by other clinicians and otherwise unexplained
episodes of social or occupational disability.
The psychoactive substance use history includes past and present
use of both licit and illicit psychoactive substances, including
but not limited to alcohol, caffeine, nicotine, marijuana, cocaine,
opiates, sedative-hypnotic agents, stimulants, solvents, MDMA (methylenedioxymethamphetamine),
androgenic steroids, and hallucinogens (47). Relevant information
includes the quantity and frequency of use and route of administration;
the pattern of use (e.g., episodic versus continual, solitary versus
social); functional, interpersonal, or legal consequences of use;
tolerance and withdrawal phenomena; any temporal association between
substance use and other present psychiatric illnesses; and any self-perceived
benefits of use. It is also important to inquire about prior treatments
for substance use disorders as well as about periods of abstinence,
including their duration, recentness, and factors that aided in
sobriety or contributed to relapse. Obtaining an accurate substance
use history often involves a gradual, nonconfrontational approach
to inquiry that involves asking multiple questions to seek the same information
in different ways and using slang terms for drugs, patterns of use,
and drug effects. Patients are particularly likely to underestimate their
level of substance abuse and their related functional impairments;
corroboration by other family members is useful when possible. It
is also helpful to inquire about patterns of substance use by others
within the family or living constellation. For more extensive discussion
of the assessment of substance use, abuse, and dependence, the reader
is referred to the Center for Substance Abuse Treatment's
and Treatment of Patients With Coexisting Mental Illness and Alcohol
and Other Drug Abuse
(48) and APA's
Guideline for the Treatment of Patients With Substance Use Disorders
The general medical history includes available information
on known general medical illnesses (e.g., hospitalizations, procedures,
treatments, and medications), allergies or drug sensitivities, and
undiagnosed health problems that have caused the patient major distress or
functional impairment. This includes history of any episodes of
important physical injury or trauma; sexual and reproductive history;
and any history of endocrinological, infectious (including but not limited
to HIV, tuberculosis, and hepatitis C) (50), neurological disorders,
sleep disorders (including sleep apnea), and conditions causing
pain and discomfort. Of particular importance is a specific history
regarding diseases and symptoms of diseases that have a high prevalence
among individuals with the patient's demographic characteristics
and backgroundfor example, infectious diseases in users
of intravenous drugs or pulmonary and cardiovascular disease in
people who smoke. Information regarding all current and recent medications,
including hormones (e.g., birth control pills, androgens), over-the-counter
medications, herbal supplements, vitamins, complementary and alternative medical
treatments, and medication side effects, is part of the general
medical history. With all aspects of the general medical history,
obtaining corroborating information (e.g., from medical records,
treating clinicians, family) can be helpful, since ordinary errors
in comprehension, recall, and expression can lead to errors in patient
reports (51).
The personal history reviews the stages of the patient's
life, with special attention to perinatal events, delays in physical
or psychological development, formal educational history, academic
performance, and patterns of response to normal life transitions
and major life events, including parental loss or divorce; physical,
emotional, or sexual abuse; and other trauma such as exposure to
political repression, war, or a natural disaster (52–55).
The childhood and adolescent history of risk factors for later psychiatric
disorders (Table 2) may also be relevant. History of adaptive skills
and strengths to overcome challenges is also relevant.
The patient's capacity to maintain stable and gratifying
interpersonal relationships should be noted, including the patient's
capacities for attachment, trust, and intimacy. A sexual history
is obtained and includes consideration of sexual orientation and
practices, past sexual experiences (including unwanted experiences),
and cultural beliefs about sex (54). The psychosocial history also
determines the patient's past and present levels of interpersonal
functioning in family and social roles (e.g., marriage, parenting)
(56–58). This includes a delineation of the patient's history
of marital and other significant relationships. For patients with
children (including biological, foster, adopted, or stepchildren),
the psychosocial history will include information about these individuals
and their relationship to the patient.
As part of the psychosocial history, past or current stressors
are assessed and include the categories on axis IV of DSM-IV-TR:
primary support group, social environment (e.g., discrimination
and acculturation), education, occupation, housing, economic status,
and access to health care. Specific information obtained in evaluating
psychosocial stressors may include details about patients' living
arrangements, access to transportation, sources of income, insurance
or prescription coverage, and past or current involvement with social
agencies. Assessment of the patient's self-care functioning
may also include consideration of exercise behavior and money management
skills, including gambling behavior.
The sociocultural history delineates the patient's
migration history and past and current sociocultural context of
supports and stressors as well as other important cultural and religious
influences on the patient's life (59). Emphasis is given
to relationships, both familial and nonfamilial, and to religion
and spirituality that may give meaning and purpose to the patient's
life and provide support, as described in the DSM-IV-TR Outline
for Cultural Formulation (described in more detail in Section IV.B.1.a).
Did the patient lose a parent at an early age?
Was there unusual or excessive separation anxiety during
childhood or adolescence?
Were there significant problems with sleep?
Were there eating disturbances?
Were there problems making or keeping friends?
Was severe shyness a problem, including when interacting
in peer groups?
Were there problems with being bullied or bullying?
Were there frequent disciplinary problems in school?
Were there serious difficulties with temper?
Were there many school absences for medical problems
or any other problems?
Were there any delays in learning to read, write, or
do math?
Were there serious problems paying attention, finishing
school work, or completing homework?
Did the above problems lead to grade retention or special
education intervention?
Patients present for a psychiatric evaluation with their own
interests, preferences, and value systems pertaining to health care
practice, and these are another important part of the sociocultural
history. They may involve cultural factors and explanatory models
of illness that affect attitudes, expectations, and preferences
for professional and popular treatments, as described in the DSM-IV-TR
Outline for Cultural Formulation and the 2004 Core Competencies
of the American Board of Psychiatry and Neurology (60). Also important
to the assessment and treatment process are other domains such as
existential, moral, and interpersonal values and social influences such
as school, church, work, and community or other agencies. Attending
to these factors plays a crucial role in developing a therapeutic alliance,
negotiating a treatment plan, determining the outcome criteria for
successful treatment, and enhancing treatment adherence. Belief
systems may also influence the handling of privacy and confidentiality
during the evaluation as well as influence the type and amount of
information disclosed as part of any informed consent process. In
addition, patients' value systems are relevant to clinical
considerations at important life transitions (e.g., job and career
transitions, marital transitions, genetic counseling before or during
pregnancy, end-of-life planning).
The occupational history describes the sequence and duration
of jobs held by the patient, reasons for job changes, and the patient's
current or most recent employment, including quality of work relationships
and whether current or recent jobs have involved shift work, a noxious
or perilous environment, exposure to hazardous materials, unusual
physical or psychological stress, or injury or exposure to trauma
while in the military or hazardous occupations (e.g., fire and rescue,
law enforcement). Work skills and strengths are noted, as well as
the quality of the patient's relationships with co-workers
and work supervisors. Past or current experience with the workers' compensation
system and patterns of recovery or disability following episodes
of illness are also determined (61–64). When appropriate,
a history of preparation for and adjustment to retirement is included.
Relevant data about military experience include volunteer,
recruited, or draftee status; reasons for rejection at time of enlistment
(if relevant); combat exposure (if any); awards; disciplinary actions;
and discharge status.
The legal history includes a description of past or current
involvement with the legal system (65). This may include interactions
with the police without formal arrest as well as involvement with
the juvenile or criminal justice system (e.g., arrests, detentions
including jail or prison confinement). Individuals may be on probation
or parole or may have pending court appearances or active warrants
for arrest that will influence treatment planning. A history of
legal problems relating to aggressive behaviors or occurring in
the context of substance intoxication is similarly relevant. Other
past or current interactions with the court system (e.g., family
court, workers' compensation, civil litigation, court-ordered
psychiatric treatment) may serve as significant stressors for the
patient and are also important to address (55, 66).
The family history includes available information about the
patient's family constellation and the strength of relationships
with family members. Information obtained about close family members,
including parents and, if applicable, siblings, spouse, and children, will
include general information (e.g., current age or age at time of
death, position in sibship, occupation), quality of relationship
to the patient, and health status. General medical and psychiatric
illness in close relatives is noted, including disorders that may
be familial or may strongly affect the family environment. A history
of adoption or foster care or disruptions in the family environment
because of divorce, remarriage, prolonged absences of family members
(e.g., occupational absences, hospitalization, incarceration), or
deaths may be useful to elicit. Family history information will
also consist of any history of psychiatric hospitalizations, illness,
or significant symptoms, including suicide and attempted suicide in
first- and second-degree relatives. More specific questions are
important to ask depending on the patient's clinical presentation,
given the heritability of psychosis; mood disorders; anxiety disorders;
cognitive disorders; learning disabilities; developmental disabilities,
including autism, hyperactivity, or attention deficit disorder;
substance use disorders; and antisocial behavior. For family members
who have experienced psychiatric symptoms, it is helpful to learn
the treatment received and their response to treatment. It is also
important to determine first- and second-degree relatives' history
of medical disorders (67), particularly those with relevance to
psychiatric illness and treatment, such as cardiac, neurological,
and endocrine disorders. If family health problems are current,
this may contribute psychological or financial stresses for the
Construction of a formal pedigree or genogram is often helpful
in delineating family relationships and identifying a family history
of illness. The web sites of the American Medical Association (68),
the American Society of Human Genetics (69), and the March of Dimes (70)
provide additional details on the drawing of pedigrees.
The review of systems includes current symptoms not already
identified in the history of the present illness. If not already
addressed in the history of present illness, sleep, appetite, eating
patterns, vegetative symptoms of mood disorder, pain and discomfort,
systemic symptoms such as fever and fatigue, and neurological symptoms
are also relevant. In addition, common symptoms of diseases for
which the patient is known to be at particular risk because of historical,
genetic, environmental, or demographic factors are an important
part of the review of systems. Special attention should be given
to typical side effects observed with prescribed or over-the-counter
medications and other treatments, including complementary or alternative
therapies, that the patient is receiving.
Evaluation of the patient's general medical status
necessitates that a physical examination be performed. Although
the process of the physical examination is described more fully
in Section IV.A.5, specific elements assessed as part of the physical
examination may include the following:
General appearance,
height, weight, body mass index (BMI), and nutritional status
Vital signs
Head and neck, heart, lungs, abdomen, and extremities
Neurological status, including cranial nerves, motor
and sensory function, gait, coordination, muscle tone, reflexes,
and involuntary movements
Skin, with special attention to any stigmata of trauma,
self-injury, or drug use
Any body area or organ system that is specifically mentioned
in the history of the present illness or review of systems or that
is relevant to determining the current status of problems mentioned
in the past medical history
Additional items may be added to the examination to address
specific diagnostic concerns or to screen a member of a clinical
population at risk for a specific disease. For example, an individual
with mental retardation might be assessed for the physical characteristics
of a recognized syndrome.
The purpose of the mental status examination is to obtain
evidence of symptoms and signs of mental disorders, including dangerousness
to self and others, that are present at the time of the interview.
Further, evidence is obtained regarding the patient's insight,
judgment, and capacity for abstract reasoning to inform decisions
about treatment strategy and the choice of an appropriate treatment
setting. Thus, the mental status examination is a systematic collection
of data based on observation of the patient's behavior
while the patient is in the psychiatrist's view during,
before, and after the interview. During the mental status examination,
the patient might also mention past symptoms and signs, but these
should be recorded under the history of the present illness.
Responses to specific questions are an important part of the
mental status examination (71, 72), particularly in the assessment
of cognition. Consequently, in recording the findings of the mental
status examination, it is useful to include examples that illustrate
the clinical observations. For example, it would be preferable to
note that the patient exhibited poor judgment in precipitously attempting
to remove his intravenous line rather than simply describing the
patient's judgment as impaired.
Although its precise organization may vary, the mental status
examination typically contains the following elements:
and general behavior.
In describing the patient's
appearance, factors such as approximate age, body habitus, dress,
grooming, hygiene, and distinguishing features (e.g., scars, tattoos)
may be noted. The patient's general behavior, level of
distress, degree of eye contact, and attitude toward the interviewer
are also considered.
Motor activity. The
patient's level of psychomotor activity is noted, as is
the presence of any gait abnormalities or purposeless, repetitive,
or unusual postures or movements (e.g., tremors, dyskinesias, akathisia,
mannerisms, tics, stereotypies, catatonic posturing, echopraxia,
apparent responses to hallucinations).
Speech. Characteristics
of the patient's speech are described and may include consideration
of rate, rhythm, volume, amount, accent, inflection, fluency, and
Mood and affect. The
patient's expressions of mood and affect are noted. Although
the use and definitions of the terms mood and affect vary,
mood is typically viewed as referring to the patient's
internal, subjective, and more sustained emotional state, whereas
affect relates to the patient's externally observable and more
changeable emotional state (71, 73). Affect is often described in
terms of its range, intensity, stability, appropriateness, and congruence
with the topic being discussed in the interview.
Thought processes. Features
of the patient's associations and flow of ideas are described,
such as vagueness, incoherence, circumstantiality, tangentiality,
neologisms, perseveration, flight of ideas, loose or idiosyncratic
associations, and self-contradictory statements.
Thought content. The
patient's current thought content is assessed by noting
the patient's spontaneously expressed worries, concerns,
thoughts, and impulses, as well as through specific questioning
about commonly observed symptoms of specific mental disorders. These
symptoms include delusions (e.g., erotomania or delusions of persecution,
passivity, grandeur, infidelity, infestation, poverty, somatic illness,
guilt, worthlessness, thought insertion, thought withdrawal, or
thought broadcasting), ideas of reference, overvalued ideas, ruminations,
obsessions, compulsions, and phobias. Assessment of suicidal, homicidal,
aggressive, or self-injurious thoughts, feelings, or impulses is
essential for determining the patient's level of risk to
self or others as part of the clinical formulation. If such features
are present, details are elicited regarding their intensity and
specificity, when they occur, and what prevents the patient from
acting on them (11, 74–79).
Perceptual disturbances. Hallucinations
(i.e., a perception in the absence of a stimulus) and illusions
(i.e., an erroneous perception in the presence of a stimulus) may
occur in any sensory modality (e.g., auditory, visual, tactile,
olfactory, gustatory). Other perceptual disturbances that patients may
experience include depersonalization and derealization.
Sensorium and cognition. Systematic
assessment of cognitive functions is an essential part of the general
psychiatric evaluation, although the level of detail necessary and
the appropriateness of particular formal tests will depend on the
purpose of the evaluation and the psychiatrist's clinical judgment.
Evaluation of the patient's sensorium includes a description
of the level of consciousness and its stability. Elements of the
patient's cognitive status that may be assessed include
orientation (e.g., person, place, time, situation), attention and
concentration, and memory (e.g., registration, short-term, long-term).
Arithmetic calculations may be used to assess concentration or knowledge;
other aspects of the patient's fund of knowledge may also
be assessed as appropriate to sociocultural and educational background.
Additional aspects of the cognitive examination may include assessment
of level of intelligence, language functions (e.g., naming, comprehension,
repetition, reading, writing), drawing (e.g., copying a figure or
drawing a clock face), abstract reasoning (e.g., explaining similarities or
interpreting proverbs), and executive functions (e.g., list making,
inhibiting impulsive answers, resisting distraction, recognizing
Insight. The patient's
insight into his or her current situation is typically assessed
by inquiring about the patient's awareness of any problems
and their implications. Patients may or may not recognize that psychosis
or other symptoms may reflect an underlying illness or that their
behavior affects their relationships with other individuals. They
also may or may not recognize the potential benefits of treatment.
Another element of insight involves the patient's motivation
to change his or her health risk behaviors. Such motivation often
fluctuates over time from denial and resistance to ambivalence to
commitment, a sequence that has been referred to as "stages
of change" (80–82). The stages, which are not
necessarily discrete, have been labeled precontemplation (denial,
minimization); contemplation (musing
or thinking about doing something); preparation (actually
getting ready to do something); action (implementing
concrete actions to deal with the problem); and maintenance (acting
to ensure that the changes are maintained) (83). Patients who are
not quite ready to change may vacillate about modifying their behaviors
before actually committing to change and acting on it. Assessing
stages of change as part of the evaluative process leads to stage-appropriate
educational and therapeutic interventions that attempt to help patients move
to more adaptive stages in a patient-centered manner (84–86).
Judgment. The quality
of the patient's judgment has sometimes been assessed by
asking for the patient's responses to hypothetical situations
(e.g., smelling smoke in a theater). However, in assessing judgment,
it is generally more helpful to learn about the patient's
responses and decision making in terms of his or her own self-care,
interactions, and other aspects of his or her recent or current
situation and behavior. If poor judgment is present, a more detailed explication
of the patient's decision-making processes may help differentiate
the potential causes of this impairment.
The psychiatrist's primary assessment tool is the
direct face-to-face interview of the patient. Evaluations based
solely on review of records and interviews of persons close to the patient
are inherently limited by a lack of the patient's perspective.
Furthermore, the clinical interview provides the psychiatrist with
a sample of the patient's interpersonal behavior and emotional
processes. It can either support or qualify diagnostic inferences
from the history and can also aid in prognosis and treatment planning.
Important information can be derived by observing the patient's
general style of relating, the ways in which the patient minimizes
or exaggerates certain aspects of his or her history, and whether
particular questions appear to evoke hesitation or signs of discomfort.
Additional observations concern the patient's ability to
communicate about emotional issues, the defense mechanisms the patient
uses when discussing emotionally important topics, and the patient's
responses to the psychiatrist's comments and to other behavior, such
as the psychiatrist's handling of interruptions or time
The interview should be done in a manner that facilitates
the patient's telling of his or her story, while simultaneously
obtaining the necessary information. Time constraints need to be
considered and adequate time allowed for the interview. High-priority
tasks include an assessment of the patient's safety and
the identification of signs, symptoms, or disorders requiring urgent treatment.
Opening with a discussion of the purpose of the interview
offers the patient an understanding of the process. Empirical studies
of the interview process suggest that the most comprehensive and
accurate information emerges from a combination of 1) open-ended
questioning with empathic listening and 2) structured inquiry about
specific events and symptoms (87–92). When the purpose
is a general evaluation, beginning with open-ended, empathic inquiry
about the patient's concerns usually is best. Attention
to the patient's most pressing concerns, whenever possible,
will improve the therapeutic alliance and is likely to facilitate
increased patient cooperation; other inquiries may be
more limited initially in the service of the alliance. Patient satisfaction
with open-ended inquiry is greatest when the psychiatrist provides
feedback to the patient at multiple points during the interview.
Structured, systematic questioning has been shown to be especially
helpful in eliciting information about substance use and traumatic
life events and in ascertaining the presence or absence of specific
symptoms and signs of particular mental disorders (93–102)
(Section IV.A.3).
Throughout the interview, useful clinical information is obtained
by being sensitive to issues of development, culture, race, ethnicity,
primary language, health literacy, disabilities, gender, sexual
orientation, familial/genetic patterns, religious and spiritual
beliefs, social class, and physical and social environment influencing
the patient's symptoms and behavior. Respectful evaluation
involves an empathic, nonjudgmental attitude and appropriate responses
concerning the patient's cultural identity, his or her
own explanation of illness and treatment pathways, sociocultural
stressors and supports, and modes of interpersonal communication,
both verbal and nonverbal. An awareness of one's possible biases
or prejudices about patients from different subcultures and an understanding
of the limitations of one's knowledge and skills in working
with such patients may help one determine when it is advisable to
consult with a clinician who has expertise concerning a particular
subculture (103–105).
When available, professionally trained interpreters with mental
health experience should be used for encounters involving patients
with limited English proficiency and those who are deaf or have
severely limited hearing and who prefer to communicate using sign
language (106, 107). Bilingual and bicultural staff may also be
helpful (108). With cooperative patients, over-the-phone language
interpretation services can be used when other professionally trained
interpreters are unavailable, although establishing rapport with
the patient may be more difficult. Family members, community members,
or friends should not be used unless the patient refuses to use
the professional interpreter or under emergency circumstances, in
which case this should be noted in the patient record. The interpreter
should be instructed to translate the patient's own words
and to avoid paraphrasing except as needed to translate the correct
meaning of idioms and other culture-specific expressions (109–111).
When evaluating individuals who are agitated or aggressive,
the psychiatrist needs to give consideration to the patient interview
as well as to his or her own safety (13, 77, 112–116).
Establishing the presence of backup personnel and choosing an appropriate
space in which to conduct the interview are useful preparations
before meeting with an agitated or aggressive patient. Because such
individuals may become more agitated if they feel trapped within
a small room or are too closely positioned to the interviewer, a
distance of several arms' length from the patient, with
both psychiatrist and patient having access to the door, is generally
optimal. A safe office environment should not contain potentially
dangerous objects (e.g., decorative items), and the clinician should
avoid clothing that can be used against him or her (e.g., neckties,
scarves, prominent dangling earrings). Depending on the configuration
of the office or interview room and its proximity to other staff,
a mechanism for summoning assistance (e.g., a panic button) may
also be indicated.
During the interview, a nonconfrontational and straightforward
approach is often most effective. Attending to the patient's
comfort, using reflective or active listening techniques, and showing
respect for the patient's feelings and stated concerns
may aid in establishing rapport. The key to calming an aggressive
patient is affect management. Patients who are affectively aroused will
need to ventilate their feelings, and the clinician should allow
the patient to tell his or her own story. Logical or rational responses
to an affectively flooded individual may further inflame the patient.
Affect management involves acknowledging the patient's
affect, validating the affect when appropriate, and encouraging
the patient to talk about his or her feelings (116).
In some circumstances, it may be appropriate to set limits
(e.g., noting that aggressive behavior cannot be permitted) while
simultaneously emphasizing the need to attend to the safety of the
patient and others. Throughout the interview, the clinician needs
to be alert for signs that the patient's agitation is escalating
(e.g., increased body movements or pacing, clenched fists, verbal
threats, or increasing verbal volume); such signs may indicate a
need to adjust the interview style or timing. At times, it will
be best to postpone in-depth history taking or discussion of distressing
topics that are not germane to the patient's current presentation.
In some instances, administration of psychotropic medications
or judicious use of seclusion or restraint may be necessary to enhance
the safety of the patient and others (114) or to permit essential
physical examination, laboratory studies, or other diagnostic assessment.
Reliance on such measures should be justified by the urgency of
obtaining the diagnostic information and should be in compliance
with applicable laws and regulations. The psychiatrist should consider
how any special circumstances of the interview or examination may
influence clinical findings. When the patient is able to cooperate,
parts of the examination that cannot be completed or that are significantly
influenced by the use of medication, seclusion, or restraint should
be repeated if possible.
Guidelines for reducing the use of seclusion and restraint
while at the same time maintaining the safety of patients and staff
are available in a report developed by the APA with the American
Psychiatric Nurses Association and the National Association of Psychiatric Health
Systems (117). Recommendations of the report include assessing for
anger management problems, identifying risk factors (e.g., pregnancy,
asthma, head or spinal injury) before using restraint, identifying
triggers, involving patients in treatment planning, asking patients
about past experiences of seclusion and restraint, involving family,
and documenting interventions attempted before using seclusion or
Family members, other important people in the patient's
life, and records of prior medical and psychiatric treatment are
frequently useful sources of information. Collateral information
is particularly important when patients have impaired insight, including
when patients have substance use disorders or cognitive impairment,
and is essential for treatment planning when patients require a
high level of assistance or supervision because of impaired function
or unstable behavior. Family members and others who know the patient well
may provide important information about the patient's personality
before the onset of illness, since the patient's own account
may be unduly influenced by his or her mental state. Collateral
sources of information may also provide essential information about
the illness course (Section III.C), the current symptoms and behavior
(Section III.B), and the reasons for the evaluation (Section III.A).
The extent of the collateral interviews and the extent of prior
record review should be commensurate with the purpose of the evaluation,
the complexity of the clinical presentation, and the diagnostic and
therapeutic goals. For example, in an acute inpatient or emergency
setting, collateral information may be crucial to developing an
understanding of the patient's clinical condition, whereas
in long-term outpatient psychotherapy the impact on the treatment
process of obtaining collateral information from family or others
needs to be considered. Except when immediate safety concerns are
paramount, the confidentiality of the patient should be respected. At
the same time, it is permissible for the psychiatrist to listen
to information provided by family members and other important people
in the patient's life, as long as confidential information
is not provided to the informant (Sections I.A, I.B, II.C, and V.A).
Structured interviews, standardized data forms, questionnaires,
and rating scales can be useful tools for diagnostic assessment
and evaluation of treatment outcome. Table 3, while not all-inclusive,
lists many of the common structured instruments in use (see also
the CD-ROM from APA's
Handbook of Psychiatric
[118]). Such structured
instruments may be used as components for establishing a diagnosis,
measuring social or occupational function, or monitoring changes
in symptom severity or side effects over time during treatment.
Administration (Time)
Clinical Use
Quality of
Quality of Life Enjoyment & Satisfaction Questionnaire
Self-administered questionnaire; short (16-item; 5
min) or long (60-item; 15 min) format
Assessment of degree of enjoyment and satisfaction in
various areas of daily life
Endicott J, Nee J, Harrison W, et al: Quality of Life Enjoyment
and Satisfaction Questionnaire: a new scale. Psychopharmacol
Bull 29:321–326, 1993
Jean Endicott, Ph.D.; Dept. of Research Assessment
and Training, New York State Psychiatric Institute, Unit 123; 1051
Riverside Drive; New York, NY 10032; ph 212-543-5536
Mental health
status and functioning
Clinical Global Impression (CGI) Scale
Clinician-rated scale (1–2 min after clinical information
is obtained)
Global assessment of response to medication treatment
Guy W, Bonato RR (eds): Manual for the ECDEU Assessment
Battery, revised 2nd ed. Chevy Chase, Md, National Institute
of Mental Health, 1970, pp 12.1–12.6
Guy W: ECDEU Assessment Manual for Psychopharmacology, revised
ed. Washington, DC, US Department of Health, Education, and Welfare,
1976; APA (2000) Handbook of Psychiatric Measures
Global Assessment of Functioning (GAF) Scale
Clinician-rated scale, ranked 0–100 (1–2 min
after clinical information is obtained)
Assessment of patient functioning, monitoring
of change, and selection of patients suitable for short-term treatment
American Psychiatric Association: DSM-IV-TR
Social and Occupational Functioning Assessment Scale
Assessment of patient social and occupational functioning
and monitoring of change
Adverse effects
Abnormal Involuntary Movement Scale (AIMS)
Observer-rated 12-item anchored scale (5–10 min)
Assessment of patients who may have involuntary movement
disorders (from antipsychotic medications) and
may have tardive dyskinesia
Guy W (ed): ECDEU Assessment Manual for Psychopharmacology, revised
ed. DHEW Publ No ADM 76-338. Washington, DC, US Department of Health,
Education, and Welfare, 1976
Guy 1976; APA (2000) Handbook of Psychiatric Measures
Rating Scale for Extrapyramidal Side Effects or Simpson-Angus
Extrapyramidal Symptom Rating Scale
Observer-rated 10-item anchored scale (10 min)
Assessment of dose-limiting side effects when antipsychotic
medications are initiated, titrated, and monitored and effectiveness
of anticholinergic or other agents in the treatment of extrapyramidal
side effects
Simpson GM, Angus JWS: A rating scale for extrapyramidal
side effects. Acta Psychiatr Scand Suppl 1970; 212:11–19
APA (2000) Handbook of Psychiatric Measures
Delirium Rating Scale Revised–98 (DRS–R98)
Clinician-administered structured exam (15–30
Assessment of a broad range of delirium symptoms: the 16-item
scale can be used to diagnose delirium; the 13-item severity subscale can
be used to rate symptom severity
Trzepacz PT et al: Validation of the Delirium Rating ScaleRevised–98: comparison
with the Delirium Rating Scale and the Cognitive Test for Delirium.
J Neuropsychiatry Clin Neurosci 2001; 13:229–242;
erratum, 2001; 13:433
© Paula T. Trzepacz, M.D., Lilly Research Laboratories,
Indianapolis, IN 46285; firstname.lastname@example.com
Mini-Mental State Examination (MMSE)
Clinician-administered 30-item structured scale (5–10
Detecting and tracking the progression of cognitive impairment
associated with neurogenerative diseases
Folstein MF et al: "Mini-Mental State":
a practical method for grading the cognitive state of patients for
the clinician. J Psychiatr Res 1975; 12:189–198
Administrator of the Mini-Mental LLC, 31 St. James Avenue,
Suite 1, Boston, MA 02116; ph 617-587-4215; APA (2000)
of Psychiatric Measures
Alcohol use
CAGE Questionnaire
Self-report or observer-rated 4-item questionnaire
(<1 min)
Screening for alcohol problems
Ewing JA: Detecting alcoholism: The CAGE questionnaire.
Mood disorders
Beck Depression Inventory, 2nd Revision (BDI-II)
Self-report or observer-rated 21-item questionnaire,
ranked on a 0–3 scale (5–10 min)
Assessment of severity of depressive symptoms in patients
with diagnosed depressive illness and monitoring of treatment effects
Beck AT et al: An inventory for measuring depression. Arch
Gen Psychiatry 1961; 4:561–571
Harcourt Assessment, Inc., 19500 Bulverde Road, San Antonio,
TX 78259; ph 800-211-8378; http://harcourtassessment.com/haiweb/Cultures/en-US/default.htm
Hamilton Depression Rating Scale (Ham-D)
Observer-rated 21- or 17-item checklist, ranked on
a 0–4 or 0–2 scale (15–20 min)
Assessment of severity of depressive symptoms in patients
with primary depressive illness and monitoring changes with treatment
Hamilton M: A rating scale for depression.
J Neurol Neurosurg Psychiatry 1960; 23:56–62
Guy W: ECDEU Assessment Manual for Psychopharmacology, revised
ed. DHEW Publ No ADM 76-338. Washington, DC, US Department of Health,
Education, and Welfare, 1976
Quick Inventory of Depression SymptomatologySelf-Report
Self-report 16-item scale including the nine domains
of major depressive disorder (5–7 min)
Assessment of depressive symptom severity and symptomatic
changes in a time efficient manner to gauge effects of treatment
Rush AJ et al: The 16-Item Quick Inventory of Depressive Symptomatology
(QIDS), Clinician Rating (QIDS-C), and Self-Report (QIDS-SR): a
psychometric evaluation in patients with chronic major depression. Biol
Psychiatry 2003; 54:573–583; erratum, 2003; 54:585
Trivedi MH et al: The Inventory of Depressive Symptomatology,
Clinician Rating (IDS-C) and Self-Report (IDS-SR), and the Quick
Inventory of Depressive Symptomatology, Clinician Rating (QIDS-C)
and Self-Report (QIDS-SR) in public sector patients with
mood disorders, a psychometric evaluation. Psychol Med 2004; 34:73–82
Patient Health Questionnaire (PHQ-9)
Self-report, clinician-scored 9-item questionnaire
ranked on 0–3 scale and scored 0–27 (<2 min)
Assessment of DSM-IV depressive disorder diagnoses
and grading of depressive symptom severity
Copyright 1999 Pfizer, Inc. http://www.pfizer.com/pfizer/phq-9/index.jsp; http://www.depressionprimarycare.org/clinicians/toolkits/materials/
Geriatric Depression Scale (GDS)
Self-report 30-item scale (10–15 min)
Screening for depressive illness in geriatric patients, assessment
of severity, and monitoring change with treatment
Yesavage JA et al: Development and validation of a
geriatric depression screening scale: a preliminary report. J Psychiatr
Res 1982; 17:37–49
Yesavage et al. 1982; APA (2000)
of Psychiatric Measures
Young Mania Rating Scale (YMRS)
Clinician-administered 11-item checklist, ranked on
a 0–4 or 0–8 scale (15–30 min)
Assessment of the severity of mania and evaluation
of changes in manic symptoms with treatment over time
Young RC et al: A rating scale for mania: reliability, validity
and sensitivity. Br J Psychiatry 1978; 133:429–435
Young et al 1978; APA (2000)
of Psychiatric Measures
Anxiety disorders
Hamilton Anxiety Rating Scale (HARS)
Clinician-administered 14-item scale, with items ranked
0–5 (15–30 min)
Assessment of the severity of overall anxiety in patients with
diagnosed anxiety or depressive disorders and monitoring outcome
of treatment
Hamilton M: The assessment of anxiety states by rating. Br
J Med Psychol 1959; 32:50–55
Hamilton 1959; Anxiety Disorders Prevention Program,
Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Pittsburgh,
Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
Clinician-administered semistructured interview (30
min initially)
Assessment of overall obsessive-compulsive disorder
severity and monitoring change with treatment
Goodman WK et al: The Yale-Brown Obsessive Compulsive
Scale, I: development, use, and reliability. Arch Gen Psychiatry
1989; 46:1006–1011
University of Florida, College of Medicine, Department
of Psychiatry, P.O. Box 100256, 1600 SW Archer Road, Gainesville,
FL 32610; APA (2000) Handbook of Psychiatric Measures
Brief Psychiatric Rating Scale (BPRS)
Clinician-rated 18-item scale, ranked 1–7
(20–30 min)
Global assessment of response to treatment in patients
with moderate to severe psychotic disorders
Overall JE, Gorham DR: The Brief Psychiatric Rating Scale:
recent developments in ascertaining and scaling. Psychopharmacol
Bull 1988; 24:97–99
Overall and Gorham, http://www.psychrehab.com; APA
(2000) Handbook of Psychiatric Measures
Positive and Negative Syndrome Scale (PANSS)
Clinician-rated 3-subscale, 5-factor, 30-item scale
rated based on information from a structured interview (30–40
min) and informant information
Assessment of severity of common symptoms
in patients with schizophrenia and other psychotic disorders, delineation
of target symptoms, and monitoring of treatment response
Kay SR et al: Positive and Negative Syndrome Scale (PANSS)
Rating Manual. Toronto, ON, Multi-Health Systems, 2000
Multi-Health Systems, Inc., P.O. Box 950, North Tonawanda,
NY 14120-0950; ph 800-456-3003; fax 888-540-4484; http://www.mhs.com
and agitation
Overt Aggression ScaleModified (OAS-M)
Clinician-administered 25-item scale with 9 subscales
and rating three areas, aggression, irritability, and suicidality
(30 min)
Assessment of aggressive behaviors, delineation of target
symptoms, and monitoring of change over time
Coccaro E et al: Development of neuropharmacologically based behavioral assessments
of impulsive behavior. J Neuropsychiatry Clin Neurosci
1991; 3(suppl):S44–S51
Emil Coccaro, M.D., Department of Psychiatry, Medical
College of Pennsylvania, Eastern Pennsylvania Psychiatric Institute,
3200 Henry Avenue, Philadelphia, PA 19129; APA (2000)
of Psychiatric Measures
Source. Information
in this table was derived from APA's
of Psychiatric Measures
Although most commonly used in psychiatric research, rating
scales may also help psychiatrists structure a thorough line of
questioning. In addition, self-report scales may be valuable in
opening communication with patients about their symptoms, feelings,
or experiences. At the same time, these tools vary considerably
as to their reliability and validity. Potential cultural, ethnic,
gender, social, and age biases are relevant to the selection of
standardized interviews and rating scales and the interpretation
of their results (119–125). Furthermore, clinical impressions
of treatment response should consider the relative importance of
specific symptoms to the patient's function and well-being
and the relative impact of specific symptoms on the patient's
social environment. Consequently, rating scales should never be
used alone to establish a diagnosis or clinical treatment plan;
they can augment but not supplant the clinician's evaluation,
narrative, and clinical judgment (11, 126–129).
For persons with chronic diseases, and particularly those
with multiple comorbid conditions, structured assessment of physical
and instrumental function may be useful in assessing strengths and
disease severity (130). Functional assessments include assessment
of physical activities of daily living (e.g., eating, using the
toilet, transferring, bathing, and dressing) and instrumental activities
of daily living (e.g., driving or using public transportation, taking
medication as prescribed, shopping, managing one's own
money, keeping house, communicating by mail or telephone, and caring
for a child or other dependent) (131, 132). Impairments in these
activities can be due to physical or cognitive impairment or to
the disruption of purposeful activity by the symptoms of mental
Formal assessment of physical and instrumental activities
of daily living may be appropriate for patients who are disabled
by old age or by chronic mental illness or general medical conditions.
Such assessments facilitate the delineation of the combined effects
of multiple illnesses and chronic conditions on patient's
lives, and such assessments provide a severity measure that is congruent
with patients' and families' experience of disability.
In addition, functional assessment facilitates the monitoring of
treatment by assessing important beneficial and adverse effects
of treatment.
Laboratory tests are included in a psychiatric evaluation
when they are necessary to establish or exclude a diagnosis, to
aid in the choice of treatment, or to monitor treatment effects
or side effects (16, 133–144). When laboratory tests are
obtained, relevant test results are documented in the evaluation,
with their importance for diagnosis and treatment indicated in the
clinical formulation or treatment plan.
Diagnostic tests used during a psychiatric evaluation include
those that do the following:
Detect or rule out the
presence of a disorder or condition that has treatment consequences.
Examples include urine screens for substance use disorders, neuropsychological
tests to ascertain the presence of a learning disability, and brain
imaging tests to ascertain the presence of a structural neurological
Determine the relative safety and appropriate dose of
potential alternative treatments. For example, tests of hematological,
thyroid, renal, and cardiac function in a patient with bipolar disorder
may be needed to help the clinician choose among available mood-stabilizing
medications (145), or evaluation of cardiac or pulmonary function
may be important in determining a patient's medical status
prior to electroconvulsive therapy (146).
Provide baseline measurements before instituting treatment,
with subsequent measurements used to assess for effects of treatment.
For example, baseline and follow-up electrocardiograms may be required
to identify effects of antipsychotic or tricyclic antidepressant
medications on cardiac conduction, whereas baseline and follow-up glucose
levels and lipid panels may be required to identify effects of second-generation
antipsychotic agents.
Monitor blood levels of medications when indicated (e.g.,
for effectiveness, toxicity, or adherence).
Under each of these circumstances, the potential utility of
a test will be determined by multiple interrelated factors, including
the following:
The likelihood that
an individual from a population of similar patients (e.g., of similar age,
gender, treatment setting) would have the condition. This probability
is also referred to as the prevalence of
the condition in that population. In general, conditions that are
more prevalent in the population are more likely to be correctly
identified by use of a diagnostic test. In the context of obtaining
baseline measurements, the likely prevalence of the condition at
a later date may also be relevant.
The probabilities that the test will correctly detect
a condition that is present (true positive), incorrectly identify
a condition as present when it is not (false positive), correctly
identify a condition as absent (true negative), or incorrectly identify
a condition as absent when it is actually present (false negative).
Although information about these probabilities is available for
many tests, the key point to consider in clinical practice is that
false negative and false positive test results do occur. Furthermore,
incorrect identification of a condition can result in unnecessary
and potentially detrimental evaluations and interventions; incorrectly
viewing a condition as absent can lead to other crucial signs and
symptoms of the condition being ignored.
The treatment implications of the test results. Obviously,
a test will be of benefit if it correctly detects a previously unidentified
and treatable condition. However, the treatment implications may
be nil if the test correctly detects a condition that is already known
to be present on the basis of clinical examination or history or
if it correctly detects a benign or incidental condition that leads
to further unnecessary testing with no beneficial effect on treatment.
Given the wide range of clinical situations evaluated by psychiatrists,
there are no specific guidelines about which tests should be "routinely" done.
It is important to have a clear rationale for the ordering of tests
(12, 23, 26), and each patient should be considered individually.
Nevertheless, some general principles may aid in deciding on particular
diagnostic assessments. For example, tests may be ordered on the
basis of the setting (e.g., some patients seen in emergency departments
may be at increased risk for certain conditions that warrant diagnostic
tests), the clinical presentation (e.g., certain tests are warranted
for patients with new onset of delirium), or the potential treatments
(e.g., patients may need certain tests before initiation of lithium
therapy). For tests that require the patient's participation,
factors such as language, education level, intelligence, culture,
and level of alertness can affect the testing process and may influence
the choice of diagnostic approaches. Patient preferences are also
important to consider. Furthermore, the potential benefits of identifying
and treating a particular condition need to be weighed against the
costs (e.g., time, money, physical pain, emotional stress) of indiscriminate
More detail on the use of laboratory testing to aid in diagnosis
and to guide treatment is provided in APA practice guidelines for
specific disorders. Table 4 provides examples of and general indications
for tests that may be indicated depending on the status of the patient.
Basic laboratory tests (e.g., complete blood count; blood
chemistries, including lipid profile, B12,
folate; urinalysis)
Used to screen for general medical conditions or provide baseline
measures prior to treatment. Recommended frequency of screening
may vary with health status and with specific ongoing treatments
(e.g., second-generation antipsychotics, lithium).
Medication levels
Used to monitor therapeutic levels of medications.
Pregnancy test
Some psychiatric conditions and treatments may entail
risks to a pregnant woman or her fetus.
Fasting blood glucose or hemoglobin A1c
Used to diagnose diabetes or help determine risk. Patients prescribed
second-generation antipsychotics may be at increased risk of developing
Lyme serology, syphilis serology, HIV test
May assist in evaluation of cognitive and behavioral changes.
Individuals with behavioral problems such as impulsivity or drug
use may be at increased risk for HIV infection.
Thyroid function tests
May be important for patients with suspected mood disorder, anxiety
disorder, or dementia. Used to monitor lithium effects.
Toxicology screen, blood alcohol level
Used to screen for substance use or abuse. Individuals
with a mental disorder are at increased risk for substance abuse.
Used to assess effects of medications that may influence cardiac
conduction (e.g., tricyclic antidepressants, some antipsychotics).
May also be indicated depending on age and health status.
Chest X ray
Used to diagnose cardiopulmonary disorders (e.g., pneumonia,
tuberculosis) that may contribute to delirium. May also be part
of a pre-ECT evaluation depending on age and health status.
Imaging studies
Structural (e.g., computed tomography [CT],
magnetic resonance imaging [MRI]) and functional
(e.g., positron emission tomography [PET], single
photon emission computed tomography [SPECT], electroencephalogram [EEG],
functional magnetic resonance imaging [fMRI]) studies
may indicate regional brain abnormalities related to a psychiatric
illness and its management.
Lumbar puncture
Used to diagnose central nervous system infection (e.g., meningitis,
herpes, toxoplasmosis, syphilis, Lyme disease). May be important
for differential diagnosis of delirium.
Used to diagnose sleep disorders, including sleep apnea. May
be important for differential diagnosis of depression, psychosis,
or other cognitive or behavioral changes.
Psychological testing
May be requested when cognitive deficits are suspected
or there is need to grade for severity or progression of symptoms
over time. May also be helpful in establishing a diagnosis (e.g.,
dementia, mental retardation) or in delineating specific deficits
that affect thought processes, treatment, or vocational planning.
Neuropsychological testing has a broad range of application,
but the decision to order neuropsychological testing for an individual
patient remains a matter of clinical judgment (147). Neuropsychological
testing may be requested when cognitive deficits are suspected or
there is a need to grade for severity or progression of deficits
over time. In addition, neuropsychological testing can be helpful
in distinguishing between cognitive disorders and malingering or
factitious disorders. When patients present later in life with the
new onset of psychosis or mood disorder accompanied by cognitive
deficits, neuropsychological testing may also be helpful in distinguishing
dementia from other psychiatric syndromes. In research studies,
typical patterns of cognitive deficits have been identified in a
variety of psychiatric disorders, including Alzheimer's
disease (148), schizophrenia (149–151), bipolar disorder
(152–156), major depressive disorder (157–160),
and autism (161, 162). Findings have highlighted the fact that cognitive
deficits and associated impairment of social and occupational functioning
may persist despite successful treatment of other core symptoms
of an illness. For example, executive dysfunction may persist in
otherwise responsive depression (163), and working memory may remain impaired
in schizophrenia independent of response of positive and negative
symptoms (149, 164). Thus, for some patients, a better understanding
of persistent neuropsychological impairments can aid in treatment
and vocational planning.
An understanding of the patient's general medical
condition is important in order to 1) properly assess the
patient's psychiatric symptoms and their potential cause, 2) determine
the patient's need for general medical care, and 3) choose
among psychiatric treatments that can be affected by the patient's
general medical status (16, 22, 25, 26, 34, 144, 165, 166). The
psychiatrist also ensures that a recent medical workup with appropriate laboratory
tests and monitoring is performed. The psychiatrist should be informed
about the results of the medical workup and incorporate this information
into the evaluation. The psychiatrist's close involvement
in the patient's general medical evaluation and ongoing
care can also improve the patient's care by promoting cooperation,
facilitating follow-up, and permitting prompt reexamination of symptomatic
areas when symptoms change.
The physical examination may be performed by the psychiatrist,
another physician, or a medically trained clinician. Considerations
influencing the decision of whether the psychiatrist will personally
perform the physical examination include potential effects on the
psychiatrist-patient relationship, the purposes of the evaluation,
and the complexity of the medical condition of the patient. The
timing, scope, and intensity will vary according to clinical circumstances. For
example, the physical examination of an otherwise healthy patient with
paranoia, or the genital-rectal examination of a patient with a
history of sexual abuse, may be deferred to a more appropriate time
and setting.
In most circumstances, the physical examination should be
chaperoned. Particular caution is warranted in the physical examination
of persons with histories of physical or sexual abuse or with other
features that could increase the possibility of the patient's
being distressed as a result of the examination (e.g., a patient
with an erotic or paranoid transference to the psychiatrist). All
but limited examinations of such patients should be chaperoned.
In many settings, it has become commonplace for the care of
psychiatric patients to draw on the expertise of multidisciplinary
teams. In the evaluation phase of care, other members of the clinical
team (e.g., nurses, psychologists, occupational therapists, social
workers, case managers, peer counselors, chaplains) may gather data
or perform discipline-specific assessments. The psychiatrist responsible
for the patient's care reviews and integrates these assessments
into the psychiatric evaluation of the patient and works with other
members of the multidisciplinary team in developing and implementing
a plan of care.
The opportunity to improve systematic observations of patients' behavior
by staff is an advantage of controlled settings such as hospitals,
partial hospital settings, residential treatment facilities, and
other institutions. Several types of observations may be gathered,
according to the patient's specific situation:
These are relevant to all patients
in all settings and include notes on patients' behavior, statements
and expressed concerns, cooperativeness with or resistance to staff,
sleep/wake patterns, and self-care.
Diagnosis-specific observations. These
are observations relevant to confirming a diagnosis or assessing
the severity, complications, or subtype of a disorder. Examples
include recording signs of withdrawal in an alcohol-dependent patient
and observations during meals for patients with eating disorders.
Patient-specific observations. These
are observations aimed at assessing a clinical hypothesis. An example
is observation of behavior following a family meeting for a patient
in whom family conflicts are suspected of having contributed to
a psychotic relapse.
Observations of response to treatment
Examples include systematic recording
of a target behavior in a trial of behavior therapy, observations
of the effects of newly prescribed medications, and nurse-completed
rating scales to measure changes after behavioral or psychotherapeutic
The actual assessment process during a psychiatric evaluation
usually involves the development of initial impressions and hypotheses
during the interview and their continual testing and refinement
on the basis of information obtained throughout the interview and from
mental status examination, diagnostic testing, and other sources
The integrative formulation aids in understanding the patient
as a unique human being and allows the psychiatrist to appreciate
the patient's environment, strengths, challenges, and coping
skills. The formulation includes information specific to the patient
that goes beyond what is conveyed in the diagnosis; it will vary
in scope and depth with the purpose of the evaluation. Components
of the formulation include phenomenological, neurobiological, psychological,
and sociocultural issues involved in diagnosis and management (60, 168–179).
As relevant to each domain, the formulation will typically include
a concise synthesis of what is known about the patient (e.g., individual
characteristics, genetic predispositions, general medical conditions
or laboratory abnormalities, past life experiences and developmental
history, extent and quality of interpersonal relationships, central
conflicts and defense mechanisms) and the patient's past
and current symptomatology (including childhood or subsyndromal
illness and predisposing, precipitating, perpetuating, or protecting
factors) as well as the responses of symptoms to treatment. Variations
in phenomenology with factors such as a patient's age or
gender can be relevant in determining whether or not a behavior
is indicative of psychopathology (180). Thus, the formulation may
also include a discussion of the diagnostic, therapeutic, and prognostic
implications of the evaluation findings.
The DSM-IV-TR Outline for Cultural Formulation (Table 5) provides
a systematic method of considering and incorporating sociocultural
issues into the clinical formulation (181–185). Depending
on the focus and extent of the evaluation, it may not be possible
to do a complete cultural formulation based on the findings of the
initial interview. However, when cultural issues emerge, they may
be explored further during subsequent meetings with the patient.
In addition, the information contained within the cultural formulation
may be integrated with the other aspects of the clinical formulation
or recorded as a separate element.
The cultural formulation begins with a review of the individual's
cultural identity and includes the patient's self-construal
of identity over time (186). Cultural identity involves not only
ethnicity, acculturation/biculturality, and language but
also age, gender, socioeconomic status, sexual orientation, religious
and spiritual beliefs, disabilities, political orientation, and
health literacy, among other factors.
Cultural identity of the individual
Cultural explanations of the individual's
Cultural factors related to psychosocial environment
and levels of functioning
Cultural elements of the relationship between the individual
and the clinician
Overall cultural assessment for diagnosis and care
Source. From DSM-IV-TR,
pp. 897–898.
Next, the formulation explores the role of the cultural context
in the expression and evaluation of symptoms and dysfunction, including
the patient's explanatory models or idioms of distress
through which symptoms or needs may be communicated. These are assessed against
the norms of the cultural reference group. Treatment experiences
and preferences (including complementary and alternative medicine
and indigenous approaches) are also identified. Cultural factors
related to psychosocial stressors, available social supports, and levels
of function or disability are also assessed; during this process,
the roles of family/kin systems and religion and spirituality
in providing emotional, instrumental, and informational support
are highlighted.
The cultural formulation also includes specific consideration
of cultural elements influencing the relationship between the individual
and the clinician. In this regard, it is important for clinicians
to cultivate an attitude of "cultural humility" (187)
in knowing their limits of knowledge and skills rather than reinforcing
potentially damaging stereotypes and overgeneralizations. Differences
in language, culture, or social status, as well as difficulties
in identifying and understanding the cultural significance of behaviors
or symptoms, may add to the complexities of the clinical encounter.
Transference and countertransference may also be influenced by cultural
considerations and may either aid or interfere with the treatment
relationship. Further, the potential effect of the psychiatrist's
sociocultural identity on the attitude and behavior of the patient
should be taken into account in the subsequent formulation of a
diagnostic opinion.
The cultural formulation concludes with an overall assessment
of the ways in which these varied cultural considerations will specifically
apply to differential diagnosis and treatment planning.
An additional component of the formulation involves an assessment
of the patient's risk of harm to self or others. This may
include consideration of suicide or homicide risk as well as other
forms of self-injury (e.g., cutting behaviors, accidents), aggressive
behaviors, neglect of self-care, or neglect of the care of dependents.
The risk assessment is intended to identify specific factors that
may increase or decrease a patient's degree of risk, thereby suggesting
specific interventions that may modify particular risk factors or
address the safety of the patient or others. Specific risk factors
may include demographic parameters (e.g., age, gender), past behavior
(e.g., suicide attempts, self-injury, aggression), psychiatric diagnoses,
psychiatric symptoms (e.g., anxiety, hopelessness), co-occurring
general medical conditions, sociocultural factors, psychosocial
stressors, or individual strengths and vulnerabilities. For patients
with suicidal behaviors, this risk assessment process is described in
detail in APA's
Practice Guideline for
the Assessment and Treatment of Patients With Suicidal Behaviors
Although standardized rating scales of suicidal or aggressive behaviors
are often used in research and may suggest helpful lines of clinical
inquiry, their utility in clinical risk assessment is limited by
their low predictive value (11).
For individuals with dependent children, the risk assessment
also includes an evaluation of the patient's capacity to
parent. In addition to considering the number and ages of any children,
the assessment reviews the patient's capacity to meet the
needs of dependent children, both in general and during psychiatric
crises if these are likely to occur. The overall health, including
mental health, of the children is also relevant, especially when
the patient's psychiatric condition is likely to affect
the children through genetic or psychosocial mechanisms or to impede
the patient's ability to recognize and attend to the needs
of a child.
On the basis of information obtained in the evaluation, a
differential diagnosis is developed. The differential diagnosis
comprises conditions (including personality disorders or personality traits)
described in the
Diagnostic and Statistical Manual
of Mental Disorders,
Fourth Edition, Text Revision
(DSM-IV-TR) (188), APA's current edition of DSM. A multiaxial
system of diagnosis provides a convenient format for organizing
and communicating the patient's current clinical status,
other factors affecting the clinical situation, the patient's
highest level of past functioning, and the patient's quality
of life (188, pp. 27–33). General medical conditions are
established through history, examination, diagnostic tests, medical
records, and consultation.
The DSM classification and the specific diagnostic criteria
are meant to serve as guidelines to be informed by clinical judgment
in the categorization of the patient's condition(s) and
are not meant to be applied in a rote fashion. (Other issues in
the use of DSM and its application in developing a psychiatric diagnosis
are discussed in DSM-IV-TR, pp. xxiii–xxxv and 1–12.)
To augment the DSM multiaxial approach, some clinicians also find
it helpful to identify the patient's level of defensive
functioning or incorporate dimensional or other approaches into
their diagnostic assessments (188, pp. 807–813; 189, 190).
The initial treatment plan addresses any specific diagnoses
and psychiatric needs of the patient that have been identified during
evaluation. If diagnostic or other questions have been posed or
additional information is necessary, these issues should be addressed
in the treatment plan.
The initial treatment plan begins with a determination of
the appropriate treatment setting and includes an explicit statement
of the diagnostic, therapeutic, and rehabilitative goals for treatment
that includes short-term as well as longer-term goals. In the case
of patients who initially will be treated in an inpatient or partial
hospital setting, this implies apportioning the therapeutic task
between a hospital phase and a posthospital phase. Within the acute
care setting, some goals may be targeted for achievement within
several days, whereas other goals will be targeted for completion
by the time of discharge. On the basis of the goals, the plan specifies
further diagnostic tests and procedures, further systematic observations
or additional information to be obtained, and specific therapeutic
modalities to be applied.
A comprehensive treatment plan addresses biological, psychological,
and sociocultural domains. The psychiatrist can select from a range
of individual, group, and family therapies to create an integrated
multimodal treatment that includes biological and sociocultural
interventions (60).
Quality care involves treatment plans that are safe, timely,
effective, efficient, equitable (i.e., not influenced in quality
by personal characteristics such as gender, ethnicity, geographic
location, and socioeconomic status), and person-centered (7). Such
treatment plans encourage recovery from illness through community
integration and empower patients to make choices that improve their
quality of life (191). Thus, the treatment plan is ideally the result
of collaboration between the patient, the psychiatrist, and other
members of the treatment team as well as the primary care practitioner
for patients who have an established source of primary care.
A range of potentially effective treatments is initially considered.
More detailed consideration and documentation of the risks and benefits
of treatment options may be needed in the following circumstances:
when a relatively risky, costly, or unusual treatment is under consideration;
when involved parties disagree about the optimal course of treatment;
when the patient's motivation or capacity to benefit from
potential treatment alternatives is in question; when the treatment
would be involuntary or when other legal or administrative issues
are involved; or when available treatment options are limited by
external constraints (e.g., financial barriers, insurance restrictions,
geographic barriers, service availability, the patient's
capacity to participate in the proposed treatment). Such considerations
are also relevant when considering the level of care needed to provide
an individual patient with appropriate treatment. In addition, level-of-care
determinations will vary with the diagnosis, the presence of co-occurring
general medical or psychiatric disorders (including substance use disorders),
the assessment of the patient's risk to self or others,
the current severity of symptoms, the patient's prior illness
course and complications, his or her psychosocial supports, his
or her treatment adherence, and the strength of the therapeutic
alliance, among other factors. In some circumstances, it is also
important for the psychiatrist to be able to recognize the limitation
of health care resources and demonstrate the ability to act as an
advocate for patients within their sociocultural and financial constraints
Although the consideration of forensic evaluations is outside
the scope of this practice guideline, there are times when the general
psychiatric evaluation may need to address legal or administrative
concerns (Section V.C). Examples include deciding between voluntary
and involuntary admission, determining whether legally mandated
treatment should be pursued in objecting patients, determining whether
there is a duty to protect (e.g., by modifying the patient's
treatment, increasing outpatient visit frequency, initiating hospitalization,
warning the victim) if the patient is deemed a potential risk to
others, and deciding on the level of observation needed to address
the patient's safety (11). In situations such as these,
the psychiatrist's decision making will depend on the risk
assessment (Section IV.B.1.b) as well as other relevant aspects
of the history, examination, symptoms, diagnosis, and clinical formulation.
Assessment of the patient's decision-making capacity may
also be needed as part of the informed consent process. When a patient's
capacity to consent to treatment is uncertain, questioning to determine
mental status should be extended to include items that test the
patient's decision-making capacity (192). As with other
aspects of the evaluation, it is important to document the rationales
for making a particular treatment decision, including a discussion
of supporting evidence from the evaluation findings.
An assessment of family, peer networks, and other support
systems is an important part of the psychiatric evaluation because
of the potential role of these systems in ameliorating or augmenting
the patient's signs and symptoms of illness. This is particularly
true when evaluating individuals with complex biopsychosocial challenges
or serious psychiatric or general medical conditions. If the initial
evaluation indicates that aspects of the care system have an important
role in the patient's illness and treatment, goals are
developed in response to these findings. Systems may be more open
to considering change at times of crisis. Consequently, as well
as generating goals for the patient's diagnosis and individual treatment,
the evaluation may lead to goals for intervening with the family,
other important people in the patient's life, other professionals
(e.g., therapists), general medical providers, and governmental
or social agencies (e.g., community mental health centers or family
service agencies). Specific plans may be needed for addressing problems
in the care system that are seen as important to the patient's
illness, symptoms, function, or well-being and that appear amenable
to modification. For example, a parent may be unable to attend follow-up
appointments unless issues relating to care of dependents are addressed;
financial issues or formulary restrictions may preclude patients
from obtaining their medications; or geographic constraints may
limit access to a full range of treatment options. Plans to address such
systems issues should consider feasibility, the patient's
wishes, and the willingness of other people to be involved.
Considerations of privacy and confidentiality are an integral
component of any psychiatric encounter. Aspects of privacy and confidentiality
relating to communication with other medical professionals and with
sources of collateral information have been discussed above (
, I.B, II.C, and IV.A.2). In general, the default position is
to maintain confidentiality unless the patient gives consent to
a specific intervention or communication. However, the psychiatrist
is justified in attenuating confidentiality to the extent needed
to address the safety of the patient and others (10, 11). This includes
the ability to communicate necessary information about the patient
to medical personnel in the context of an emergency situation. It
is also permissible for the psychiatrist to listen to information
provided by family members and other important people in the patient's
life, as long as confidential information is not provided to the
The Health Insurance Portability and Accountability Act (HIPAA)
contains guidelines for release of the results of psychiatric evaluations.
State laws may be more restrictive, and if so, state laws take precedence
over HIPAA. According to HIPAA, information can be released without
a specific consent form for purposes of "treatment, payment,
and health care operations." Otherwise, patients must sign
an authorization form that indicates the information to be used
or disclosed, the purposes to which it will be put, the recipient
of the information, and an expiration date. HIPAA gives special
protection to psychotherapy notes if they are kept in a separate
part of the medical chart (193, 194). The interpretation of HIPAA
and other federal and state laws about confidentiality continues
to evolve, and legal or risk management consultation should be sought
if there are questions about the regulations related to release
of information and protection of psychiatric records (195).
For individuals in treatment for substance use disorders,
the provisions of 42 CFR '§2.11 will apply (196) and will
generally be more strict and supersede the provisions of HIPAA (197).
As with HIPAA, necessary information may be disclosed to medical
personnel in the context of treating a condition that poses an immediate
threat to the health of any individual and that requires immediate
medical intervention. Under such circumstances, documentation in
the medical record needs to include "the name of the medical
personnel to whom disclosure was made and their affiliation with
any health care facility; the name of the individual making the
disclosure; the date and time of the disclosure; and the nature
of the emergency" (42 CFR '§2.51 [196]).
Medical records may also be viewed by others in addition to
the clinician writing the note (198) or other members of an interdisciplinary
treatment team. These include third-party payers, quality assurance/peer
review evaluators, the patient, and, in certain jurisdictions, the
executor of an estate after a patient's death. Furthermore,
records may be part of future or current legal or administrative
hearings, including disability litigation, divorce and custody adjudication,
competency determinations, and actions of medical licensing boards.
Such accessing of patient's medical records needs to be
taken into consideration when documenting the evaluation, formulation,
diagnosis, and plan of treatment.
Third-party payers and their agents frequently request data
from psychiatric evaluations to make determinations about whether
a hospital admission or a specific treatment modality will be covered
by a particular insurance plan. Despite the blanket consents to
release information to payers that most patients must sign to obtain
insurance benefits, it is useful for the psychiatrist to obtain,
whenever feasible, contemporaneous consent for such communications.
In some instances, it may be necessary to inform the patient what
specific information has been requested and obtain specific consent
for the release of that information. With valid consent, the psychiatrist
may release information to a third-party reviewer, supplying the
third-party reviewer with sufficient information to understand the
rationale for the treatment and why it was selected over potential
alternatives. However, the psychiatrist may also withhold information
about the patient not directly relevant to the utilization review
or preauthorization decision (199, 200).
When a patient is admitted to a hospital or other residential
setting, the patient's legal status should be promptly
clarified to establish whether the admission is voluntary or involuntary,
whether the patient gives or withholds consent to evaluation and
recommended treatment, whether the patient appears able to make
treatment-related decisions, and whether an advance directive is
in place. If there is a potential legal impediment to necessary treatment,
action should be taken to resolve the issue.
The decision to hospitalize a patient involuntarily will depend
on multiple factors, including the estimated level of risk to the
patient and others, the patient's level of insight and willingness
to seek care, and the legal criteria in that jurisdiction. In general,
patients at risk for causing harm to themselves or others will satisfy
the criteria for involuntary admission; however, the specific
requirements vary from state to state (201), and in some states,
willingness to enter a hospital voluntarily may preclude involuntary
admission. To that end, psychiatrists need to be familiar with their
specific state statutes regarding involuntary hospitalization.
Advance directives are attempts to ensure that individuals' wishes
about treatment will be honored. Such directives may relate to wishes
about treatment at the end of life (202) but may also relate to
wishes about psychiatric treatment (203) or assignment of a durable power
of attorney or health care proxy to make decisions in
the event that the individual lacks capacity to do so (204). Although
the specifics of advance directive regulations vary by jurisdiction,
psychiatrists should include in their evaluation whether the patient
has executed an advance directiveand, if so, the nature
of the advance directive should be determined.
In every institution, whether public or private, fiscal and
administrative considerations limit treatment options. Usually there
are constraints on length of stay and on the intensity of services
available. Further constraints can arise from the absence or inadequate
funding of aftercare services or of a full continuum of care. The
initial assessment of treatment needs should not be confounded unduly
with concerns about financing or availability of services, although
the actual treatment may represent a balancing of optimal treatment
and external constraints. A common example is the situation in which
a patient's safety requires a level of supervision not available
in a given facility. Another example is when a patient requires
a general medical evaluation that cannot be carried out in a free-standing
psychiatric facility and requires the patient's transfer
to a general hospital. If such issues result in a major negative
effect on patient care, efforts should be made to find alternatives,
and the patient, family, and/or third-party payer should be
informed of the limitations of the current treatment setting and/or
While advanced chronological age alone does not necessitate
a change in the approach to the psychiatric evaluation, the strong
association of old age with chronic disease and related impairments
may increase the need for emphasis on certain aspects of the evaluation. The
general medical history and evaluation, cognitive mental status
examination, and functional assessment may need to be especially
detailed because of the high prevalence of disease-related disability,
use of multiple medications, cognitive impairment, and functional impairment
in older people. The psychiatrist should attempt to identify all
of the general medical and personal care clinicians involved with
the patient and to obtain relevant information from them if the
patient consents. It is also helpful to obtain information from
the family.
The personal and social history includes coverage of common
late-life issues, including the loss of a spouse or partner, the
loss of friends or close relatives, residential moves, the new onset
of disabilities, financial concerns related to illness or disability,
and intergenerational issues, such as informal caregiving or financial
transfers between members of different generations. It is important
to evaluate intergenerational strains such as midlife couples with
young children who cannot care for elderly relatives or, increasingly,
patients in their 90s whose children are now in their 70s and ill
The psychiatrist may need to accommodate the evaluation to
patients who cannot hear adequately. Use of sign language interpreters,
amplification, a quieter interview room, and enabling lip reading
are possible means to do this. When an elderly patient is brought
for psychiatric evaluation by a family member, special effort may
be necessary to ensure that both patient and family member have
an opportunity to talk to the psychiatrist alone.
Increasing numbers of individuals with mental illness are
incarcerated in jails, prisons, and other correctional facilities
and require psychiatric evaluation (205–208). In addition,
suicide is one of the leading causes of death in correctional settings,
and urgent suicide assessments may be needed for individuals at
risk (11, 209, 210).
The psychiatric evaluation of incarcerated individuals will
include the general elements common to any psychiatric evaluation
(211–213) but will place additional emphasis on aspects
of the individual's alcohol and substance use history and
legal history, including previous episodes of incarceration and
associated behavioral changes. Psychosocial stressors, including
new legal complications (e.g., denial of parole), receiving bad
news about loved ones at home, and experiencing sexual assault or
other trauma, are also important to assess, as these may increase the
likelihood of suicidal behaviors (214). Similarly, the recentness
of the incarceration (210, 214, 215) or placement in isolation (216–219)
may be relevant to determination of suicide risk. Depending on the
likely duration of incarceration, options for care following transfer
between correctional institutions or for aftercare following release may
also need to be explored as part of the evaluation.
Access to space that allows for auditory privacy and physical
safety is necessary to adequately perform psychiatric evaluations
in correctional settings (212).
Evaluations of persons who are homeless may require both modifications
of the evaluation process and unique interviewing skills. The disengaged
lifestyle and mistrust often encountered in homeless persons may
make a classically direct approach difficult if not impossible (220).
As a result, the first step toward psychiatric evaluation is engagement.
This process can take from days to years in nonclinical settings
(e.g., on the street, under bridges, in shelters). Evaluation becomes
possible when the homeless person believes that engaging with the
psychiatrist will not recapitulate previous negative experiences,
lost opportunities within the health care system, and encounters
in jail and prison that heighten a fear of consequences from talking
honestly. By necessity, then, the full psychiatric evaluation of homeless
persons typically unfolds over numerous, often brief, and seemingly
casual interactions.
The evaluation of individuals with mental retardation presents
a number of clinical challenges. Although psychiatric illnesses
occur at increased rates in those with mental retardation (221, 222), it is not always possible to establish a definitive axis I
diagnosis as a cause for behavioral symptoms (223). Depending on
the extent of the patient's intellectual limitations, the
diagnosis of mental retardation may have been unrecognized before
the behavioral symptoms began.
In interviewing individuals with mental retardation, particular
attention needs to be given to the phrasing of questions so that
they will be understandable to the patient. The use of general psychiatric
self-report scales or other structured interview formats may be
problematic in this regard (221, 224). Behavioral observations or
functional measures will often carry a greater weight in the assessment
process, and patients with more severe mental retardation may be
unable to report on their own mental experiences (225, 226). Thus,
obtaining a comprehensive description of symptoms, signs, and aspects
of history from family members, caretakers, and other professionals
is often crucial. This is particularly true when persons with mental
retardation present for evaluation in the context of a behavioral
crisis, because otherwise minor events (e.g., changes in routine,
upsetting interpersonal interactions) may be quite distressing and
result in catastrophic reactions. Similar issues with evaluation
may be observed in individuals with other developmental disabilities.
Evaluation for co-occurring general medical conditions is
particularly important in adults with mental retardation, given
higher rates of undetected medical illnesses (222, 227) as well
as the tendency for atypical clinical presentations of medical illnesses
(140, 227).
Psychiatric evaluation is, by necessity, highly individualized
to the patient and to the treatment setting, making the development
of rigorous research designs challenging. Nonetheless, a number
of aspects of psychiatric interviewing and assessment may lend themselves
to formal study and are discussed in further detail below. In addition,
the research agenda for DSM-V (228) provides suggestions for research
relating to psychiatric diagnosis, which has many areas of overlap
with research on psychiatric assessment.
Some research, predominantly conducted in primary care settings,
has examined the differences between specific interviewing approaches.
For example, approaches to enhancing reporting and recall of historical
information have been evaluated (229, 230). Additional studies have assessed
the effects of communication style and vocabulary on outcomes such as
patient satisfaction (231–236). The development of new
evaluation strategies could help strengthen psychiatric interviewing
approaches. In addition, it will be important to expand such research
across different patient subgroups (e.g., according to age, gender,
sexual orientation, race, ethnicity, cultural background), to individuals
with psychiatric disorders, and to collaborative models of assessment
and care. Measures of outcomes will also need to be expanded to
include factors such as treatment adherence and the strength of
the therapeutic alliance. Furthermore, studies will need to assess
whether guideline-concordant approaches to assessment are associated
with improved outcomes in community-based patient samples (237).
Research has also focused on the impact of technology on information
gathering and the physician-patient encounter. For example, some
studies have examined differences in the information elicited by
face-to-face interviews as compared with computer-aided assessments
or telephone interviews (238, 239). Other studies have assessed
computerized documentation by physicians at the time of evaluation
and its effect on patient perceptions (240–242). Patients
and family members are increasingly learning about possible diagnoses
and treatments through direct-to-consumer advertising and through
Internet-based educational resources, which they sometimes bring
to the evaluation. Systematic study of the influences of these information
sources on the assessment and treatment planning processes would be
useful. It also remains unclear whether use of template-based electronic
health records as compared with narrative-based health records will
influence the evaluation process, the physician-patient relationship,
or communication with other members of the health care team. Thus,
with the increasing use of technology in medicine, including computer-based interviews
and telepsychiatry, the influence of such technologies is worthy
of additional study in the full range of psychiatric settings.
Although rating scales have been widely used in clinical research
for assessment by the clinician and self-assessment, they are less
often incorporated into psychiatric evaluations in clinical practice.
To be most useful, rating scales need to be valid and reliable as
well as demonstrate practical utility in typical clinical settings.
Further study of clinical rating scales is required in clinical
samples including patients with potentially confounding co-occurring
disorders (243). Development and testing of rating scales also need
to consider the different requirements for rating scales that are
used in initial diagnostic assessments as compared with those used
in monitoring of signs and symptoms over time or with treatment.
The ability to use rating scales to detect prodromal or subsyndromal
disorders as part of the psychiatric evaluation would be an important
step in the design and testing of preventive approaches to psychiatric
disorders. Ideally, research on rating scales could lead to the development
of a limited set of formal systematic measures for screening and
monitoring, with resulting benefits in identification and treatment
of common psychiatric disorders, including substance use disorders.
An integral part of the psychiatric evaluation is the process
by which the information gathered as part of the psychiatric evaluation
is synthesized and integrated into the development of a multiaxial
diagnosis and biopsychosocial formulation. In addition to research on
the validity and reliability of specific diagnoses, further research
is needed on variations in both clinical and community presentations
across different patient subgroups (e.g., according to age, gender,
sexual orientation, race, ethnicity, cultural background) and in
the presence of co-occurring general medical and psychiatric conditions.
It is anticipated that the development of DSM-V will stimulate such
research across many diagnostic areas, guided by APA's
systematic efforts to review existing data and provide agendas for
new research (228). With the advent of electronic health records
and the increasing availability of decision-support tools, computerized approaches
that may permit development of differential diagnoses or formulations
will need to be compared to clinician-generated assessments. Longitudinal
research on the reliability and validity of approaches
to the clinical formulation may aid in fine-tuning this aspect of
With regard to diagnostic testing, neurogenetics and structural
and functional neuroimaging techniques are areas of active and promising
research. A burgeoning body of literature has reported associations
between genetic markers (e.g., apoplipoprotein E 4 allele, dopamine D4 allele,
catechol-O-methyltransferase polymorphisms,
promoter polymorphisms of the serotonin transporter gene)
and the presence of psychiatric illnesses or symptoms (244–251). Neurogenetic
approaches may ultimately be useful in distinguishing between genetic
and environmental etiologies of psychiatric disorders as part of
the psychiatric evaluation (252), thereby permitting greater specificity
in treatment planning and outcome measurement. While some have speculated
that characterization of the particular genotype of a patient will
lead to "personalized medicine" by guiding treatment
choices, significant support for such therapeutic guidance in psychiatric
disorders is not yet substantiated by the literature. The potential
for progress in this area merits continued vigilance for
reports of its impact on the practice of psychiatry.
Neuroimaging techniques are currently used in identifying
central nervous system processes such as infection, malformations,
cerebrovascular events, and malignancy. Accumulating evidence also
suggests other applications of neuroimaging in psychiatric evaluation. In
cognitive disorders of late life, such as Alzheimer's disease,
neuroimaging techniques have been evaluated for use as surrogate
markers for the microscopic neuropathologies that characterize the
illness (253–256). Functional neuroimaging with positron
emission tomography or single-photon emission computed tomography
has demonstrated an association between reduced regional activity
(metabolism or perfusion) in temporoparietal regions and the presence
and severity of Alzheimer's disease (257–264),
whereas other dementing illnesses do not show this temporoparietal
feature. The reproducibility of these findings has enhanced the
differentiation between Alzheimer's disease and other dementing
illnesses (265). Ongoing work aims to confirm the clinical utility
of such information.
In patients with schizophrenia and mood and anxiety disorders,
structural and functional neuroimaging studies have reported differences
between patients and healthy control persons (266–288)
as well as differences in some patient subgroups (289–292)
and in responders and nonresponders to some treatments (293–302).
Nevertheless, the clinical utility of neuroimaging techniques for
planning of individualized treatment has not yet been shown. Further
research is needed to demonstrate a clinical role for structural
and functional neuroimaging in establishing psychiatric diagnoses,
monitoring illness progression, and predicting prognoses.
Norman Abeles, Ph.D.
Renato D. Alarcon, M.D., M.P.H.
Mark A. Amdur, M.D.
Kamal Artin, M.D.
David Baron, M.S.Ed., D.O.
Carl C. Bell, M.D.
David W. Brook, M.D.
Beth Ann Brooks, M.D.
Karen Broquet, M.D.
R.W. Burgoyne, M.D., Ph.D.
Gabrielle A. Carlson, M.D.
Mitchell J.M. Cohen, M.D.
Paul D. Cox, M.D., C.G.P.
Larry Culpepper, M.D., M.P.H.
Glenn Currier, M.D., M.P.H.
David L. Cutler, M.D.
Sarah DeMichele, M.D.
William R. Dubin, M.D.
Michael A. Fauman, M.D., Ph.D.
Joel Feiner, M.D.
Paul Jay Fink, M.D.
Peter Forster, M.D.
K.W.M. Fulford, D.Phil., F.R.C.P., F.R.C.Psych.
Paulette Marie Gillig, M.D., Ph.D.
Leslie H. Gise, M.D.
Sir David Goldberg, M.D.
Lawrence S. Gross, M.D.
Douglas G. Jacobs, M.D.
Douglas A. Kalunian, M.D.
Elisabeth J.S. Kunkel, M.D.
Ira Lesser, M.D.
James W. Lomax, M.D.
Henry Mallard, M.D.
David Mallott, M.D.
Marlin R. Mattson, M.D.
Peter McGeorge, M.D. M.B.Ch.B., F.R.A.N.Z.C.P.
Hunter L. McQuistion, M.D.
Jeffrey L. Metzner, M.D.
Kenneth Minkoff, M.D.
Mark Munetz, M.D.
Marvin Nierenberg, M.D.
Ann E. Norwood, M.D.
Lewis A. Opler, M.D., Ph.D.
John Peteet, M.D.
Herbert S. Peyser, M.D.
Harold Alan Pincus, M.D.
Henry Pinsker, M.D.
Brian Robertson, M.D.
Barbara R. Rosenfeld, M.D.
Barry W. Rovner, M.D.
M. David Rudd, Ph.D., A.B.P.P.
John Z. Sadler, M.D.
Warren Seides, M.D.
Michael Serby, M.D.
Joel J. Silverman, M.D.
Robert Stern, M.D., Ph.D.
Nada Stotland, M.D., M.P.H.
Jeffrey Stovall, M.D.
Paula T. Trzepacz, M.D.
Mitchell G. Weiss, M.D., Ph.D.
Cindy Wigg, M.D.
Bonnie Zima, M.D., M.P.H.
Mark Zimmerman, M.D.
Sidney Zisook, M.D.
Academy of Psychosomatic
American Academy of Addiction Psychiatry
American Academy of Clinical Psychiatrists
American Academy of Family Physicians
American Association for Emergency Psychiatry
American Association of Directors of Psychiatric Residency
American Association of Suicidology
American Group Psychotherapy Association
Association for Academic Psychiatry
Association for Behavioral and Cognitive Therapies
Group for the Advancement of Psychiatry
National Institute of Mental Health
Royal College of Psychiatrists
World Federation for Mental Health
The following coding system is used to indicate the nature
of the supporting evidence in the summary recommendations and references:
randomized clinical trial.
A study of an intervention
in which subjects are prospectively followed over time; there are
treatment and control groups; subjects are randomly assigned to
the two groups; both the subjects and the investigators are blind
to the assignments.
clinical trial.
Same as above but not double-blind.
[B] Clinical trial. A
prospective study in which an intervention is made and the results
of that intervention are tracked longitudinally; study does not
meet standards for a randomized clinical trial.
Cohort or longitudinal
A study in which subjects are prospectively
followed over time without any specific intervention.
[D] Control study. A
study in which a group of patients and a group of control subjects
are identified in the present and information about them is pursued
retrospectively or backward in time.
Review with secondary
data analysis.
A structured analytic review of
existing data, e.g., a meta-analysis or a decision analysis.
[F] Review. A
qualitative review and discussion of previously published literature
without a quantitative synthesis of the data.
[G] Other. Textbooks,
expert opinion, case reports, and other reports not included above.
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