Initial psychiatric assessment: A practical guide to the clinical interview

Issue: BCMJ, Vol. 45, No. 4, March 2003, page(s) 172-173 Articles
Daniel Lin, BSc, Jason Martens, MSc, Agnieszka Majdan, MA , Jonathan Fleming, MB, FRCP

Noting the lack of a comprehensive assessment instrument, the authors present a tool to simplify the initial psychiatric assessment and improve its diagnostic reliability.

The authors present a psychiatric assessment tool that has been clinically valuable to medical students and residents in completing comprehensive psychiatric assessments. This four-page document ensures that the clinician takes an efficient yet comprehensive approach to screening for psychiatric illnesses. Residents and medical students at various teaching hospitals in Vancouver, BC, have found this instrument useful.

Psychiatric assessment form [Word doc] PDF [17 KB requires Adobe Acrobat]

Preamble

Despite the major advances in diagnosing and classifying psychiatric illness and the widespread education of health professionals and the public about psychiatric disorders, frequently treatable psychiatric illnesses—with their associated significant morbidities—are often overlooked. At least half of all depressive disorders in primary care remain undetected.[1]

Recognizing the complexity of completing a comprehensive psychiatric evaluation, Daniel Lin, Jason Martens, and Agnieszka Majdan developed an aid to clinicians to assist in recording the essential information required to make a psychiatric diagnosis (see the Figure [Word doc] PDF [17 KB requires Adobe Acrobat]). Their schema borrows from the current diagnostic criteria for the major psychiatric disorders. They list the core features of 13 common syndromes and provide prompts for the relevant past history and the current mental status examination.

Although this instrument has not been validated, clinical experience has demonstrated its utility in assisting the busy clinician in completing and recording a focused, comprehensive psychiatric evaluation that will provide the diagnostic cornerstone required to help patients return to wellness.

—JF

Introduction

It is widely accepted that clinical interviewing is the fundamental diagnostic tool in psychiatry. Indeed, Schreiber[2] states that “the psychiatric interview is the essential vehicle for assessment of the psychiatric patient.” Unlike other areas of medicine, psychiatry lacks external validating criteria, such as lab tests or imaging, to help confirm or exclude diagnoses.[3] With the clinician’s diagnosis and subsequent treatment plan being determined by the clinical data obtained from the interview and physical examination, any strategy that facilitates the systematic collection of clinical information is likely to improve the diagnostic reliability of the assessment.

Inexperienced clinicians or health practitioners less familiar with mental illness may consider the initial psychiatric assessment rather daunting given the vast array of disorders that need to be considered and the lack of functional tools available to assist them. It appears that in most studies of the current literature concerning psychiatric interviewing, standardized, structured interviews such as the Structured Clinical Interview for DSM-IV (SCID) and rating scales such as the Hamilton Depression Rating Scale and the Montgomery-Asperg Depression Rating Scale are examined. In some studies, researchers evaluate the diagnostic effectiveness and reliability of these structured interviews,[4,5] while in other studies they are used as methods to evaluate treatment interventions.[6,7] Structured interviews such as these may provide some guidance to the novice interviewer regarding specific questions that may be used to elicit various symptoms, but due to time restrictions, their general clinical utility is limited.

Realizing the complexity of psychiatric interviewing and the need to accurately and systematically assess the signs and symptoms of the major psychiatric disorders, the authors developed a tool utilizing a typical outline of the psychiatric interview yet covering the diagnostic criteria required to make a differential and preferred diagnosis (see the Figure [html version] PDF [17 KB requires Adobe Acrobat]).

Development

We completed a MEDLINE search for studies on history-taking in psychiatry. No articles were found that provided a clinical guide to interviewing. Several major psychiatric texts were also reviewed for summaries of the psychiatric interview[2,3,8] and a standard outline was extracted based on these findings. We then added the clinical features of the major psychiatric illnesses to this outline utilizing the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).[9]

The form is four pages in length and provides appropriate spaces for note-taking in order to document a thorough psychiatric history. The document was made available to medical students and residents training in psychiatry at the University of British Columbia and has been used in a variety of clinical and teaching settings. The form was subsequently improved by incorporating changes suggested by these users. Medical students and residents involved in psychiatric intake at the various hospitals in the Lower Mainland have found this document very useful.

Conclusion

The Psychiatric Assessment Form was designed to assist health care workers perform comprehensive psychiatric assessments and screening for major mental illnesses. It should be used by individuals with some understanding of the interview process and the signs and symptoms of psychiatric disorders. Though research comparing the use of this interview tool to others has not yet been performed, both residents and medical students who have used it note its ease of use and comprehensiveness. We believe that this guide to the psychiatric interview may be particularly effective for interns, residents, medical students, and nursing staff in inpatient and outpatient psychiatric settings.

Competing interests

None declared.

References Top

1. Paykel ES, Tylee A, Wright A, et al. The defeat depression campaign: Psychiatry in the public arena. Am J Psychiatry 1997;154(6 suppl):59-65. PubMed Abstract 
2. Schreiber SC. Psychiatric Interview, Psychiatric History and Mental Status Exam. In: Hales RE, Yudofsky SC, Talbott JA (eds). Textbook of Psychiatry. 3rd ed. Washington, DC: American Psychiatric Press, 1999:193-223. 
3. Manley MRS. Psychiatric interview, history and mental status exam. In: Kaplan HI, Sadock BJ (eds). Comprehensive Textbook of Psychiatry. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2000:652-677. Full Text 
4. Steiner JL, Tebes JK, Sledge WH, et al. A comparison of the structured clinical interview for DSM-III-R and clinical diagnoses. J Nervous Mental Dis 1995;183:365-369. PubMed Abstract 
5. Schramke CJ, Stowe RM, Ratcliff G, et al. Poststroke depression and anxiety: Different assessment methods result in variations in incidence and severity estimates. J Clin Exp Neuropsychol 1998;20:723-737. PubMed Abstract 
6. Vieta E, Martinez-Aran A, Goikolea JM, et al. A randomized trial comparing paroxetine and venlafaxine in the treatment of bipolar depressed patients taking mood stabilizers. J Clin Psychiatry 2002;63:508-512. PubMed Abstract Full Text 
7. Umbricht DS, Wirshing WC, Wirshing DA, et al. Clinical predictors of response to clozapine treatment in ambulatory patients with schizophrenia. J Clin Psychiatry 2002;63:420-424. PubMed Abstract Full Text 
8. Gelder M, Gath D, Mayou R, et al. Oxford Textbook of Psychiatry. 3rd ed. Oxford, UK: Oxford University Press, 1996:25-55.  
9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994. 

Daniel Lin, BSc, Jason Martens, MSc, Agnieszka Majdan, MA, and Jonathan Fleming, MB, FRCP

Mr Lin, Mr Martens, and Ms Majdan are medical students at the University of British Columbia. Dr Fleming is an associate professor in the UBC Department of Psychiatry.

CONTENT

Abstract
Preamble
Introduction
Development
Conclusion
Competing interests
References

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DISCUSSION

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