Psychiatric assessment

Introduction

Psychiatry is the ultimate clinical speciality. At one level, it is about one unique organ—the brain. Unlike other organs, our brains can argue, change jobs, vote and perform many other things. However, the practice of psychiatry is concerned with more than the brain, or even the mind; when the ways we think/feel/behave/interact go wrong, clinical psychiatry interrogates, formulates and treats. We rely on what people tell us (and do not mention or conceal); a unique mental state examination (MSE), evaluating this information in relation to different versions of the history given by a person’s close friends and relatives; and reading medical notes from mental health professionals, general practitioners and other sources. This chapter will teach you how to take a comprehensive history and complete an MSE in situations in which you may be pressed for time, your patient is distressed, or the setting (emergency department, busy clinic, hospital ward lacking privacy) works against your objectives. More specialist assessments are listed at the end; no matter where your career takes you, you will encounter these complex patients.

Thoughtful planning, careful timing and good technique will increase the reliability of your psychiatric interview (i.e. the chance that another clinician would have/will produce the same history, MSE findings and formulation as this interview). Involved in this branch of medicine, psychiatrists produce more reliable findings than many other medical and surgical specialities. The absence of specific laboratory or radiological tests to ‘prove’ a diagnosis should not be seen as a disadvantage; it makes the interview process more important and gives clinicians the responsibility of getting it right the first time. If you are new to this, talk through your first assessments, before and after, with your supervising clinician. The potential areas to question are vast, so a helpful steer from someone experienced will hasten your acquisition of competencies, case by case. At first attempts, many students feel exhausted after completing a detailed psychiatric assessment; learning how to enquire for maximum yield will be time well invested for your future career. If you specialize as a primary care/family physician, you will see more cases of depression than most busy psychiatrists in theirs. If your destination is surgery or interventional medicine, the skills you learn in psychiatry will save some of your patients from unnecessary medical investigations, even treatments. For every completed assessment, with competent record keeping, the patient will benefit from your efforts well into the future.

Preparation

Preparation may be less important if you are a medical/nursing/other student or junior trainee; your trainers will not want you to approach a new patient (meaning new to you) with pre-read assessments and pre-conceived ideas. In emergency rooms, you do need to read something about the patient to determine if you need to take steps to protect your safety or his; a history of violence is a strong predictor of future violence, just as a history of self-harm predicts subsequent self-harm and suicide. Take time to search electronic notes for past safety concerns and evaluate if there were assaults on health professionals, perhaps in circumstances similar to your current setting. Risk varies with circumstances, and some patients may have particular triggers (become stimulated during lengthy interviews, resent being challenged on detail, do not like being interviewed by men, etc.) or have had prior difficulties in some settings (one-to-one meetings, crisis interviews). You need to commit at least 1 hour face-to-face time (longer for children and for people with intellectual disability), during which you are unlikely to be interrupted. In general hospitals, the demand for interviews is invariably ‘right now’, but few psychiatrists would wake a patient to interview unless absolutely necessary.

Some patients may be sedated (medication overdoses, either self-administered or iatrogenic) and it may be better to wait until their minds are clearer. If your patient is drunk, intoxicated on other substances or withdrawing from these, there are two reasons to delay the interview. First, the MSE is not reliable in this patient group; people are disinhibited, angry, volatile (elated or dysphoric) or mixtures of these and more likely to talk down (and up) their difficulties. The second reason is your safety; assaults in mental health care are not common, but one assault is one too many. Remember that you are much more likely to be assaulted by an intoxicated person than by a sober patient with severe mental illness (SMI).

Plan and be practical. Decide how you will record key dates and other details (important for individual patients, but easy for us to forget) and direct speech (see later for the value of direct quotations). Even in this digital age, pen and paper are more efficient and sensitive to patients’ needs. Think about what the likely outcomes of assessment will be; there are circumstances in which a collateral history before the history and MSE will yield more reliable information, such as suspected prodrome or negative symptoms in schizophrenia and cognitive decline in older people. Whilst, legally, you do not need someone’s permission to receive information, it is standard to ask permission from the patient for this (ask for seniors’ advice). It is defensible in law to seek information, but not to share it without consent. There are exceptions where the doctor may overrule confidentiality (e.g. significant potential risk of adverse outcomes in untreated psychosis or dementia—including situations in which exploitation by others is suspected).

Think also about who needs to be in the room with you; younger people, until mid-teens, have a parent or guardian present (this has advantages and disadvantages), and some adults ask for a partner or friend to sit in (usually more disadvantages than advantages). If your assessment of an adult patient has another adult insisting on joining the interview for reasons that are not clear, always consider why that might be the case (e.g. an abusive controlling partner, lack of boundaries within a family, other secrets). Referring clinicians will tell you if an interpreter is required, or if there are communication challenges (hearing difficulties, dysphasias, intellectual disability or cognitive decline); these can be mitigated with planning (amplification devices, picture cards, Yes or No options written out to point to answers, etc.). A familiar interpreter is useful, but be aware if the interpreter is leading your interview, perhaps by adding more questions to yours or ‘interpreting’ answers rather than translating them. If you are concerned about this, ask the interpreter to turn away from the patient and face you; this makes your eye contact the main non-verbal communication with the patient, and the interpreter’s role is limited to translating. As a rule, using family members as interpreters for a first interview, or when sensitive information might be revealed, is discouraged.

Circumstances of the interview

Clarify who is asking for this assessment. Even if this interview was requested by the patient, you need to make clear to him your role, and the limits of confidentiality before you begin. No patient has a right to complete confidentiality; if you discover details of (for example) suicidal intent and plans, then you have a responsibility to share that information with others, and act to reduce the risks that this patient will end his life. The same principle applies to stated threats or ideas of harm to others (including children); share and act. Patients will often ask for some information not to be shared, for various reasons. Try to respect that wish, although record the nature of any objections. Discuss the specifics with your supervisor; in England Caldicott Guardians are appointed for each locality to assist with difficult decisions on confidentiality.

Introduce yourself by name, and make clear how junior/senior you are in the service: ‘I am a student here and Dr X suggested we speak for about an hour so I can discuss your case with Dr X later’. If you think it will help, offer a handshake, although recently introduced social distancing measures currently make this less practical. Do not overthink it; if the person (for whatever reasons, some are cultural including a male-female dynamic, other reasons reflect infection control and an elbow bump establishes your professional relationship) does not shake your hand, smile, sit down and begin the interview. If the patient recoils from you, make a factual note of this (‘he was not pleased to see me and turned away as I approached’) as this is a positive finding that might indicate paranoia or past negative experiences with clinicians. Be open and honest at the start of your interview: ‘Doctor X has asked me to assess your difficulties to see if there are psychological aspects we can identify and help you with’ or ‘I understand you have taken an overdose of tablets (or harmed yourself), and a psychiatric interview is a necessary part of our assessment and treatment’. If there is potential bias in the interview (e.g. you are admitting him to hospital following the completion of a legal involuntary committal by others, assessing him following a disagreement with another professional or you are preparing a court report), say this and record these circumstances at the start of your notes.

Keeping patients safe is the primary objective. Even a busy emergency department must provide a safe room for patients who have attended as a result of self-harm. These rooms are private, quiet, free from ligature points or equipment that could be used to injure, and have more than one door. Speedy exit is important if the interview overstimulates the patient and the interviewer (you) needs to leave quickly to protect your safety. This said, the vast majority of non-intoxicated emergency room patients welcome the time to talk about what led them here, and to explore solutions to their difficulties. Wanting to ‘talk about it’ in a crisis or at a low point is a universal human experience; this is true even for patients who did not choose to come for psychiatric evaluation. Crisis interviewees show a range of behaviours, from people who freely communicate distressing emotions to those who will seek to conceal them. Suicidal ideas evoke shame and guilt; speaking about them is usually a great relief. However, some patients may choose a junior member of the team (e.g. a student [you]), to whom they disclose distressing suicide plans. This might be because they do not want anything done about it or to reflect other mixed, strong feelings. The important point is that you have already had an explicit conversation about the limits of confidentiality, and that you act professionally to share this new risk information with others.

Six-point checklist before your assessment begins:

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  Time and place: when? For how long? And where will you interview?

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  Safety: yours then his. Think through what you now know about this patient. Have you read about past safety concerns? Have you had a conversation with a senior colleague about risks, and what you need to do to mitigate these? What are the means by which you will get help if needed quickly?

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  Preparation: available past notes. Decide whether you want to get a collateral history after or before your interview. Who else will be in the room?

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  Dignity and privacy: ensure the interviewee feels comfortable, safe and respected. Acknowledge the disruption of a long interview.

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  Record keeping during interview (pen and paper): write down key names, dates and some quotations as they are said. In your first attempts at psychiatric interview, write out some history and MSE headings as prompts.

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  If the room has a computer, avoid staring at the screen when you could be interacting with your patient.

It is strongly recommended that you adhere closely to the structure of an interview outlined here as you learn how to complete a psychiatric evaluation; this improves the written records and reduces the chance you will forget a major component of either the history or the MSE.