Overview of a Psychiatric Encounter

While there may be variability between how differentphysiciansPhysiciansIndividuals licensed to practice medicine.Clinician–Patient Relationship conduct the encounter, and a physician may tailor the encounter to suit the needs of a patient’s diagnosis, the general structure should be reproducible and follow a logical course.

1. Review available records and secure a safe, private place for the psychiatric interview.
2. Observe the patient’s nonverbalcommunicationCommunicationThe exchange or transmission of ideas, attitudes, or beliefs between individuals or groups.Decision-making Capacity and Legal Competence cues and assess their level ofagitationAgitationA feeling of restlessness associated with increased motor activity. This may occur as a manifestation of nervous system drug toxicity or other conditions.St. Louis Encephalitis Virus.
3. Introduce yourself to the patient.
4. Inquire about the patient’s chief reason for presentation.
5. Obtain the patient’s recent history of presenting illness and conduct the psychiatric interview.
6. Obtain the patient’s past personal history (i.e., past medical/psychiatric history,family historyFamily HistoryAdult Health Maintenance,social historySocial HistoryAdult Health Maintenance).
7. Conduct a mental state exam.
8. List the differential diagnosis.
9. Develop an appropriate plan of care with the treatment team:
   • Level of care required (hospitalizationHospitalizationThe confinement of a patient in a hospital.Delirium, intensive outpatient, outpatient)
   • Pharmacotherapy
10. Determine an appropriate follow-up interval.

Initial Part of Psychiatric Assessment

• Before speaking with the patient:
  • Secure a safe, private place for the interview:
    • Especially important forpatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with potential for violence in the psychiatric hospital or emergency room setting 
    • Providers must have access to easy escape, and the room should be clear of objects that pose potential harm to themselves or others.
  • A review of past medical records and laboratory studies is also helpful but may alsobiasBiasEpidemiological studies are designed to evaluate a hypothesized relationship between an exposure and an outcome; however, the existence and/or magnitude of these relationships may be erroneously affected by the design and execution of the study itself or by conscious or unconscious errors perpetrated by the investigators or the subjects. These systematic errors are called biases.Types of Biases the interview.
• Initial contact with the patient:
  • Observe nonverbalcommunicationCommunicationThe exchange or transmission of ideas, attitudes, or beliefs between individuals or groups.Decision-making Capacity and Legal Competence and assess their level ofagitationAgitationA feeling of restlessness associated with increased motor activity. This may occur as a manifestation of nervous system drug toxicity or other conditions.St. Louis Encephalitis Virus.
  • Introduce yourself to the patient and establish the doctor-patient relationship.
  • Use open-ended questions.
  • May require contacting collateral informants forpatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship who are poor historians.

History of the Present Illness

• Determine the onset and characteristic of symptoms: Be mindful of any prior stressful events, medical illness, or substance use.
• Course of symptoms:
  • History of similar symptoms in the past
  • Waxing vs. waning or both intermittently
  • Progression of symptoms 
• Triggers for symptoms: ameliorating and worsening triggers
• Screen for 5 key diagnostic criteria:
  • Mood symptoms: depression vs.maniaManiaA state of elevated excitement with over-activity sometimes accompanied with psychotic symptoms (e.g., psychomotor agitation, inflated self esteem and flight of ideas). It is often associated with mental disorders (e.g., cyclothymic disorder; and bipolar diseases).Bipolar Disorder
  • Psychotic symptomsPsychotic symptomsBrief Psychotic Disorder
  • Anxiety-related symptoms
  • Substance use
  • Suicidality/homicidality

Obtaining Past History

• Past medical/surgical history:
  • Many medical illnesses have symptoms that can induce psychiatric conditions (e.g.,hypothyroidismHypothyroidismHypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions.Hypothyroidism and depression).
  • Current medications, including dietary supplements, are also important to note.
• Family historyFamily HistoryAdult Health Maintenance:
  • Psychiatricfamily historyFamily HistoryAdult Health Maintenance is important, as some mental illnesses are seen more predominantly in the children and family members of affectedpatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship.
  • Medicalfamily historyFamily HistoryAdult Health Maintenance is also important.
• Social historySocial HistoryAdult Health Maintenance:
  • Much more extensive than other history taking
  • Developmental/early childhood history
  • Education level
  • Occupation history and financial resources
  • Religious/spiritual beliefs 
  • Relationships, dating,sexual orientationSexual orientationThe sexual functions, activities, attitudes, and orientations of an individual. Sexuality, male or female, becomes evident at puberty under the influence of gonadal steroids (testosterone or estradiol), and social effects.Sexual Physiology, and sexual history 
  • Hobbies and interests

Mental Status Examination (MSE)

• Psychiatric equivalent of the physical exam 
• Some components of the MSE are obtained through observation, while others are through questions.
• Useful for identifying cognitive impairments, disturbances in mood,psychotic symptomsPsychotic symptomsBrief Psychotic Disorder, and suicidal thoughts

Evaluation of Suicide Risk

• One of the most critical components of psychiatric assessment
• Determines whether patient meets criteria for inpatient vs. outpatient treatment
• Definitions:
  • Passive death wishes: when one thinks about not waking up without actively taking actions to harm oneself
  • Self-harm: methods to causepainPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways without intent to completesuicideSuicideSuicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death.Suicide (e.g., cutting) 
  • Suicidal ideationSuicidal ideationA risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm.Suicide: when thoughts have escalated to acts of self-harm 
  • Suicide attemptSuicide attemptThe unsuccessful attempt to kill oneself.Suicide: an action committed (e.g., shooting, hanging, overdose) in an attempt to harm oneself
  • Suicidal ideationSuicidal ideationA risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm.Suicide and past attempts are independent risk factors forsuicideSuicideSuicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death.Suicide. 
• Start with more-indirect questions, such as “Have you ever felt that life wasn’t worth living?”
• Psychiatrists can then be direct and ask:
  • “Have you had thoughts or plans to kill yourself?”
  • “Do you have access to a firearm?”
• Formulation of a specific suicidal plan is indicative of more serious and imminent intent than vague self-harm ideas without concrete plans.

Psychiatric Rating Scales

• Research-validated provider- or patient-reportedscalesScalesDry or greasy masses of keratin that represent thickened stratum corneum.Secondary Skin Lesions that are used to assist in diagnosis and to assess mental status
• Often administered quickly with paper and pencil 
• Not sufficient to diagnose a psychiatric condition on their own
• For MSE:
  • Mini-mental state examinationMini-Mental State ExaminationMajor Neurocognitive Disorders (MMSEMMSEMajor Neurocognitive Disorders)
  • Montreal Cognitive AssessmentMontreal Cognitive AssessmentMajor Neurocognitive Disorders (MoCAMoCAMajor Neurocognitive Disorders)
• For depression:
  • Patient health questionnaire
  • Beck Depression inventory II
• ForanxietyAnxietyFeelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders.Generalized Anxiety Disorder:
  • GeneralizedanxietyAnxietyFeelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders.Generalized Anxiety Disorder disorder 7 (GAD-7)
  • Screen for child anxiety-related disorders (SCARED) 
• For obsessive compulsive disorder: Yale Brown Obsessive CompulsiveScaleScaleDermatologic Examination (Y-BOCSY-BOCSThe Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is a clinician-rated scale for assessing the severity of obsessive and compulsive symptoms.Obsessive-compulsive Disorder (OCD)) 
• ForADHDADHDAttention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline.Attention Deficit Hyperactivity Disorder: VanderbiltADHDADHDAttention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline.Attention Deficit Hyperactivity Disorder diagnostic rating 
• For substance use disorders
  • Cut down,Annoyed,Guilty,Eye-opener (CAGE): specifically for briefscreeningScreeningPreoperative Care foralcohol use disorderAlcohol use disorderAlcohol is one of the most commonly used addictive substances in the world. Alcohol use disorder (AUD) is defined as pathologic consumption of alcohol leading to impaired daily functioning. Acute alcohol intoxication presents with impairment in speech and motor functions and can be managed in most cases with supportive care.Alcohol Use Disorder
    • Have you ever felt you needed toCut down on your drinking?
    • Have peopleAnnoyed you with your drinking?
    • Have you feltGuilty about your drinking?
    • Eye-opener: Have you ever had to drink 1st thing in the morning?

References

1. American Psychiatric Association. (2006). Practice guidelines for the psychiatric evaluation of adults, second edition. Am J Psychiatry. 163(6Suppl), 1–36.https://pubmed.ncbi.nlm.nih.gov/16866240/ 
2. Royal Children’s Hospital. (2024). Mental state examination. Retrieved June 17, 2025, fromhttps://www.rch.org.au/clinicalguide/guideline_index/mental_state_examination/
3. Sadock, BJ, Sadock, VA, & Ruiz, P. (2014). Chapter 5: Examination and diagnosis of the psychiatric patient. In Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed., pp. 192–289. Philadelphia, PA: Lippincott Williams and Wilkins.