The clinician obtains assessment data from several sources:

• Interview with the patient and his or her family
  
• History and physical examination
  
• Records from other healthcare facilities or prior treatment
  
• Laboratory and psychological tests
  
• Assessments by other professionals and paraprofessionals.

Other assessment techniques that are useful in diagnosis and treatment planning are discussed in Chapter 31.

The single most important source of information is the interview with the patient and family, which includes initial and ongoing conversations. Listening carefully to the patient and his or her family is a high-level skill that is essential to quality care across all settings.

Astute observation and attentive listening are hallmarks of the effective interviewer. During the interview, the clinician should be sensitive to both verbal and nonverbal cues that can be used to focus the interview. An effective interviewer lays the groundwork for a therapeutic relationship by building rapport through active listening (see Chapter 2). The interview should be adjusted to fit the needs and understanding levels of the individual patient and family and should proceed in an orderly fashion, letting the patient’s answers guide subsequent questions and finishing discussion on one topic before moving to another.

Before beginning the interview the clinician should introduce himself or herself, explain the purpose of the interview, and try to make the patient and family as comfortable as possible. If the clinician and patient are not fluent in the same language, a translator may be needed, but subtleties of patient communication may be sacrificed in the process of translation and interpretation.

The key elements of the interview are the identifying information, the chief complaint, the history of the present illness, the past psychiatric history, the personal history, family history, medical history, substance abuse history, and the Mental Status Examination (MSE).

30.3.1 Identifying Information

This information establishes the patient’s identity. His or her name should be recorded, along with any nickname or alternative names he/she may have been known by in the past (e.g., maiden name). Date of birth, or at least age, and race are other essential parts of every person’s record. If a patient is a member of a particular subculture based on ethnicity, country of origin, or religious affiliation, it may be noted here (e.g., Conservative/observant Jew). A traditional part of the identifying data is a reference to the patient’s civil status: single, married, separated, divorced, or widowed. If none of these traditional categories apply, and the person is in a committed relationship (hetero- or homosexual) this should be noted. If the patient is not the sole supplier of information this should be noted in this section.

30.3.2 Chief Complaint

The chief complaint is the patient’s responses to the question, “What brings you to see me/to the hospital today?” or some variant. The answer is usually quoted verbatim, placed within quotation marks, and should be no more than one or two sentences. Even if patients are very disorganized or hostile, quoting their response can give an immediate sense of where they are as the interview begins and provides information as to the accuracy of the information being provided to the clinician. In such cases, or if patients give no response, a brief statement of how the patient came to be evaluated should be made and enclosed in parentheses.

30.3.3 History of the Present Illness

The present illness history should begin with a brief description of the major symptoms that brought the patient to psychiatric attention. The most troubling symptoms should be detailed initially and a more thorough review can be subsequent. At a minimum, the approximate time since the patient was last at his/her baseline level of functioning, and in what way he/she is different from that now, should be described, along with any known stressors, the sequence of symptom development, and the beneficial or deleterious effects of interventions. How far back in a patient’s history to go, especially when he/she has chronic psychiatric illness, is sometimes problematic. In patients who have required repeated hospitalization, a summary of events since last discharge (if within 6 months) or last stable baseline is indicated. It is rare for more than 6 months of history to be included in this section; it is usually limited to the past month.

Extended elements in the history of the present illness would include events in a patient’s life at the onset of symptoms, as well as exactly how the symptoms have affected the patient’s occupational functioning and important relationships. Any concurrent medical illness symptoms, medication usage (and particularly changes), alterations in the sleep–wake cycle, appetite disturbances, and eating patterns should be noted. Significant negative findings should also be included.

30.3.4 Past Psychiatric History

Most of the major psychiatric illnesses are chronic in nature. Hence, patients may have had previous episodes of illness with or without treatment. New onset of symptoms, without any previous psychiatric history, becomes increasingly important with advancing age in terms of diagnostic categories to be considered. At a minimum, the presence or absence of past psychiatric symptomatology should be recorded, along with psychiatric interventions taken and the result of such interventions. An explicit statement about past suicide and homicide attempts should be included.

A more detailed history would include names and places of psychiatric treatment, dosages of medications used, and time course of response. The type of psychotherapy, the patient’s feelings about former therapists, adherence to treatment as well as circumstances of termination are important. It is also relevant to note what the patient has learned about the biologic and psychologic factors predisposing him/her to illness, signs and symptoms of relapse, and whether there were precipitating events.

30.3.5 Past Medical History

In any clinical assessment it is important to know about the patient’s general health status. Any current medical illness and treatment should be noted along with any major past illness requiring hospitalization. Previous endocrine or neurologic illness are of particular pertinence. Information should include significant illnesses throughout the lifespan. A careful past medical history can also at times bring to light a suicide attempt, substance abuse, or dangerously careless or risk-taking behavior, which might not be obtained any other way.

30.3.6 Family History

Given the evidence for familial, genetic factors in so many psychiatric conditions, noting the presence of mental illness in biologic relatives of the patient is a necessary part of any database. It is important to specify during questioning the degree of family to be considered –usually to the second degree: aunts, uncles, cousins, and grandparents, as well as parents, siblings, and children.

A history of familial medical illness including a genogram (pedigree), including known family members with dates and causes of death and other known chronic illnesses, is helpful. Questioning about causes of death will also occasionally bring out hidden psychiatric illness, for example sudden unexpected deaths that were likely suicides or illness secondary to substance abuse.

30.3.7 Personal History

At a minimum, this part of the history should include where a patient was born and raised, and in what circumstances – intact family, number of siblings, and degree of material comfort. Note how far the patient went in school. What were his/her experiences and challenges? What has been his/her occupational functioning? If patients are not working, why not? Has there been any involvement in criminal activity, and with what consequences? Has the patient ever married or been involved in a committed relationship? Are there any children? What is his/her current source of support? Does he/she live alone? Has he/she ever used alcohol or other drugs to excess and is there current use? Has he/she ever been physically or sexually abused or been the victim of some other trauma?