Before meeting the patient prepare for the interview. Determine the reason for referral and look at the available medical and psychiatric history and current medication. Ask if the patient will be attending alone or accompanied and if special arrangements will be required in the room, for example if the patient is in a wheelchair.

After introducing yourself, make sure the patient and their companion are comfortable and check if the patient can hear and understand you. If not, can communication be improved with hearing aids or writing things down and/or involvement of interpreter or the sensory team?. Apart from sensory problems, cognitive deficits (short attention span, memory problems) and dysphasia can affect communication and prevent relevant information being obtained from the patient. In these cases an informant is essential for proper assessment. Adjust the pace of dialogue to the patient’s needs: too slow for a cognitively intact patient can sound condescending, too fast for people who cannot keep up can be disastrous.

If the patient is accompanied, establish who the companion is and what their role will be during the interview. Are they an informant or will they provide support for the patient? Have they requested the assessment?

The first interview with the patient and the psychiatric history obtained in this session is extremely important as future assessments will refer to it. Thus, details on nature and onset of all previous episodes, triggers and prodromes, risk factors, duration of episodes, medical co-morbidities, interventions (medication, hospitalization, sectioning, psychotherapy, home help, etc.) and their effect, pharmacological history including compliance, quality of recovery and level of functioning when recovered, should be recorded whenever possible. Your knowledge in psychopathology should guide the questions into obtaining relevant information.

To start the interview, allow the patient or/and informant to explain their view of the presenting complaint.

Start with general questions such as ‘Have you ever had any problems to do with your mental health?’ and ‘Have you ever seen your GP or a psychiatrist for these?’, then explore each concern in turn. A patient with poor insight into his previous psychiatric problems might acknowledge having been under psychiatrists for a long time but not having had a mental health problem. Conversely, many people suffer from sub-clinical symptoms or even disorders of clinical severity but have never been assessed or had any treatment.

The context of symptoms’ onset is of great relevance in geriatric psychiatry. Social and medical factors can play a greater role than genetics in some psychiatric disorders with late onset and, without addressing these, the patient might not recover fully.

Consideration of recent losses such as retirement, bereavement, change in social and financial circumstances, social isolation, loss of abilities and increase in dependency etc. must inform therapeutic intervention, thus recording them is important.

Medical conditions as well as medications prescribed for these can be associated with psychiatric disorders: stroke¹ and cancer² have a high co-morbidity with depression; organ failure may cause delirium³; respiratory problems are frequently associated with anxiety or panic attacks⁴; some antihypertensives can cause depression⁵; cortisone⁶ and anti-Parkinsonian drugs may cause psychosis; drugs with anticholinergic effects can cause or accentuate confusion, to enumerate only some.

Conversely, care must be given to falsely perceived onset of symptoms. A classic example is memory problems starting ‘suddenly’ after the spouse’s death; it is often the case that the patient’s memory problems had been more longstanding but not apparent due to spouse’s interventions and prompting. Careful questioning of relatives and other informants would probably reveal cognitive problems prior to bereavement. Sometimes the perceived onset is in fact an aggravation of pre-existing symptoms or the moment at which their intensity becomes significant.

An answer such as ‘I have always had this problem’ requires clarification as to why they presented for assessment now.

The present disorder might have started in a different form, for example psychosis or confusion following a long depressive episode pointing towards a diagnosis of psychotic depression; confusion following a serious illness, surgery or stroke suggesting delirium; depression with previous episode(s) of mania suggesting bipolar disorder; dementia starting with depression, anxiety or psychosis; substance abuse starting with anxiety or depression. A sudden onset of psychiatric symptoms can suggest organic aetiology.

After identifying the presenting complaint, brief questioning about any other problem, be it social, medical or psychiatric, will help complete the picture.

One approach is to start with the personal history and once you have information about the patient’s lifeline and major life events start asking about the psychiatric history. On one hand this reassures the patient that you are assessing them in an holistic way and are not only ‘fishing’ for symptoms and, on the other hand, it gives you a better view of the previous level of functioning and, if applicable, the impact of the psychiatric problem on their lives. Some patients may prefer to go straight to the problem.