The Primary Care Psychiatric Interview

John Onate MD

Glen L. Xiong MD

Robert McCarron DO

A 55-year-old homeless man with type 2 diabetes and hypertension presents for an initial evaluation with a chief complaint of “pain in my feet.” A quick review of the chart shows poor adherence to follow-up appointments. The man is disheveled and poorly groomed. He avoids eye contact and looks downward during the interview. The patient says he is not sure when he first noticed the foot pain and states, “I don’t know why I came in this time. I’m so far gone it does not matter anyway.”

CLINICAL HIGHLIGHTS

The mental status examination for a psychiatric evaluation is analogous to the physical examination for a general medical assessment.
The AMPS screening tool (Figure 1.1) includes four primary clinical dimensions of the psychiatric review of systems: Anxiety, Mood, Psychosis, and Substance use. This approach can be easily used in the primary care setting as a starting point to develop a reasonable differential diagnosis for common psychiatric disorders.
The psychiatric interview places an emphasis on psychosocial function and should give a personalized description of the patient from a biopsychosocial perspective.
One helpful time-saving strategy is the use of the Supplemental Psychiatric History Form to help gather a preliminary psychiatric history. A patient should complete this form either before the first clinic visit or during later visits, if a psychiatric illness is suspected.

Clinical Significance

Up to 75% of all mental health care is delivered in the primary care setting (1). Unfortunately, reimbursement constraints and limited psychiatric training in most primary care curricula often discourage full exploration and thorough work-up of mental illness (2). Due to the stigma of psychiatric conditions, patients are often reluctant to present to mental health settings and may not seek treatment (3). However, most nonemergent psychiatric conditions can be treated successfully in primary care settings. The ability of the primary care clinician to carefully screen for and evaluate psychiatric symptoms is critical in order to accurately diagnose and effectively treat the underlying psychiatric disorder (4).

Clinical assessment relies heavily on both obtaining the medical history and completing a physical examination for general medical conditions. A similar approach is taken for psychiatric disorders with two main differences. First, the psychiatric interview places additional emphasis on psychosocial stressors and functioning. Second, the mental status examination is analogous to the physical examination for a general medical work-up and is the cornerstone for the psychiatric evaluation. Both of these tasks may be accomplished effectively with improved organization and practice. This chapter divides the psychiatric assessment into three sections: (1) the psychiatric interview, (2) the mental status examination, and (3) time-saving strategies.

The Psychiatric Interview

The initial interview is important as it sets the tone for future visits and will influence the initial treatment (5, 6). While the information obtained
from the interview is critical to establish a diagnosis, a collaborative, therapeutic relationship is a key component to a successful treatment plan. Therefore, the clinician should try to balance the urgency to obtain information with the need to establish a positive, trusting therapeutic alliance with the patient. Similar in style and complementary to the general medical history, the psychiatric interview is outlined below (Table 1.1).

CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS

The interview starts with a subjective recounting of the presenting problems from the patient’s perspective using open-ended questions. Reflective statements may be used to clarify and summarize particular problems (e.g., “You are telling me that you have been depressed for 3 months and because of that you feel like things will never get better.”). Clarification and confirmative restatements may also be used (e.g., “You are depressed because you feel that you cannot support your family and not because you lost your house and have to move into a smaller apartment. Did I get this right?”).

It is important to organize the sequence of events with each problem individually, giving the most time to the problem with the highest priority. For patients with multiple chronic problems, setting an agenda at the beginning of the encounter will also help them to understand and
conceptualize their medical problems. The history of present illness (HPI) should include the duration, severity, and extent of each symptom along with exacerbating and ameliorating factors. Patients vary greatly in their recall of subjective historical material, and often vague or contradictory material surfaces. Once consent is obtained from the patient, it is important to follow up on any inconsistencies with the patient and gather collateral information by speaking with family members and other treatment providers.

Table 1.1 Outline of the Primary Care Psychiatric Interview

Chief complaint and history of present illness (HPI)	For the first few minutes, just listen to better understand the chief complaint(s) Make note of changes in social or occupational function Use the AMPS screening tool for psychiatric symptoms
Past psychiatric history	Ask about past mental health providers and hospitalizations Inquire about whether the patient has ever thought of or attempted suicide
Medication history	Ask about medication dosages, duration of treatment, effectiveness, and side effects
Family history	The clinician might ask, “Did your grandparents, parents, or siblings ever have severe problems with depression, bipolar disorder, anxiety, schizophrenia, or any other emotional problems?”
Social history	*Socioeconomic status* “How are you doing financially and are you currently employed?” “What is your current living situation and how are things at home?”
	*Interpersonal relationships* “Who are the most important people in your life and do you rely on them for support?” “How are these relationships going?”
	*Legal history* “Have you ever had problems with the law?” “Have you even been arrested or imprisoned?”
	*Developmental history* “How would you describe your childhood in one sentence?” “What was the highest grade you completed in school?” “Have you ever been physically, verbally, or sexually abused?”

PSYCHIATRIC REVIEW OF SYSTEMS: AMPS SCREENING TOOL

A thorough review of the major psychiatric dimensions (or “review of systems”) should be completed for patients who present with even a single psychiatric symptom. In the time-limited primary care setting, this can be a difficult task. The most commonly encountered primary care psychiatric disorders involve four major clinical dimensions and can be remembered by the AMPS mnemonic: Anxiety, Mood, Psychosis, and Substance use disorders (Figure 1.1). Patients who present with isolated psychiatric complaints such as depression, irritability, anxiety, insomnia, and unexplained physical complaints and those with established psychiatric disorders such as personality or eating disorders should be assessed for the presence of anxiety, mood, psychotic, and
substance use disorders. We recommend incorporating the AMPS screening tool as part of the HPI. The conversation flows more naturally when the practitioner queries the patient comprehensively about both past and current symptoms. When a particular dimension is present and causing distress, further exploration is indicated (Table 1.2).

Figure 1.1 Psychiatric review of systems: AMPS screening tool.

Anxiety

Anxiety is common in the primary care setting and often comorbid with mood, psychotic, and substance abuse disorders. It is sometimes the primary etiology for a depressive or substance use disorder and the secondary condition(s) will not remit unless the primary anxiety disorder is treated. Anxiety is also a significant acute risk factor for suicide that is commonly underappreciated (see Chapter 14). The quickest and most effective way to screen for an anxiety disorder during the interview is to simply ask, “Is anxiety or nervousness a problem for you?” If the patient reports feeling anxious, it is advisable to say, “Please describe how your anxiety affects you on an everyday basis.” Depending on the answer, follow-up questions will help develop a reasonable differential diagnosis.

Mood

The best way to understand a patient’s mood is to ask, “How would you describe your mood or emotions over the past few weeks?” The self-reported mood is also an important part of the mental status exam and should be rated as either congruent or incongruent with the corresponding affect. The two main components of mood (depression and mania) should be fully assessed during each primary care psychiatric interview.

Depression is often secondary to and comorbid with primary anxiety, sleep, substance use, and other psychiatric disorders. Depressive symptoms should always be asked about when treating another psychiatric condition—even if the chief complaint is not depression. The two screening questions for a current major depressive episode are: (1) “Have you been feeling depressed, sad, or hopeless over the past two weeks?” and (2) “Have you had a decreased energy level in pleasurable activities over the past few weeks?” The sensitivity and specificity for the detection of a major depressive episode using these screening questions are 96% and 57%, respectively (6). If the answer to either of these two questions is positive, the clinician should have a high index of suspicion for a depressive disorder and probe further. An open-ended approach would be to ask, “What is your depression like on an everyday basis?” or “How does your depression affect your daily life?” In most cases, depressed patients will discuss their troubling symptoms and there will be no need to go through the entire “checklist” for depression (e.g., changes in appetite, energy, sleep, concentration). The Patient Health Questionnaire (PHQ-9) is a nineitem patient self-report form that can be used in the primary care setting to screen for depression or quantify changes in the severity of depression over the course of treatment. All depressed patients should be asked

about suicidal thoughts, plans, and intent, with documentation of answers in the medical record.

Table 1.2 The AMPS Screening Tool for Common Psychiatric Conditions

	SCREENING QUESTIONS	FOLLOW-UP QUESTIONS	DIAGNOSTIC AND TREATMENT INSTRUMENTS^a
Anxiety	“Is anxiety or nervousness a problem for you?”	“Please describe how your anxiety affects you on an everyday basis.” “What triggers your anxiety?” “What makes your anxiety get better?”	Generalized Anxiety Disorders Scale (GAD – 7)
Mood	Depression^b “Have you been feeling depressed, sad, or hopeless over the past 2 weeks?” “Have you had a decreased energy level in pleasurable activities over the past few weeks?”	“What is your depression like on an everyday basis?” “How does your depression affect your daily life?” “Do you have any thoughts of wanting to hurt or kill yourself or somebody else?”	Patient Health Questionnaire (PHQ-9) Mood Disorder Questionnaire (MDQ)
	Mania/hypomania “Have you ever felt the complete opposite of depressed, when friends and family were worried about you because you were too happy?” “Have you ever had excessive amounts of energy running through your body, to the point where you did not need to sleep for days?”	“When did this last happen, and please tell me what was going on at that time.” “How long did this last?” “Were you using any drugs or alcohol at the time?” “Did you require treatment or hospitalization?”
Psychosis	“Do you hear or see things that other people do not hear or see?” “Do you have thoughts that people are trying to follow, hurt, or spy on you?” “Do you ever get messages from the television or radio?”	“When did these symptoms start?” “What triggers your symptoms?” “What makes your symptoms get better?”	None recommended for the primary care setting
Substance use	“How much alcohol do you drink per day?” “Have you been using any cocaine, methamphetamines, heroin, marijuana, PCP, LSD, ecstasy, or other drugs?”	If yes: “How often do you use?” “As a result of the use, did you experience any problems with relationships, work, finances, or the law?” “Have you ever used any drugs by injection?”	CAGE^c CAGE-AID (adapted to include drugs) Alcohol Use Disorders Identification Test (AUDIT-C)
		If no: “Have you ever used any of these drugs in the past?”
^aThese are suggested instruments that could be considered. More details about relevant instruments are available in the corresponding chapters. ^bIf either of these two questions is answered affirmatively, follow-up questions should be asked and a PHQ-9 should be administered. ^cSee Chapters 6 and 7 for details.