15 Obtaining the Psychiatric History
Essential Questions
Syndromal history:
How old were you when you first had these symptoms?
- How many episodes have you had?
- When was the last episode?
Mnemonic for treatment history: Go CHaMP
- General questions.
- Who is your current Caregiver?
- Have you been psychiatrically Hospitalized?
- Have you taken Medications for these symptoms?
- Have you had Psychotherapy?
Recommended time: 10 minutes
The past psychiatric history (PPH) risks becoming a tedious exercise in documentation. You can avoid this by realizing how vital the PPH is to your twin goals of establishing a diagnosis and formulating a treatment plan.
Specific psychiatric disorders have specific natural histories, with characteristic risk factors, prodromal signs, ages at onset, and prognoses. Obtaining a detailed PPH for a particular patient allows you to compare the course of her illness with the textbook’s version of the course of illness, increasing the likelihood that you will make a correct diagnosis.
Often, patients will come to you after having been treated for many years. One reason such patients are eventually referred to an expert consultant is that experts are great at eliciting a detailed history of prior treatments. They can determine exactly what has been tried in the past and whether past treatment trials have been adequate. From this information, they can present informed recommendations about what should be tried next. And they can do all this in one or two 50-minute sessions.
Potential pitfalls in obtaining the PPH are similar to those lurking during the HPI. At one end of the continuum, some interviewers become so caught up in the intricacies of the PPH that they spend most of the evaluation time on it, to the detriment of, for example, the PROS. At the other end, the PPH can become a rote exercise and may be obtained too superficially, depriving the interviewer of information necessary to make a firm diagnosis.
Obtain the Syndromal History
Generally speaking, the HPI will take between 5 and 10 minutes, at the end of which you should have a few provisional diagnoses in mind. Your next job is to obtain the history of these syndromes. Specifically, you want to learn age at onset, premorbid functioning, and history of subsequent episodes up to the present.
Age at Onset
Knowing the age at onset may help you to decide between potential diagnoses, with anxiety disorders having a much earlier onset than either mood disorders or schizophrenia (Jones 2013).
Premorbid Functioning or Baseline Functioning
See Chapter 14 for a discussion of premorbid functioning/baseline functioning.
History and Precipitants of Subsequent Episodes up to Present
Include questions about the severity of episodes and exacerbations, as well as the duration of episodes. Often, this information comes out when you are obtaining the treatment history. For example, episodes of mania or exacerbations of schizophrenia often correspond with hospitalizations.
As with hospitalizations, a time-efficient method of asking about episodes is to ask about the first one, the latest one, and the total number of episodes.
- When did you have your first breakdown?
- How many have you had in total?
- When was your last one?
Obtain the Treatment History
You ask about prior treatments mostly to help with future treatment decisions but also to help nail down a diagnosis. For example, if lithium was helpful for an affective episode, bipolar disorder would be high on your list. You want to know what has been tried in the past and whether it has worked. Accuracy and detail are important here, because a sloppy treatment history can lead to poor future treatment decisions. For example, patients may be falsely labeled “treatment resistant” on the basis of old records indicating that numerous medications were “tried but were unsuccessful.” On closer questioning, such patients may in fact have had few adequate trials of medication.
I suggest the following format for obtaining the treatment history:
General questions
Current caregivers
Hospitalization history
Medication history
Psychotherapy history
Use the mnemonic Go CHaMP so that you don’t miss any category.
You won’t necessarily ask your questions in the above order—in fact, you will obtain much of this information during the HPI—but it’s helpful to think about these five aspects of the treatment history to make sure that you haven’t neglected to ask important questions. At some point during the interview, mentally review whether you have obtained enough information about each of these categories.
General Questions
More sophisticated and forthcoming patients will tell you almost everything you need to know about the treatment history in response to a general question. Other patients will require more specific questioning.
In some cases, the best “treatment” for a particular patient was a close relationship with someone or their escape from a dysfunctional relationship. You can learn this from a careful history, and it may become a part of your treatment recommendations.
Current Caregivers
You will need to know who your patient is seeing currently. If he is a new patient, you may be the only caregiver. If you are interviewing a patient with a chronic mental illness, he will likely have both a therapist and a psychopharmacologist, and he may also have a case worker (usually a social worker), a group therapist, and a primary care doctor (a family practitioner or an internist) and may be involved in day treatment or residential treatment.
Hospitalization History
For patients who have had multiple hospitalizations, do not spend your time ascertaining the names of the hospitals and dates of each admission; this could take the entire 50 minutes. Instead, find out when they were first and last hospitalized and about how many hospitalizations they’ve had over their lifetime. If a patient has had many hospitalizations, try to find out if they are clustered around a specific few years. Some patients will have had several hospitalizations earlier in the course of their disorder because they had little insight into their problem and were noncompliant with their medications. Later in life, their hospitalizations may be spaced much farther apart. Alternatively, the opposite pattern may appear, in which an affective disorder worsens with age. Think of hospitalizations as markers of disease severity.
In addition to asking these questions, it is often useful to ask why your patient was hospitalized:
Your assumptions about reason for hospitalization may be wrong, as illustrated by the following example.
CLINICAL VIGNETTE
A patient with chronic schizophrenia stated that he’d been hospitalized several times over the past 2 years. The resident initially assumed that these hospitalizations were for psychotic decompensations, but when asked, the patient said that most were alcohol detoxification admissions. This prompted the resident to obtain a much more thorough substance abuse history than he had planned.
Medication History
The most important limit on the bioavailability of medication has nothing to do with pharmacodynamics or pharmacokinetics; rather, it is patient noncompliance.
Dr. Ross Baldessarini
Chief of Psychopharmacology
McLean Hospital
To the extent possible, document all the medications the patient has tried. Many patients will not remember generic names or may only remember what the pill looked like or the side effect it caused. Obviously, the more you know about alternative names, shapes, and side effects of medication, the more efficiently you will be able to obtain this history. I find smartphone apps such as Epocrates to be helpful, because they have photographs of medications, which help patients identify them. For psychologists and social workers, a number of books have been published that teach the basics of psychopharmacology to non-MDs, and I recommend that you become familiar with this information.
Many psychiatric medications take several weeks to have a therapeutic effect. Antidepressants take 4 to 6 weeks. Antipsychotics may take 1 to 2 weeks or longer, depending on the clinical situation. Thus, merely documenting that a patient has tried a particular medication does not mean that he’s had an adequate trial.
At this point, a normalizing question may be helpful:
HOW ACCURATE ARE PATIENTS WHEN RECALLING PRIOR TREATMENTS?
A fascinating study examined this clinically relevant but underexplored question (Posternak and Zimmerman 2003). An independent evaluator interviewed 73 patients who had been treated in an academic psychiatric clinic for an average of 3.5 years. After the interview, researchers reviewed clinic charts to determine how accurately the patients recalled their antidepressant trials. The results? They did pretty well, overall, recalling 80% of the monotherapy (single medication) trials over the prior 5 years. However, they only remembered 26% of augmentation trials (i.e., when a second medication is added to the first to boost the response). And augmentation trials that were over 2 years old were not remembered by anybody. The bottom line is that your patient will accurately recall medications tried if the regimen has always been simple, but those who have taken combinations of medications will be much less reliable.
CLINICAL VIGNETTE
A resident was doing a psychopharmacologic evaluation of a 46-year-old married Latino woman with a several-year history of depression and anxiety. During the treatment history, the patient stated that she had taken a number of different antidepressants from different classes with only minimal effectiveness. The resident asked a normalizing question about whether the patient had taken her medications consistently; she responded that she only took them when she felt anxious, which varied from daily to once every 2 weeks. In fact, the resident was unable to document an adequate trial of any antidepressant and subsequently focused on educating the patient on the necessity of consistently taking medications.
Psychotherapy History
In recent years, psychotherapies have become increasingly tailored to specific disorders, and evidence of effectiveness has become irrefutable (Barlow 2014). In addition, it has become clear that therapy can have negative side effects, as can medication. Thus, obtaining a history of psychotherapeutic treatments is important.
These basic parameters of session frequency and length of treatment are usually nonthreatening and easy to elicit.
More often than not, your patient will not know the technical name of the therapy he received. You can compensate for this by describing the therapy.
You can also ask a more open-ended question:
Knowing this may or may not be useful. For example, a patient may say she had a therapist, when in fact she was seen by a psychiatrist once a month for brief visits. This was more likely psychopharmacologic management than psychotherapy.
This information will be particularly valuable in assessing the patient’s suitability for further therapy.
The way a patient ended treatment may tell you much about how he viewed treatment and may help you plan how to proceed with your own treatment of the patient. Some patients, for instance, have a history of ending therapy by simply not showing up for the next session. Others may have had a stormy termination. Others may have terminated “by the book” but continue to feel unexpressed sad or angry feelings toward the therapist.