APA Updates Guidelines on Psychiatric Evaluation in Adults
Am Fam Physician. 2016 Jul 1;94(1):62-64.
Author disclosure: No relevant financial affiliations.
Key Points for Practice
The initial psychiatric evaluation should include a review of the patient's mood, anxiety level, thought content and process, perception, and cognition, and history of trauma and psychiatric history.
In the setting of current suicidal ideas, identify the intended course of action, access to suicide methods, motivations for suicide and reasons for living, quality of the therapeutic alliance, and history of suicidal behaviors of biologic relatives.
Quantitative measures of symptoms, level of functioning, and quality of life should be obtained to improve clinical decision making and treatment outcomes.
From the AFP Editors
The American Psychiatric Association (APA) recently released the third edition of its guidelines on psychiatric evaluation of adults. The nine-part guideline has been updated based on new evidence identified since the previous edition was released in 2006. Although the strength of the evidence supporting the recommendations in the updated guidelines is low, there is consensus that their benefits clearly outweigh the harms. In cases where the balance of benefits and harms is difficult to judge, or the benefits or harms are unclear, the APA made suggestions for care instead of recommendations. For more information about these guidelines, including tips for implementation, see the full report from the APA.
Guideline 1: Review Symptoms, Trauma History, and Treatment History
The APA recommends that the initial psychiatric evaluation include a review of the patient's mood, anxiety level, thought content and process, perception, and cognition. The clinician should review the patient's trauma history and his or her psychiatric history, including psychiatric diagnoses, treatments (type, duration, and medication dosages), adherence and response to treatments, and history of psychiatric hospitalization and emergency department visits for psychiatric issues. The goal of this guideline is to improve the quality of the clinician-patient relationship, the accuracy of psychiatric diagnoses, and the appropriateness of treatment selection. Knowledge of prior psychiatric diagnoses can inform the current diagnosis because a patient may be presenting with a continuation of a previously diagnosed disorder, or may now have a different disorder that commonly co-occurs with the first. Past treatments are relevant because lack of effectiveness may suggest a need to reconsider the accuracy of the diagnosis. Symptoms that emerge during treatment (e.g., hypomania or mania in a patient with depression) may also require reassessment of the diagnosis.
Guideline 2: Evaluate Substance Use
To identify patients with substance use disorder and to facilitate treatment planning, the APA recommends that clinicians assess the patient's use of tobacco, alcohol, and other substances (e.g., marijuana, cocaine, heroin, hallucinogens), as well as misuse of prescribed or over-the-counter medications or supplements. Ensuring that initial psychiatric evaluations include assessment of substance use may improve the differential diagnosis because substance use disorders, other psychiatric disorders, and other medical conditions may share similar presenting symptoms, such as anxiety, depression, mania, and psychosis.
Guideline 3: Assess Risk of Suicide
The APA recommends that clinicians evaluate the patient's current suicidal ideas, plans, and intent, including active or passive thoughts of suicide or death; prior suicidal ideas, plans, and attempts, including attempts that were aborted or interrupted; prior intentional self-injury in which there was no suicide intent; anxiety symptoms, including panic attacks; hopelessness; impulsivity; current or recent substance use disorder or change in use of alcohol or other substances; presence of psychosocial stressors (e.g., financial, housing, legal, school/occupational, or interpersonal/relationship problems; lack of social support; painful, disfiguring, or terminal illness); and aggressive or psychotic ideas, including thoughts of physical or sexual aggression or homicide. The clinician who conducts the initial psychiatric evaluation should document an estimation of the patient's suicide risk, including factors influencing risk.
If the patient reports having current suicidal ideas, the APA recommends that clinicians identify the intended course of action if symptoms worsen; determine the patient's access to suicide methods, including firearms; identify possible motivations for suicide (e.g., attention or reaction from others, revenge, shame, humiliation, delusional guilt, command hallucinations) and reasons for living (e.g., sense of responsibility to children or others, religious beliefs); assess the quality and strength of the therapeutic alliance; and ask about the history of suicidal behaviors in the patient's biological relatives. If the patient has attempted suicide in the past, the clinician should ask about details of each attempt (e.g., context, method, damage, potential lethality, intent).
Guideline 4: Assess Risk of Aggressive Behaviors
To identify patients at risk of aggressive behaviors, the APA recommends that the initial psychiatric evaluation of a patient include assessment of current or past aggressive or psychotic ideas, including thoughts of physical or sexual aggression or homicide; past aggressive ideas or behaviors (e.g., homicide, domestic or workplace violence, other physically or sexually aggressive threats or acts); legal or disciplinary consequences of past aggressive behaviors; exposure to violence or aggressive behavior, including combat exposure or childhood abuse; and current or past neurologic or neurocognitive disorders or symptoms. The clinician who conducts the initial psychiatric evaluation should document an estimation of the patient's risk of aggressive behavior, including homicide, and factors influencing risk.
If the patient reports having aggressive ideas, the APA recommends that clinicians assess the patient's impulsivity, including anger management issues; determine the patient's access to firearms; identify specific persons toward whom homicidal or aggressive ideas or behaviors have been directed; and ask about the history of violent behaviors in the patient's biological relatives.
There is no evidence that risk of aggression is increased by asking about past experiences, symptoms such as impulsivity, or current aggressive and homicidal ideas or plans. However, assessment could identify persons as being at risk when they are not, which could result in unneeded hospitalization or other consequences. Just as it is not possible to predict which persons will exhibit aggressive behaviors, there is no way to predict which ones would be incorrectly identified as being at risk, and no way to estimate the potential magnitude of this harm.
Guideline 5: Evaluate Cultural Factors
To identify cultural factors that could influence the therapeutic alliance, promote diagnostic accuracy, and enable treatment planning, the APA recommends determining the patient's need for an interpreter—even if the patient speaks the same language as the clinician—and assessing cultural factors related to the patient's social environment. Persons from different backgrounds may have different explanations of illness, views of mental illness, and preferences for psychiatric treatment, particularly given the cross-cultural differences in the stigma of psychiatric disorders. For this reason, the APA also suggests assessing the patient's personal and cultural beliefs, and cultural explanations of psychiatric illness. For example, an individual's self concept, response to stressors, or current symptoms may be shaped by racism, sexism, or discrimination; by traumatic experiences during or after migration from other countries; or by challenges of acculturation, including intergenerational family conflict. Cultural factors can also influence the patient's style of relating with authority figures, such as health care professionals.
Guideline 6: Assess Medical Health
The APA recommends that clinicians determine whether the patient has an ongoing relationship with a primary care health professional. Persons with psychiatric disorders can have medical conditions that influence their functioning, quality of life, and life span. Compared with the general population, mortality rates are increased in persons with mental illness, particularly those with psychotic disorders, depressive disorders, alcohol or substance use disorders, personality disorders, and delirium. To identify nonpsychiatric medical conditions that could affect the accuracy of a psychiatric diagnosis and the safety of the treatment plan, the APA recommends that the initial psychiatric evaluation include assessment of the patient's general appearance and nutritional status; involuntary movements or abnormal motor tone; coordination and gait; speech, including fluency and articulation; sight and hearing; physical trauma, including head injuries; past or current medical illnesses and related hospitalizations; relevant past or current treatments, including surgeries, other procedures, or complementary and alternative treatments; allergies or drug sensitivities; sexual and reproductive history; and past or current sleep abnormalities, including sleep apnea. It also recommends that clinicians document all current and recent medications (prescribed and nonprescribed, including herbal and nutritional supplements and vitamins) and adverse effects of these medications.
In addition, the APA suggests that the initial psychiatric evaluation include assessment of the patient's height, weight, and body mass index; vital signs; skin, including any stigmata of trauma, self-injury, or drug use; cardiopulmonary status; past or current endocrine disease; past or current infectious disease, including sexually transmitted diseases, human immunodeficiency virus infection, tuberculosis, hepatitis C, and locally endemic infectious diseases (e.g., Lyme disease); past or current neurologic or neurocognitive disorders or symptoms; and past or current symptoms or conditions associated with significant pain and discomfort. The APA also suggests that clinicians review the patient's constitutional symptoms (e.g., fever, weight loss), eyes, ears, nose, mouth, throat; and cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, endocrine, hematologic, lymphatic, and allergic/immunologic symptoms.
Guideline 7: Use Quantitative Tools
To improve clinical decision making and treatment outcomes, the APA suggests that the initial psychiatric evaluation include quantitative measures of symptoms, level of functioning, and quality of life (e.g., rating scales, patient questionnaires). Clinical decision making, including diagnosis and treatment planning, requires a careful and systematic assessment of the type, frequency, and magnitude of psychiatric symptoms, as well as an assessment of the effect of those symptoms on the patient's day-to-day functioning and quality of life. There are several potential benefits to obtaining this information as part of the initial psychiatric evaluation through the use of quantitative measures. Compared with a clinical interview, these tools may help the clinician conduct a more consistent and comprehensive review of the patient's symptoms, which may prevent potentially relevant symptoms from being overlooked.
Guideline 8: Involve the Patient in Decision Making
To improve patient engagement and knowledge about his or her diagnosis and treatment options, the APA recommends that during the initial psychiatric evaluation, the clinician should explain the differential diagnosis, risks of untreated illness, treatment options, and benefits and risks of treatment. The clinician should also ask about the patient's treatment preferences and collaborate on decisions about treatment. Such collaboration may improve the therapeutic alliance, satisfaction with care, and adherence with treatment.
Guideline 9: Document the Psychiatric Evaluation
When a patient's care is being provided by multiple health care professionals using a shared treatment or treatment team approach, collaboration and coordination of care are crucial. To improve clinical decision making and increase coordination of psychiatric treatment with other clinicians, the APA recommends documenting the rationale for treatment selection, including the specific factors that influenced the treatment choice. It suggests that clinicians also document the rationale for clinical tests.
Guideline source: American Psychiatric Association
Evidence rating system used? Yes
Literature search described? Yes
Guideline developed by participants without relevant financial ties to industry? Yes
Published source: PsychiatryOnline. November 2015.
Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.
This series is coordinated by Sumi Sexton, MD, Associate Deputy Editor.
A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.
Copyright © 2016 by the American Academy of Family Physicians.
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