initial psychiatric evaluation questions

Population: Patients in psychiatric units in Switzerland. She reports no conflicts of interest with her work on these guidelines. For example, NQF Measure 0310, “Back Pain: Shared Decision Making” (http://www.qualityforum.org/QPS/0310) considers if the medical record of a patient with back pain includes documentation that a discussion occurred between the physician and the patient, prior to surgery, of the following: 1) treatment choices, including alternatives to surgery; 2) risks and benefits; and 3) evidence of effectiveness. This approach could also have unintended consequences: As described under “Potential Benefits and Harms,” when the amount of time available for an evaluation is constrained, time used to focus on assessment of suicide risk could reduce time available to address other issues of importance to the patient. General Interview. Questions vary depending on the purpose of the evaluation, but most evaluations include the same basic questions. 2006; Piatt et al. Each treatment arm contained the psychoeducational medication training. Authors compared prescribed medications with patient preferences. Intervention: Participants completed a questionnaire adapted from the Health Screening Survey, including quantity or frequency items for alcohol use, dieting, tobacco, and exercise in the previous 3 months; perceptions of a past or current alcohol problem; and seven past-year alcohol consequence items from the AUDIT. Magnitude of effect: Not applicable. They also should not be viewed as suggesting the use of a standardized scale to identify individuals at high suicide risk. Because these exceptions occur frequently in many settings, the approach to implementation might involve measuring for the presence or absence of any text in a field labeled “primary health care professional” rather than for the presence or absence of a specific name. One of the last steps in the hiring process for police officers, the psychological exam can make or break your chances at a law enforcement career. For example, clinicians performing “standard care” in these studies may have been more diligent about involving patients in decision making because these patients were being monitored. Assessment may occur directly or by review of the results of a recent assessment by another clinician. The context and accuracy of the information obtained in the interview are also important to keep in mind before applying it to treatment planning. In many cultures, families play an important source of support during times of illness, and in some cultures treatment decisions are made by family members rather than by the individual. For many patients, language needs can be easily determined. 1985; http://internal.psychology.illinois.edu/~ediener/SWLS.html) has been developed and used to assess life satisfaction and quality of life in individuals with chronic mental illness. Relative to the general population, mortality rates are increased for individuals with mental illness, particularly those with psychotic disorders, depressive disorders, alcohol/substance use disorders, personality disorders, and delirium (Chang et al. 2012). The authors explained that there was a smaller number of patients available at the rural center than at the urban center; the proportion of control patients from each center was equal to the proportion of intervention patients from each center. Timing: Patients were assessed at baseline and again at 5 weeks. Cultural factors are also important to consider when framing questions, since issues such as shame, guilt, or humiliation can be culturally mediated and influence a patient’s risk or willingness to discuss suicidal thoughts or suicide plans. Other treatments may be prohibited or misunderstood because of cultural beliefs. Department of Psychiatry, Wright State University Boonshoft School of Medicine, Dayton, OH, USA. Timing: The study was conducted from 2001 to 2005. 2005). The process is fully described in a document available on the APA website: http://www.psychiatry.org/File%20Library/Practice/APA-Guideline-Development-Process--updated-2011-.pdf. Groups were rated for adherence, attitudes toward treatment, symptoms, and social functioning. A strong social support network can also serve as a protective factor. Comparators: The control group was provided with general information about psychiatric advance directives, copies of standard psychiatric advance directive forms, and a toll-free number for the local consumer organization that provides consultation on psychiatric advance directives. In addition, the patient’s apparent therapeutic response, lack of response, or reported side effects may not be a direct result of the treatment itself. Excluded were patients who had a terminal condition or global aphasia. Elements of the examination, such as vital signs, height, and weight, may also be obtained by nursing staff or a medical assistant. Assessment of psychiatric symptoms and psychiatric treatment history is by definition a core activity of an initial psychiatric evaluation. No differences were found between the groups regarding compliance, insight into psychosis, psychosocial function (GAF), or relatives’ expressed emotion scores post-intervention or at 1-year follow-up. Detection bias: Moderate Risk: Patients were assessed using self-reports. Intervention: Subjects were asked what treatment they preferred and then were randomly assigned to receive supportive-expressive psychotherapy, sertraline, or pill-placebo. It is probable that those who consumed larger amounts of alcohol would be less likely to agree to participate in the study. Also, the proxy of haloperidol use must be used to determine whether use of the CAM-ICU improves clinical decision making. Furthermore, there may be opportunities to improve quality in these areas for patients across healthcare settings, not just mental health. The authors also noted that the intervention was feasible for most of the patients and did not require additional time spent by physicians. 2013; Witt et al. Detection bias: Low Risk: With the presence of a computerized patient management system, rates of haloperidol use and compliance with CAM-ICU assessments could be collected reliably. In addition, this approach may not encourage clinicians to formulate an overall estimation of risk of aggressive behaviors, as information on these independent risk factors may be collected for other reasons, such as to assess suicide risk or substance use. 2004). 2012; Harris and Barraclough 1997; Hawton and van Heeringen 2009; Li et al. Intervention: Patients received a physical examination by a general practitioner, tests of sight and hearing, computerized medical questionnaire, SMA-12, and an ECG. In addition to supporting clinical decision making and communication, such documentation can also serve as a foundation for planning of treatment. Sponsor-related bias: Low Risk: There is no conflict of interest statement in the study. 0000002920 00000 n Patients can be encouraged to consider completing a psychiatric advance directive, advance care plan, or health care proxy at a time when they have the decisional capacity to do so (Moye et al. Intervention had no effect on medication management. Side effects of somatic treatments for psychiatric conditions can also produce or increase the risks of preexisting medical conditions (Goldberg and Ernst 2012). Do you typically (i.e., almost always) obtain quantitative measures of these items on at least one occasion after initial evaluations of your patients? Furthermore, research studies have demonstrated the validity and reliability of many quantitative measures, including both self- and clinician-administered scales, which can also be useful in routine clinical practice (Rush et al. 1991; Haney et al. 2013; Lemogne et al. In all situations, a necessary first step will be selecting appropriate scales for use. 2007). For patients who present with a psychiatric symptom, sign, or syndrome in any setting, is formulation of an appropriate treatment plan improved when the initial psychiatric evaluation typically (i.e., almost always) includes assessment of his or her language needs (i.e., basic language ability and need for an interpreter)? “Quantitative measures” are defined as clinician- or patient-administered tests or scales that provide a numerical rating of features such as symptom severity, level of functioning, or quality of life and have been shown to be valid and reliable. 2009; Zimmerman and McGlinchey 2008b; Zimmerman et al. A popular treatment for anxiety, depression, bipolar, P.T.S.D., and many mental disorders. Other barriers relate to the amount of time that the clinician has available to engage in shared decision making or the lack of other resources (e.g., reimbursement, decision aids, other health professional staff) to help support the shared decision-making process (Friedberg et al. Selection bias: Low Risk: The authors used logbook of emergency department patients to identify consecutive patients. Comparators: One control group at each site who did not receive medical screening. Attrition bias: High Risk: An intention-to-treat analysis was performed to minimize attrition bias. He reports no conflicts of interest with his work on these guidelines. 0000001739 00000 n Exclusion criteria: obvious alcohol or drug intoxication, prior psychiatric diagnosis, patients with medical complaints who overdosed or attempted suicide. An individual with uremia or obstructive sleep apnea may feel apathetic, fatigued, and inattentive, wrongly implying the presence of depression even in the absence of mood changes. Initial evaluation appointments may last from 60-90 minutes. I am seeing a psychiatrist for my anxiety, panic attacks, insomnia and seizures. Population: The patients were recruited for the study from seven psychiatric centers within a rural region of Germany. Furthermore, as described under “Implementation,” no standardized scale for assessing risk has been shown to have clinically useful specificity, sensitivity, or predictive value. Overreliance on quantitative measures may lead other key elements of the patient’s symptoms and life circumstances to be overlooked. More specific results are unavailable for review. 2011). Attrition bias: Not applicable. The body of research evidence is made up of many randomized controlled trials and several observational studies. Increasing numbers of young adults reside with their parents (Vespa et al. 63 of the 100 patients had an organic etiology for their psychiatric symptoms. For patients who present with a psychiatric symptom, sign, or syndrome in any setting, are diagnostic accuracy and treatment safety improved when the initial psychiatric evaluation typically (i.e., almost always) includes the following elements of a review of systems? Selection bias: High Risk: Patients in the intervention group were different in several ways from patients in the control group. The relevance of past treatments to diagnostic accuracy is more indirect but still relevant. Discussion may also be initiated with a brief open-ended question, which is conducive to capturing the nuances and narrative of the patient’s concerns. Attrition bias: High Risk: Although the study defined enrolled subjects as the ones who completed the survey and then agreed to return to complete the SCID and the AUDIT, there is a potential for attrition bias in that only 50 of the initial 149 who completed the survey agreed to return. Approximately 24% of patients had disorders due to psychoactive substance use; 31% had schizophrenia, schizotypal, or delusional disorders; and 16% had mood disorders. Attrition bias: High Risk: 8 of the 84 patients in the treatment group, and 11 of the 64 patients in the control group, were lost to follow-up. This guideline is not appropriate for quality measurement because the balance of benefits and harms of the suggested assessments is uncertain. Use of the scale was associated with greater diagnostic accuracy as compared with assessment without the scale, but the effect was weak and the study population was limited to patients in an intensive care setting. Such details may be important in judging whether a patient’s symptoms appear to be treatment resistant, with associated implications for treatment planning. No differences were found between the groups regarding compliance, insight into psychosis, or Global Assessment of Functioning score, or in relatives’ expressed emotion scores, after the intervention or at 1-year follow-up. There were nonsignificant trends for the participants to have shorter duration of illness and for fewer to have a previous substance abuse diagnosis or to have experienced a previous compulsory admission. As electronic health records become more commonly used, electronic capture of quantitative measures can allow computerized decision-support systems to be used in guiding evidence-based treatment (Trivedi et al. Although proximal and distal risk factors may each be modifiable, they may require different types of interventions to address risk. As described under “Implementation,” the use of shared decision-making approaches within an initial psychiatric evaluation depends on the individual patient and the clinical context. If the patient has had a recent medical assessment, the psychiatrist may be able to review the results of the history, physical examination, and laboratory or imaging findings in lieu of a direct assessment of the patient. In the units performing structured risk assessments, there was a 68% decrease in the number of aggressive incidents. 2011) or stopped before any injury occurs (Barber et al. and "How many hours do you work per week?" Substance Abuse 9. Exposure may occur through direct experience or by observing an event in person or through technology (e.g., television, audio/video recording) or by learning of an event that occurred to a close family member or close friend. A substantial body of epidemiological, cohort, and case-control studies has shown associations between the risk factors described in this guideline and medium- to long-term relative risk of aggression in populations (Coid et al. The new strategy involved all patients starting with an admission interview, followed by a tour of the unit and an explanation of the program. Reporting bias: Low Risk: The battery of tests was prespecified. There was no evidence that better compliance produced a better therapeutic result. Unlike an outcome measure, a process measure should not depend on the patient’s response or report. 2011; Zimmerman and McGlinchey 2008a; Zimmerman et al. Another key potential benefit of obtaining quantitative measures during an initial evaluation is to establish baseline measurements against which progress can be measured as treatment unfolds. The clinician could discuss the likely diagnostic possibilities or explain why symptomatic treatment is still indicated, even in the absence of a clear diagnosis. Determining the quality and strength of the therapeutic alliance is also a multifaceted clinical judgment. Attrition bias: Low Risk: Attrition was not discussed in the study, implying that all 60 patients initially chosen to be a part of the study also participated in the follow-up. Population: The study sample comprised 89 consecutive patients attending a psychiatric outpatient clinic and fulfilling the following criteria: a diagnosis of primary or secondary depression according to the criteria of Feighner et al. Also, when filling out questionnaires, patients may not accurately represent their own alcohol or substance use. The authors, Dr. Swanson and Dr. Swartz, have received research support from Eli Lilly. All of the subjects in the study were voluntary participants who were paid a nominal amount (75¢) for completing the questionnaires required for study inclusion. Subjects who received written information with verbal reinforcement, but not those who received only the handout, were significantly more compliant than the control subjects. t�(БV@S�q"#K0�y�k��@�? Population: Data were collected from the first 75 patients enrolled in an ongoing study comparing the efficacy of supportive-expressive (SE) psychotherapy with sertraline or pill-placebo in the treatment of major depressive disorder (MDD). Inquiring about the patient’s current quality of life and level of functioning can often serve as a starting point for discussing his or her overarching goals and preferences for achieving them. In individuals with delirium, such discussions may be able to occur during periods of greater lucidity. An update of the literature search was conducted in September 2014 using the same databases and search strategies used for the October 2011 search. 2015). Do you typically (i.e., almost always) review these items during initial psychiatric evaluations of your patients? Two of the studies identified “at risk drinking” rather than a diagnosis of an alcohol use disorder per se. This is template for an initial psychiatric evaluation (i.e. There were 324 psychiatric units in the area that were screened on eligibility criteria (i.e., majority of patients have an acute psychiatric disorder, patients are admitted directly onto the unit, patients usually stay less than 3 months, patients are 18–65 years old, and the unit admits all potential patients and is not specialized for the treatment of specific disorders). Timing: Twenty-four-week intervention. Personality Disorders 7. Time-based terms such as “current,” “recent,” or “prior” are often used in clinical contexts without a clear meaning. Performance bias: Moderate Risk: Patient’s self-report measures could have been influenced by the knowledge that they had been in the intervention group. The assessment was the previously validated extended Swiss version of the Broset Violence Checklist (BVC-CH). Using outcome measures to promote better outcomes, Clinical Neuropsychiatry: Journal of Treatment Evaluation, Comparative performance of two drug interaction screening programmes analysing a cross-sectional prescription dataset of 84,625 psychiatric inpatients, Usefulness of symptom feedback to providers in an integrated primary care--mental health care clinic, https://doi.org/10.1176/appi.books.9780890426760.pe02, American Psychiatric Association 2013b, U.S. Preventive Services Task Force 2009, American College of Obstetricians and Gynecologists 2010, American College of Obstetricians and Gynecologists 2011, American College of Obstetricians and Gynecologists 2012, Assessment and Management of Risk for Suicide Working Group 2013, Assessment and Management of Risk for Suicide Working Group 2013, Hall-Lipsy and Chisholm-Burns 2010, American Psychiatric Association 2013a, U.S. Department of Health and Human Services (2014, Roshanaei-Moghaddam and Katon 2009, Centers for Medicare and Medicaid Services 2014, National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research 1979, AMA Council on Ethical and Judicial Affairs 2012, AMA Council on Ethical and Judicial Affairs 2012, Centers for Medicare and Medicaid Services 2014, American Psychiatric Association 2013b, http://www.ncbi.nlm.nih.gov/books/NBK47095, American Psychiatric Association 2013c, American Psychiatric Association 2013c, The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults. Self-reported impressions of improvement and patient satisfaction with treatment were also assessed at follow-up. This limits the overall applicability of this study to general U.S. populations. The age of the study may also limit its applicability in terms of changes in the healthcare delivery system, laboratory assessments, and the typical characteristics of individuals who present for an emergency evaluation. A mental health assessment is when a professional -- like your family doctor, a psychologist, or a psychiatrist -- checks to see if you might have a mental problem and what type of treatment may help. Detection bias: Moderate Risk: Compliance was measured by a series of three questions to the patient and also a pill count. Sponsor-related bias: Moderate Risk: The project was funded in part by Eli Lilly and Company, which could have introduced bias into the study design or results. APA recommends (1C) that the initial psychiatric evaluation of a patient include review of the following aspects of the patient’s psychiatric treatment history: Past and current psychiatric diagnoses, Past psychiatric treatments (type, duration, and, where applicable, doses), Adherence to past and current pharmacological and nonpharmacological psychiatric treatments, Response to past psychiatric treatments, History of psychiatric hospitalization and emergency department visits for psychiatric issues, As recommended in “Guideline III: Assessment of Suicide Risk” and “Guideline IV: Assessment of Risk for Aggressive Behaviors.”. Outcomes: In the intervention period, as compared with the baseline, there was a significant decrease in the numbers of aggressive incidents (relative risk reduction [RRR] compared with controls of − 68%, P < 0.001), number of patients engaging in aggression (RRR = − 50%, P < 0.05), and time spent in seclusion (RRR = − 45%, P < 0.05). There is also considerable variability by state on the case law and statutes that address the Tarasoff duty to protect (Soulier et al. Consistency: Consistent: All studies used a quantitative assessment tool to aid in diagnosis. 0000008954 00000 n Finally, as described under “Potential Benefits and Harms,” cost may be a decisive barrier to the implementation of quantitative measures in usual clinical practice, particularly if the potential benefits are uncertain for the patients treated within a specific clinical practice. Reviewing these free text records for measurement purposes would be impractical. 1990; Ten Have et al. Ambulatory Care Quality Improvement Project (ACQUIP). Intervention: Patients included in the study were assessed by a physician in training or gerontologist using the Confusion Assessment Method and the Delirium Index after conducting brief cognitive testing, including the Mini-Mental State Exam and logic questions, as well as an interview with nursing staff about the patients’ symptoms and sleep pattern. In some clinical contexts, such as a planned outpatient assessment, patients may be asked to complete an electronic- or paper-based form that inquires about key elements of the medical history and review of systems. Forty subjects (19%) were excluded from analyses because of missing baseline collateral data. The most consistent predictor of subject-collateral discrepancy scores was subjects’ recent drug use. The CAM-ICU showed superior sensitivity and negative predictive value (64% and 83%) compared with the ICDSC (43% and 75%). These guideline statements are consistent with recommendations of the Institute of Medicine that patient-centered care be delivered as one element of high-quality health care (National Research Council 2001). There were no significant differences among groups on pretest scores. The physical examination may be performed by the psychiatrist, another physician, or a medically trained clinician. Timeframe of recent onset or exacerbation. In terms of current and prior psychiatric diagnoses, information about principal and working diagnoses is relevant, when available, with specific attention to co-occurring psychiatric disorders, including neurodevelopmental disorders, neurocognitive disorders, substance use disorders, and personality disorders. Are understood to be randomly assigned to a psychiatric outpatient clinic in the discussion improving outcomes quality. Measures ( Harding et al in rehospitalization rates at which substance use when... 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