Psychiatric History

The psychiatric history is probably one of the most difficult histories to conduct, as the patient may present with no physical symptoms at all, just a general sense of feeling low. As a result, they may not give you much information at all and not be willing to engage with your questions. ‌

The biggest mistake that students make when taking a psychiatric history for depression is losing their structure. It is important to remember that we still want to find out about the presenting complaint – feelings of lethargy, poor sleep, loss of appetite are all symptoms and we want to explore when these started, how long they have been occurring for etc. Similarly, we need to know the patient’s medical history (whether they have experienced this before). Mental health conditions do also have a genetic component and can run in families – likewise, some medication can make you feel depressed. When people are feeling low, many might take to smoking, alcohol or even drugs as a vice – so how can we not ask about these aspect as a doctor? We must!!!‌

The reason why medical students lose their structure is often because during the presenting complaint, the patient may reveal or give a cue which explains where their depression originates from. By exploring the cue (which you should do), we forget to take the rest of the presenting complaint and can spend hours talking about the tragic event which might have occurred in the patient’s life. The key to avoiding this is to acknowledge the cue, and ask the patient how they are feeling about it. Then, use the ideas, concerns and expectations to get yourself back on track to finish the presenting complaint, like we have seen done before.‌

Another difference for psychiatric histories is the systems review, where we need to enquire about other mental health symptoms. One thing which you absolutely cannot forget here is to screen for risk – if you do not do this, and your patient commits suicide, that is negligent on the doctor’s part. To remember this, the acronym helps.‌

Finally, in the social history, one thing which will be of great interest is enquiring about the patient’s support network. We need to know whether they have a family/partner who will give them emotional help through this difficult time, or whether they are all alone and require more help from the health service. ‌

Anyways, let’s go through the history template for depression and see how you can use this advice to create a comprehensive and efficient structure.

Introduction

• Good afternoon, my name is _______ and I am one of the student doctors here. Is it _______(patient’s name)?
• I just wanted to ask you some questions about how you are feeling and what has brought you in to see the doctor today, and then I’ll take that information, relay it to the consultant and we can go from there.
• Before I start, are you comfortable or would you likely me to get you anything? Do you mind if I take a seat?
• So, what has brought you in to see the doctor today?

(P) Presenting Complaint

• Summarise patient’s answer and ask first screening question) – Apart from this, have you noticed anything else?
• (Ask second screening question) – Ok, anything else?
• (Ask third screening question) – Before talking more about your [symptom], are there any other symptoms?
• (Last screening question) – Are you sure that there is nothing else?
• (Once we are sure there are no other questions, we can now address each symptom in turn) – Now I just want to ask some questions about the symptoms you have been feeling? Go through each symptom.

• Depressed – Ok, so you mentioned that you have been feeling down, can you tell me a little bit more?

(I) Ideas, Concerns, Expectations

At this point, it is likely that the patient may reveal an underlying cause which might explain their symptoms. This could be a death in the family, a break up, any precipitating factor. The best thing to do next is explore this a bit deeper, and then use the ideas, concerns and expectation to get back on track. If they do not tell you the cause, then use the ideas question to enquire why they think they might be feeling this way.

• (If they tell you the cause):
  “I’m sorry to hear about this, how have you been coping?”
  Can you tell me a bit more about what happened?

• (If they do not tell you or no obvious trigger)
  Ok, you have been feeling these symptoms for some time, do you have any idea of what it could be?
  Are you particularly concerned about anything?
  What were you hoping to get out of the visit today?

• (After acknowledging their concerns, explain to the patient that in order to get the best help, you need to understand exactly what the patient is feeling)

(S) Systems Review

• (In response to them telling you their expectation from today’s visit) Ok, in order to do that, first I would like to ask you a few more specific questions just to get a more accurate picture of why you might be experiencing these symptoms.

Specific Systems Review (MAC-SPR)

• M (Mood):
  Does your mood vary throughout the day?
  Is it worse at any particular time?

• A (Appetite):
  Have there been any changes in your appetite recently?
  Have you lost or put on any weight recently?

• C (Cognitive):
  How do you feel your ability to concentrate has been?
  Do you often blame yourself when things go wrong?
  How do you feel about the future?

• S (Sleep):
  How are you sleeping?
  Do you take anything to help you sleep? 

• P (Psych):
  Have you ever experienced any period of euphoria during this time?
  During this time, have you heard any voices speaking, or felt that someone is putting thoughts into your head?

• R (Risk) – (One of the most important parts of a psych history!)
  When people feel down and depressed, they can often feel that life is not worth living. Have you ever felt like this?
  Have you ever had any thoughts of taking your own life?
  Do you have any plans
  Have you ever tried?
  Have you ever tried others in any way?
  Do you feel anyone is trying to harm you?

General Systems Review: (Ask general questions to rule out red flags):

(Fever) Have you got a fever?

(Glands) Have you got any swollen glands?

(Weight) Have you noticed any weight loss?

(Appetite) Have you noticed any changes in your appetite?

(Bowels) Have you experienced any changes in your bowel movements?

(Waterworks) Are your waterworks all fine?

(Tired) Have you been feeling more tired than usual?

(Travel) Have you travelled anywhere recently?

(Night sweats) Do you wake up in the night drenched in sweat?

(Rash) Have you got any rashes?

(If woman, and abdominal pain, enquire about pregnancy) Are you on the contraceptive pill? Is there a chance you could be pregnant?

(P) Past Medical History

• And now, about your health in general, have you ever seen your doctor about something like this before?
• Do you have any other medical conditions, such as diabetes, blood pressure or asthma?
• Have you ever had any surgeries?
• Have you ever been admitted into psychiatric hospital before?
• Are you currently under any community mental health teams?

 (F) Family History

• Is there any incidence of mental health problems in your family?
• Are there any other conditions which run in your family?

(D) Drug History

• Are you currently taking any prescribed medication?
• Do you take anything else, over the counter?
• Do you have any allergies?

(S) Social History

• (Work) And now, a little but more about yourself in general, do you work at the moment? What do you do?
• (Home) Do you live with any family or friends? Are you married? Do you have any children?
• (Independence) Would you say that you are fairly independent?

And now these are some questions that we ask everyone:

• Do you smoke? (Have you ever smoked? / When did you start? / How many a day?)
• Do you drink? (How much a week? And for how long?)​
• Is there any recreational drug use?