The General Medical Psychiatric Interview

Robert M. McCarron, DO, DFAPA

Jeremy DeMartini, MD

John Onate, MD

A 30-year-old woman with a history of chronic low back pain and intermittent headaches and tobacco use presents to transfer care from another provider with the following opening statement, “That horrible doctor ignored my pain and wanted me to suffer! I heard you are the best doctor in town. I can already tell we are going to be great friends!” The woman’s speech is loud and somewhat fast. When the provider suggests she try physical therapy instead of an opioid medication, she yells, “Why don’t you just kill me now?” The provider wonders if the patient is bipolar and whether she needs to be psychiatrically hospitalized.

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 9-1) includes 4 primary clinical dimensions of the psychiatric review of systems: Anxiety, Mood, Psychosis, 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.

FIGURE 9-1 Psychiatric review of systems: AMPS screening tool. Reprinted with permission from McCarron RM. Primary Care Psychiatry. 2nd ed. Philadelphia, PA: Wolters Kluwer; 2018.

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 workup of mental illness.² Owing 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 or severe psychiatric conditions can be treated successfully in general medical care settings. The ability of the primary care clinician to carefully screen for and evaluate psychiatric symptoms is paramount to accurately diagnose and effectively treat the underlying psychiatric disorder.⁴ Also, management of chronic general medical conditions, such as chronic physical pain, is usually much easier if psychiatric conditions are addressed.

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 2 main differences. First, the psychiatric interview places additional emphasis on psychosocial stressors and overall level of functioning. Second, the mental status examination is analogous to the physical examination for a general medical workup 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 3 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 Although 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 in Table 9-1.

TABLE 9-1 Outline of the Primary Care Psychiatric Interview

Chief complaint and history of present illness	For the first few minutes, just listen to better understand the chief complaint(s) and start the mental status examination 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?”

Chief Complaint and History of Present Illness

The vast majority of physicians interrupt before patients can share their opening concerns.⁷ By starting with open-ended questions and allowing the patient to share their perspective, the interviewer can establish rapport and start their mental status examination. Of course, this investment of time may temporarily take away from discussion of other medical conditions, but it is generally well worth the time. Reflective statements may be used to clarify and summarize particular problems (e.g., “You are telling me that you feel your previous physician did not care about your pain as he stopped your opiate medication.”). Clarification may also be used (e.g., “Can you explain to me why you think your previous physician stopped the opiate medication?”). Gentle confrontation can be used to point out inconsistencies or bring topics to the forefront that a patient is avoiding or expressing ambivalence about (e.g., “When I started asking you about physical therapy you said you want me to kill you, but later you insisted that you are not suicidal, can you explain this to me?”).

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 should include the duration, severity, and extent of each symptom along with exacerbating and ameliorating factors. Patients vary greatly in their recall of 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.

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 but critically important task. The most commonly encountered primary care psychiatric disorders involve 5 major clinical dimensions and can be remembered by the AMPS mnemonic: Anxiety, Mood, Psychosis, Substance use disorders (Figure 9-1). We recommend incorporating the AMPS screening tool into your daily practice, but especially when a patient has an established psychiatric disorder (including personality and eating disorders) or presents with psychiatric complaints, such as depression, anxiety, insomnia, and unexplained physical complaints. When a particular dimension is present and causing distress, further exploration is indicated (Table 9-2).

Anxiety

Anxiety is common in the primary care and pain medicine settings and often comorbid with mood, psychotic, and substance misuse disorders. It is sometimes the main catalyst 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 and poorly screened (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 (e.g., “What type of situations or events trigger your anxiety”) will help develop a reasonable differential diagnosis. Also, if anxiety is a problem, it may be helpful to
ask the patient if it is a “big problem, small problem, or somewhere in between.” A numerical scale may also be used to quantify the level of anxiety.

TABLE 9-2 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 1. “Have you been feeling depressed, sad, or hopeless over the past 2 weeks?” 2. “What do you usually like to do for fun and have you stopped doing this over the past few weeks?” Mania/hypomania 1. “Have you ever felt the complete opposite of depressed, when friends and family were worried about you because you were too happy?” 2. “Have you ever had excessive amounts of energy running through your body, to the point where you did not need to sleep for days?”	“What is your depression like on an everyday basis?” “How does your depression affect your daily life?” “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?”	Patient Health Questionnaire (PHQ-9) Mood Disorder Questionnaire (MDQ)
Psychosis	1. “Do you hear or see things that other people do not hear or see?” 2. “Do you have thoughts that people are trying to follow, hurt, or spy on you?” 3. “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	1. “How much alcohol do you drink per day?” 2. “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?” If no: “Have you ever used any of these drugs in the past?”	CAGE^c CAGE-AID (adapted to include drugs) Alcohol Use Disorders Identification Test (AUDIT-C)
^dSuicide	1. “Do you ever wish you could go to sleep and not wake up?” 2. “Do you have any thoughts of wanting to hurt or kill yourself or somebody else?”	“Have you ever tried to hurt or kill yourself in the past?” “Do you have guns or other items you could use to harm yourself?”
^aThese are suggested instruments that could be considered. More details about relevant instruments are available in the corresponding chapters. ^bIf either of these 2 questions is answered affirmatively, follow-up questions should be asked and a PHQ-9 should be administered. ^cSee Chapters 6 and 7 for details. ^dSuggest asking about suicide if one of the AMPS questions is positive.

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 examination and should be rated as either congruent or incongruent with the corresponding affect. The 2 main components of mood (depression and mania) should be fully assessed during each primary care psychiatric interview.

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