Taking a Psychiatric History – A General Framework
The following framework is to be used as a generic guide for taking a history from a
patient with mental health needs. Any additional specialist clinical communication
tasks may be integrated within this process if it seems appropriate, aids fluency and
maintains rapport and engagement with the patient. These tasks may also be
carried out separately, i.e.: mental test state, CAGE etc. PLEASE NOTE: You need
to be flexible and responsive. This may mean that you do not carry out the history in
the order written below, but that you cover the criteria. With practice this becomes
easier.
Throughout the history taking process you need to:
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Use appropriate language (avoid jargon)
Make appropriate use of questions; open, closed and clarifying.
Pace questions and allow time for your patient to respond
Acknowledge your concerns
Demonstrate empathy and sensitivity – it may be difficult or
frightening for the patient to divulge their problems.
Encourage questions and deal with them appropriately.
Remain non-judgmental and avoid defensive personal responses.
Introduce yourself to the patient
Identify the patient positively (name, date of birth for
inpatient; name and date of birth for outpatient) DO NOT simply reel out
name, age and occupation as your first questions!
The first stage of the consultation benefits from predominantly open questions
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Put the patient at ease and establish rapport
Explain the confidential nature of the interview
Ask the patient to describe the presenting complaint (e.g. depressed,
anxious, thoughts, voices etc)
Elicit the patient’s own beliefs and ideas (eg: spirituality, religious)
Avoid vague evaluative comments (eg: you sound “a bit” or “kind of”
depressed/anxious)
Try not to make too many written notes as this can be distracting to the
patient and flow of the interview but jot down key events (using a time line can
help)
A variety of question styles is helpful especially clarifying questions at this stage
Ask about:
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Ask about:
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Mode of onset and duration
Provoking, exacerbating and relieving factors
Severity (eg: use a scale from 1-10)
and other characteristics of symptoms
Evolution of symptoms over time
Associated symptoms (psychiatric or other systems)
Specifically ask about self harm and suicide
Impact of symptoms on the patient’s life eg: can ask ‘what has helped?’
Does the patient feel they have now recovered and if not, why not?
Previous psychiatric and medical history and treatment such as talking
therapies. Consider impact of institutionalisation and being in hospital.
Medications (current and past and including side effects) and allergies
Smoking, alcohol and illicit drugs
Family history
Social circumstances
Personal history (including development, psychosexual
forensic). Psychosexual can often be “delicate” in someone you have just
met but you can often open up the topic by enquiring about sexual side
effects when discussing medication. Men in particular may be very shy
about volunteering any sexual problems.
Obtain a collateral history when appropriate (e.g. carer, friend, neighbours)
Conclude with an appropriate summary and analysis of history. Speak to the
patient directly using “you” (rather than in the third person like a case
presentation)
Lastly, relax and enjoy the experience!