The psychiatric interview forms the most important component in the assessment and care of clients with mental illness. It serves, first, to understand clients' difficulties and to establish a criteria-based diagnosis and, second, to begin the process of establishing a therapeutic relationship. Therefore, the interview is seen as the beginning of the treatment process. It shapes the nature of the therapeutic relationship and is a major factor in producing a favourable outcome of treatment.
Various strategies can be used to conduct an effective interview:
- Document key information during the interview unobtrusively. Note only essential information. Fill in details soon after the interview to improve your notes.
- Use a mixture of open-ended and closed-ended questions. The initial part of the interview tends to have more open-ended questions, which allow clients to tell their stories. The yes or no questions that come later are useful to clarify details. You may switch back to openended questions when one component is finished and another begins (e.g., when moving from past psychiatric history to past medical history).
- Avoid grilling clients with questions. Maintain a non-judgmental demeanour.
- Prepare clients with a normalizing statement when asking about sensitive areas (e.g., sexual history and gender identity). Similarly, a brief preamble indicating the routine nature of questioning around psychosis will make clients feel more at ease.
The psychiatric history is the account given by the client, both spontaneously and in answer to specific questions posed by the practitioner, about his or her difficulties. It is usually documented under the following headings:
The mental status examination is a record of objective observations of the thoughts, emotions, behaviour and perceptions of the client, as elicited by the practitioner. It is best considered as both distinct and complementary to the mental health interview. Mental status is often assessed on an ongoing basis throughout the course of the interview, as well as with specific questions after history-taking. As with a physical examination, the information is documented directly as gathered, and does not include the practitioner's interpretation of the client's difficulties. In addition to aiding an accurate diagnosis, mental status provides a baseline systematic description of the client's presentation. As such, it is a useful measure of change over time. It also serves as an important tool for communication between practitioners.
As outlined by Snyderman and Rovner (2009), the mental status examination is usually documented under the following headings:
Physical and mental illnesses are often intertwined. Many medical illnesses present with psychiatric symptoms, and physical symptoms are common in mental illnesses. Being aware of this relationship is particularly relevant to treating clients in primary care settings.