Statement 1. APA recommends (1C) that the initial psychiatric evaluation of a patient include review of the patient’s mood, level of anxiety, thought content and process, and perception and cognition.
Statement 2. APA recommends (1C) that the initial psychiatric evaluation of a patient include review of the patient’s trauma history.
Statement 3. 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 issuesThe goal of this guideline is to improve the quality of the doctor-patient relationship, the accuracy of psychiatric diagnoses, and the appropriateness of treatment selection.
The strength of research evidence supporting this recommendation is low. No prospective studies have addressed whether outcomes such as diagnostic accuracy and appropriate treatment planning are improved when the initial psychiatric evaluation includes review of psychiatric symptoms, trauma history, and psychiatric treatment history. Despite this, there is consensus by experts that the potential benefits described above clearly outweigh the potential harms.
The process of determining a patient’s psychiatric diagnosis is complex (American Psychiatric Association 2013b). It requires knowledge of whether a patient is experiencing specific symptoms or exhibiting specific signs. Diagnostic accuracy also requires gathering information about the temporal development and duration of those signs and symptoms. For trauma-related diagnoses, as well as for neurocognitive disorders that are due to traumatic brain injury, the presence of a traumatic event is a precondition of diagnosis. Past trauma can also be a risk factor for the development of other diagnoses such as depressive or anxiety disorders (Hovens et al. 2012). A significant proportion of individuals with psychiatric illnesses appear to have experienced traumatic events (Coverdale and Turbott 2000; Cusack et al. 2004; Frueh et al. 2005; Lu et al. 2013; Oram et al. 2013; Posner et al. 2008), but trauma-related diagnoses such as posttraumatic stress disorder are often overlooked (Mueser et al. 1998). Thus, it is intuitively obvious that reviewing a patient’s trauma history is essential to diagnostic accuracy. Knowledge of prior psychiatric diagnoses can also inform current diagnosis, since a patient may be presenting with a continuation of the prior disorder or may now have a different disorder that commonly co-occurs with the first (Gadermann et al. 2012; Kessler and Wang 2008; Kessler et al. 2005; Lenzenweger et al. 2007). The relevance of past treatments to diagnostic accuracy is more indirect but still relevant. If a patient has not responded to the primary treatments for a given diagnosis, it may suggest a need to reconsider the accuracy of that diagnosis. Treatment-emergent symptoms and signs (e.g., hypomania or mania in a depressed patient) may also require reassessment of the diagnosis.
Selecting an appropriate treatment will be an outgrowth of the patient’s diagnosis as determined during the psychiatric evaluation; however, it also requires knowledge of the patient’s current symptoms, trauma history, and previous diagnoses and psychiatric treatment experiences. The elements of the treatment plan will vary depending on the individual needs and preferences of the patient but will generally include treatment that addresses the patient’s primary and co-occurring diagnoses. Often co-occurring psychiatric symptoms are present that are subthreshold or subsyndromal or may not respond to the treatment for the primary disorder (e.g., psychotic symptoms in mood disorders, cognitive impairment in schizophrenia). Such symptoms may contribute to functional impairments or risk of relapse and may also require specific intervention. Prior diagnoses of a co-occurring personality disorder may signal a need for a differing approach to psychotherapy than in an individual without such comorbidity. For individuals with a past trauma, this experience may influence their ability to establish a trusting relationship, and this may need to be considered in terms of the therapeutic alliance.
Recommended treatments also need to be feasible and tolerable as well as to show a preponderance of benefit over harm for the patient. Information about the patient’s past treatment provides information on the prior benefits and tolerability of specific interventions but may also be relevant to the likely benefits and adverse effects of similar treatments. However, judgments about therapeutic benefits will need to be shaped by information on the adequacy of the treatment trial. For example, a different treatment or combination of treatments may be needed if a patient’s symptoms do not respond to an adequate dose and duration of a medication or to an evidence-based psychotherapy delivered with high fidelity and for adequate duration. If a pattern of treatment resistance is identified, possible contributors need to be assessed and more aggressive treatment instituted to optimize the patient’s functional outcomes.
Information on treatment-related side effects can be important in predicting the tolerability and safety of future treatment (e.g., agranulocytosis with clozapine, neuroleptic malignant syndrome or severe dystonic reactions with antipsychotic medication). Similarly, if adherence has been difficult for the patient in the past, it may suggest difficulties with the tolerability or feasibility of a particular treatment that would need to be addressed as part of the current treatment plan. Some treatments may be less likely to benefit the patient or more likely to be harmful to the patient depending on his or her prior psychiatric diagnoses or comorbidities (e.g., antidepressants in depressive episodes that occur in the context of bipolar disorder, use of bupropion in patients with an eating disorder).
In an initial psychiatric evaluation, there are a number of reasons that it is potentially beneficial to determine whether or not the patient has been experiencing abnormalities of mood, anxiety, thought content, thought process, and perception and cognition. Such signs and symptoms are important in first developing a differential diagnosis and then determining whether or not criteria for a specific DSM diagnosis have been met. Even when symptoms are subsyndromal, they may suggest the presence of additional co-occurring conditions or signal a need for additional treatment to address residual manifestations of illness. The pattern and presence of particular signs and symptoms is often important in considering the potential benefits and risks of treatment options. Baseline data may also be useful in interpreting signs and symptoms that develop during the course of treatment, either related to emergence or progression of underlying psychiatric disorders or as side effects of treatments. There are no plausible harms to determining if the patient is experiencing specific psychiatric signs or symptoms.
Determining whether or not the patient has a history of trauma is also important. Although most traumatized individuals will not develop psychopathology in the aftermath of a trauma, acute stress disorder or posttraumatic stress disorder may be part of the differential diagnosis when trauma-exposed individuals present for a psychiatric assessment. Regardless of whether or not a trauma-related disorder is present, past trauma may need to be specifically addressed as a part of the treatment. Given the emotional impact of traumatic events on individuals, many patients feel relieved to be able to discuss traumatic experiences when these are raised in a sensitive manner. However, it is also possible that raising questions about trauma could cause distress to some patients.
Obtaining information about current and previous psychiatric diagnoses can often be critical in formulating a differential diagnosis. Choosing among treatment options can be aided by determining whether a patient has already had a trial of a particular treatment. If a treatment has been tried in the past, knowledge of the patient’s response, including therapeutic benefits and side effects, is relevant to determining whether an additional trial is warranted. In interpreting information about the patient’s response, knowledge of the patient’s adherence is also important as are specific aspects of treatment (e.g., type, duration, dose).
Assessment of psychiatric symptoms and psychiatric treatment history is by definition a core activity of an initial psychiatric evaluation. Other core activities include identifying the reason that the patient is presenting for evaluation and understanding the patient’s background, relationships, life circumstances, and strengths and vulnerabilities. Each of these elements can be affected if a patient has been exposed to trauma. As a result, it is not possible to separate the cost of assessment of these domains from the overall cost of the evaluation itself, which will vary depending on the patient, the setting, and the model of payment.
As described in the definition of “assessment” (see Glossary of Terms), there are a variety of ways that clinicians may perform these recommended assessments. Typically, a psychiatric evaluation involves a direct interview between the patient and the clinician. The specific approach to the interview will depend on many factors, including the patient’s ability to communicate, degree of cooperation, illness severity, and ability to recall historical details. In some circumstances, questions on a particular topic (e.g., traumatic experiences) may cause the patient significant distress and may have to be pursued at a later session. Sensitivity may also be needed if a patient has experienced a traumatic event such as physical or sexual assault, because this can influence the ability to establish trust within the therapeutic relationship. Factors such as the patient’s vocabulary and cultural background (American Psychiatric Association 2013a; Thombs et al. 2007) can also influence the patient’s understanding and interpretation of questions and may require additional sensitivity on the part of the interviewer. Patients with intellectual disability or neurocognitive disorders may have difficulty in understanding questions as initially posed. In older individuals, difficulty understanding questions may signal unrecognized impairments in cognition or in hearing that require more detailed assessment. Flexibility may also be needed to frame questions in a clearer manner. At times (such as an evaluation of a patient with severe psychosis or dementia), obtaining information on psychiatric symptoms and history may not be possible through direct questioning.
When available, prior medical records, electronic prescription databases, and input from other treating clinicians can raise previously unknown information. Such sources can also be used to add details or corroborate information obtained in the interview. Family members, friends and other individuals involved in the patient’s support network can be important sources of collateral information about the reason for evaluation, the patient’s current symptoms and behavior, and past history, including trauma exposure and psychiatric treatment. Additional information such as knowledge of the patient’s premorbid personality and level of function can help in identifying co-occurring disorders, including neurodevelopmental disorders, and in interpreting the onset and temporal course of the patient’s illness. Communicating with family members or other caretaking persons can be particularly important when the patient requires assistance or supervision because of impaired function, unstable behavior, or neurocognitive impairment. Communication as part of the initial evaluation can also lay the groundwork for collaborating with the patient and involved family members in planning for and educating them about treatment. The extent of collateral interviews and review of prior records will be commensurate with the purpose of the evaluation, the complexity of the clinical presentation, and the diagnostic and therapeutic goals. For example, in an acute setting, collateral information may be crucial to developing an understanding of the patient’s clinical condition, whereas in long-term outpatient psychotherapy it would be important to consider potential effects on the therapeutic relationship before obtaining collateral information from family or others. Except when immediate safety concerns are paramount, the confidentiality of the patient should be respected. In general, the default position is to maintain confidentiality unless the patient gives consent to a specific intervention or communication. At the same time, it is permissible for the clinician to listen to information provided by family members and other important people in the patient’s life, as long as confidential information is not provided to the informant.
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 psychiatric symptoms and key elements of the psychiatric history. Such forms may be completed prior to the visit or on arrival at the office and can serve as a starting point to explore reported symptoms or historical information. As an example of such a form, the DSM-5 Level 1 Cross-Cutting Symptom Measure (American Psychiatric Association 2013b) can be a useful tool to aid in the assessment of symptoms that may occur across different psychiatric diagnoses. The tool may be used both during an initial psychiatric evaluation and for subsequent monitoring. A self-report measure exists for adults and for children ages 11–17 years. A parent/guardian measure exists for children ages 6–17 years. Online versions of the measure are available at http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level1. Findings of the Level 1 measure can be amplified by follow-up questioning or the use of additional measures, such as the DSM-5 Level 2 Cross-Cutting Symptom Measures. To aid in the assessment of a patient’s exposure to trauma, a brief self-report screening measure, the Trauma History Screen (Carlson et al. 2011), is available on request from the VA National Center for PTSD at http://www.ptsd.va.gov/professional/assessment/te-measures/ths.asp.
In addition to inquiring about the reason that the patient is seeking evaluation and learning about his or her current life circumstances, asking open-ended empathic questions about psychiatric symptoms is a common initial approach to the interview. This can be followed by more structured inquiry about specific symptoms (e.g., worries; preoccupations; changes in mood; suspicions; delusions or hallucinatory experiences; recent changes in sleep, appetite, libido, concentration, memory, or behavior): What is the severity of the patient’s symptoms? Over what time course have these symptoms developed or fluctuated? Are associated features of specific psychiatric syndromes (i.e., pertinent positive or negative factors) present or absent during the present illness? What factors does the patient believe are precipitating, aggravating, or otherwise modifying the illness or are temporally related to its course? If suicidal or aggressive symptoms or behaviors are reported, these will also require further questioning to assess the patient’s level of risk, as described in “Guideline III: Assessment of Suicide Risk” and “Guideline IV: Assessment of Risk for Aggressive Behaviors.” Inquiry about specific symptoms may also be suggested by observations of the patient’s behavior during the interview. For example, the presence of tremulousness might prompt questions about anxiety or about typical symptoms of alcohol or substance withdrawal.
Inquiring about a patient’s trauma history also begins with open-ended and empathic questions. Individuals may differ in their perception of what constitutes a trauma. Asking about trauma in a nonspecific fashion will help identify the experiences that had the greatest impact for the patient as well as provide an opportunity to learn about the patient’s coping strengths and resilience in addressing past traumas. Information about traumas, including early adversity, may also be raised by the patient in the context of providing background information about his or his childhood upbringing, developmental history, school or occupational history, military history, relationship history, or family constellation. A history of childhood physical or sexual abuse is relatively common but may not be raised spontaneously by the patient unless specifically asked. Other follow-up questions about possible trauma will be suggested by other elements of the history (e.g., combat-related trauma in service members, migration stress in immigrants, posttraumatic symptoms relating to medical care in individuals who sustained a major injury or required intensive care).
In obtaining information about the past psychiatric history, questioning may vary in its level of detail at the initial meeting depending on the available time, the patient’s recall of information, the patient’s level of cooperation, and the complexity and urgency of clinical decision making. In many situations, the history of past diagnoses and treatments will need to be expanded at subsequent visits or augmented by history from other sources (e.g., prior clinicians, review of medical records). 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.
In reviewing prior trials of psychiatric treatment, the clinician may begin with open-ended questions about recent treatments, those that have been particularly helpful, and those that have been problematic. Follow-up questions could pursue more details on those treatments and then inquire about other treatments that have not yet been mentioned. Alternatively, a detailed longitudinal history of treatment can be obtained beginning with the patient’s initial episode of illness and inquiring about each treatment in sequence. It is useful to inquire specifically about the full range of treatment settings (e.g., outpatient, partial hospital, inpatient) and treatment approaches, including psychotherapies, prescribed medications, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), self-help groups, 12-step programs, over-the-counter medications, herbal products, nutritional supplements, spiritual healers, and complementary or alternative treatment approaches. After the clinician has identified the category of treatment used, additional details are helpful to obtain depending on the type of treatment. Thus, for psychotherapies, it is useful to learn more about the format of therapy (e.g., individual, family, group), its type (e.g., supportive, cognitive-behavioral, interpersonal, psychodynamic, exposure with response prevention), the length and frequency of sessions, the duration of the course of therapy, and the quality of the relationship with the treating clinician. With pharmacological treatments (e.g., prescribed medications, over-the-counter medications, herbal products, nutritional supplements), information about the formulation, route, and dose and duration of treatment is important to obtain. With neurostimulatory treatments (e.g., ECT, TMS), the device type, treatment parameters, frequency of treatments, total number of treatments, and duration of the treatment course are important to know, including whether treatment included only an acute course or was followed by less frequent maintenance treatments. Similar information can be obtained for other forms of treatment. Regardless of the details of the treatment itself, it is important to determine how the patient responded to the treatment, in terms of both therapeutic benefits and side effects. When the clinician is inquiring about therapeutic benefits, it is useful to ask about symptom response and remission as well as changes in quality of life or levels of functioning and disability. For patients who did not respond to a specific treatment, the adequacy of treatment may depend on the clinical context (e.g., obsessive-compulsive disorder typically requires a higher dose of and a longer duration of treatment with a selective serotonin reuptake inhibitor than does major depressive disorder). Such details may be important in judging whether a patient’s symptoms appear to be treatment resistant, with associated implications for treatment planning.
Typical side effects of treatment will vary with the treatment being used. Starting with open-ended questions about side effects with a particular treatment can help identify less common side effects that may have occurred and can also illuminate the kinds of side effects that may be of particular importance to the patient. With follow-up questions, the clinician can probe for more details and ask about more common adverse effects of a particular treatment, as indicated.
The clinician may also inquire in an open-ended fashion about the patient’s adherence with previous treatments—for example, by asking about the patient’s overall satisfaction with previous treatments and about any difficulties in taking medications (Velligan et al. 2010) or adhering to other forms of treatment. Problems with adherence in older individuals may signal early neurocognitive impairment that would warrant detailed cognitive assessment. Further questions can determine whether adherence problems are related to specific side effects of treatment, perceived lack of treatment benefits, personal beliefs about treatment (e.g., culturally related beliefs, personal preferences, family members’ response to treatment, delusional ideas), or logistical barriers to treatment (e.g., cost, transportation to appointments, lack of child care). Depending on the clinical context, questions about adherence may extend to asking about court-ordered treatment programs.
These recommendations should not be viewed as representing a comprehensive set of questions relating to psychiatric assessment, nor should they be seen as an endorsement of a checklist approach to evaluation. Depending on the clinical setting, the patient’s cooperation and ability to respond, the time available for the evaluation, and the type of treatment planned, some information may be more or less relevant to obtain as part of the initial assessment. The timing of the clinical event may also influence the need to obtain information at the initial interview as well as affect the level of detail that is required. With some information (e.g., severe medication side effects such as neuroleptic malignant syndrome), details are essential to obtain regardless of when the treatment may have occurred. Often, more recent symptoms, diagnoses, and details of treatment may be of greater relevance than those in the distant past.
The context and accuracy of the information obtained in the interview are also important to keep in mind before applying it to treatment planning. Simply asking about a patient’s symptoms or history will not ensure that accurate or complete information is received. In some circumstances, the patient may minimize the severity or even the existence of his or her difficulties, particularly if help seeking is not voluntary. If observations of the patient’s behavior during the interview or other aspects of the clinical presentation seem inconsistent with the patient’s reported symptoms or history, additional questioning of the patient or others may be indicated. Factors such as time pressures, interviewing style, and clinician attitudes can also influence the ability to obtain accurate information during the assessment. Thus, the interviewer will want to be aware of his or her own emotions and reactions that may interfere with the evaluation process. Individuals also vary in their ability to recall details of diagnosis and treatment in an accurate manner. Gaps and inaccuracies in patient reports can arise from ordinary errors in comprehension, recall, and expression (Patten et al. 2012; Redelmeier et al. 2001; Simon et al. 2012). More errors occur when the patient is recalling more distant events (Patten et al. 2012; Simon et al. 2012). Factors other than time may also play a role in these variations in recall (Leikauf et al. 2013). For example, in older individuals, inconsistencies in the reported history may raise the possibility of a neurocognitive disorder that would warrant more detailed assessment of cognition.
Even when rigorous approaches are used to establish diagnoses, there may be shifts in the patient’s diagnosis over time (Bromet et al. 2011; Mueller et al. 1999). Thus, the reported presence of a specific diagnosis in the past does not mean that the same diagnosis is accurate or persists. Issues with the accuracy of recall can also exist with respect to prior treatment (Simon et al. 2012). 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. Rather, they may reflect the natural course of illness (e.g., transitioning to an episode of hypomania or mania), positive or negative life events, concomitant treatments (e.g., drug-drug interactions influencing serum levels, potential for augmenting effects of psychotherapies and medication), or other biologically mediated processes (e.g., cigarette use altering metabolism of prescribed medications).
Barriers to the use of these recommendations also exist, with a major barrier being constraints on clinician time and the need to assess many aspects of the patient’s signs, symptoms, and history within a circumscribed period.
APA recommends (1C) that the initial psychiatric evaluation of a patient include assessment of the patient’s use of tobacco, alcohol, and other substances (e.g., marijuana, cocaine, heroin, hallucinogens) and any misuse of prescribed or over-the-counter medications or supplements.
The goal of this guideline is to improve, during an initial psychiatric evaluation, the identification of patients with a substance use disorder and to facilitate treatment planning.
The strength of research evidence supporting this recommendation is low. A systematic search identified four studies that address the specific clinical question described under “Review of Supporting Research Evidence.” The studies found that use of standardized questionnaires and collateral information can improve the identification of risky drinking, alcohol use disorders, and substance use compared with clinical interviews or routine care. All four studies were observational in design, and confounding factors were present in each. Furthermore, the applicability of the studies is limited. The studies mainly investigated the assessment of alcohol use, assessment did not necessarily occur in the context of a psychiatric evaluation, and the settings studied were not representative of the full range of settings in which psychiatric evaluations are performed.
Despite the low strength of this supporting research evidence, there is consensus by experts that assessing the patient’s use of tobacco, alcohol, and other substances and misuse of prescribed or over-the-counter medications or supplements as part of an initial psychiatric evaluation has benefits that clearly outweigh the harms.
Additional indirect support for this recommendation comes from studies that have examined screening for tobacco and alcohol use in primary care and other medical settings. On the basis of a rigorous systematic review (Fiore et al. 2008), the U.S. Preventive Services Task Force (USPSTF) concluded that “the net benefits of tobacco cessation interventions in adults and pregnant women remain well established” ( U.S. Preventive Services Task Force 2009, p. 551). Accordingly, the USPSTF recommends with high certainty of substantial benefit that clinicians should “ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products” and “ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke” ( U.S. Preventive Services Task Force 2009, p. 551). The USPSTF has also concluded “with moderate certainty that there is a moderate net benefit to screening for alcohol misuse and brief behavioral counseling interventions in the primary care setting for adults aged 18 years or older” (Moyer 2013, p. 212; see also Jonas et al. 2012a, 2012b). In addition, the American College of Obstetricians and Gynecologists (ACOG) recommends screening of pregnant women for smoking (American College of Obstetricians and Gynecologists 2010) and for at-risk drinking and alcohol dependence, with behavioral counseling provided if screening is positive (American College of Obstetricians and Gynecologists 2011). They also recommend screening pregnant women for opioid use (American College of Obstetricians and Gynecologists 2012). By extension, screening and behavioral counseling is very likely to be beneficial in psychiatric settings, although further research confirmation is needed. Finally, the substantial rates at which substance use disorders and other psychiatric disorders co-occur (Compton et al. 2007; Grant et al. 2004; Hasin et al. 2007; Huang et al. 2006; Smith et al. 2006) also imply that screening for alcohol and substance use disorders would be relevant to differential diagnosis. Treatment planning is also influenced by identification of co-occurring substance use disorders and other psychiatric illnesses as well as detection of medical conditions that commonly co-occur with substance use.
Assessment of tobacco, alcohol, and other substance use during the initial psychiatric evaluation may improve identification of patients with substance use disorders, including substance intoxication or withdrawal. Ensuring that initial psychiatric evaluations include assessment of substance use may improve the clinician’s differential diagnosis because substance use disorders, other psychiatric disorders, and other medical conditions may share similar presenting symptoms, including anxiety, depression, mania, and psychosis.
If assessment identifies the presence of a substance use disorder, interventions can be offered, and there may be reductions in associated morbidity and mortality, such as from cardiovascular, respiratory, or hepatic diseases; blood-borne and sexually transmitted infectious diseases; injuries from motor vehicle accidents and other trauma; or deaths from suicide. Patients’ psychological and social functioning may also be improved. Depending on the substance being used, provision of appropriate interventions may be associated with reductions in problems such as unemployment, divorce, homelessness, and criminal behaviors.
Potential harms of assessment have not been a focus of study but are likely to be minimal. Identifying a patient as having a substance use disorder when one is not present could result in unneeded treatment. If a patient becomes anxious or annoyed by being asked about substance use, this could interfere with the therapeutic relationship between the patient and the clinician. The cost of assessing substance use is difficult to separate from the overall cost of an initial psychiatric evaluation, which varies depending on the patient, the setting, and the model of payment. Another potential consequence is that time used to focus on assessment of substance use could reduce time available to address other issues of importance to the patient or of relevance to diagnosis and treatment planning.
The clinical approach to inquiring about a patient’s use of tobacco, alcohol, and other substances will vary with the context of the evaluation and with the patient’s presenting symptoms. Typically, questions will focus on current use, but past use may also be relevant in patients with current use or when past use influences planning of treatment (e.g., decision making about the prescription of medication with potential for misuse or addition of treatment to maintain remission from substance use disorder). The specific substances that are asked about may be licit and illicit and include but are not limited to tobacco, alcohol, caffeine, marijuana, cocaine, methamphetamine, club drugs, inhalants, hallucinogens, or heroin.
Questions about misuse of prescribed or over-the-counter medications or supplements can often be introduced while the clinician is taking a history of the patient’s prescribed medications. Prescribed medications that may be prone to misuse include but are not limited to androgens, benzodiazepines, barbiturates, other sedative-hypnotics, muscle relaxants, and opiate medications. Over-the-counter medications or supplements that may be misused include but are not limited to dextromethorphan, diphenhydramine, chlorpheniramine, caffeine, nicotine replacements, laxatives, and creatine. Newer substances of abuse are continuing to emerge and are frequently available over the counter, with names such as “bath salts” or “spice” that can disguise their true nature as substances of abuse.
A straightforward, nonconfrontational and open-ended approach to questions will usually elicit the most accurate responses, although individuals may underestimate their level of use or be reluctant to discuss their use of substances. Factors such as time pressures and clinician attitudes can also influence the ability to conduct an accurate assessment. When the clinician is speaking with patients about their current life circumstances and the reasons they are presenting for evaluation, it can be useful to consider whether unrecognized alcohol or substance use may be contributing to their symptoms or associated with stressors such as recent medical problems, relationship conflicts, traumatic exposures, or school/occupational, financial or legal difficulties. This can also serve as an opening to raise questions about the presence of tobacco, alcohol, or substance use. Observations made during the interview can provide additional clues to possible use (e.g., an odor of cigarettes or alcohol on the patient’s breath; physical stigmata of injection drug use; slurred speech or other evidence of substance intoxication; tremulousness, abnormal vital signs, or other indications of alcohol or substance withdrawal).
Flexibility may be needed in tailoring questions to the individual patient. Slang terms for abused substances may be better understood by patients than medical terminology, but the specific words that are chosen may need to vary depending on factors such as patient age, culture, or locality. Family members and others who are involved in the patient’s life may be able to give information that helps to identify and corroborate the type and extent of alcohol or substance use. In addition to information from spouses or intimate partners, parents of adult children who are living at home may have observed changes in behavior associated with substance use. Conversely, adult children may have noted signs of alcohol or other substance use in their parents. For individuals who reside in sober houses or community residence programs, affiliated staff members may be able to provide additional information on the patient’s alcohol and substance use.
Asking questions during the initial psychiatric interview can also be supplemented by the use of self-report rating scales such as the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure, with administration of the DSM-5 Level 2—Substance Use Measure if the patient gives a positive response on the Level 1 alcohol or substance use items (American Psychiatric Association 2013b). These measures are available online at http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures. Other measurement-based approaches to asking questions about alcohol or substance use include but are not limited to screening tests such as the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST; World Health Organization 2010); the Fagerström Test for Nicotine Dependence (Heatherton et al. 1991); the Alcohol Use Disorders Identification Test (AUDIT; Saunders et al. 1993), or its shortened form, the AUDIT-C (Bush et al. 1998); and the Drug Abuse Screening Test (DAST; Skinner 1982). In some circumstances, information from laboratory testing may be available that provides clues to substance use. Examples include urine toxicology, blood alcohol levels, and measures of substance metabolites or biological effects of alcohol use (e.g., abnormal liver function, mean corpuscular volume of erythrocytes). If the patient exhibits signs of intoxication or withdrawal, scales such as the Clinical Institute Withdrawal Assessment for Alcohol—Revised (CIWA-Ar; Sullivan et al. 1989) or the Clinical Opiate Withdrawal Scale (COWS; Wesson et al. 2002) can be used to document signs and symptoms and guide treatment. When a patient has evidence of tobacco, alcohol, or other substance use in response to screening measures, interview questions, or laboratory testing, additional follow-up questions will generally be needed. Depending on the substance(s) being used, it may be important to delineate the route, quantity, frequency, pattern, typical setting, and circumstances of use as well as self-perceived benefits and psychiatric and other consequences of use.
Barriers to carrying out an assessment for tobacco, alcohol, and other substance use include the time required for a thorough assessment and lack of certainty that information obtained will be of value in establishing a diagnosis (e.g., because patients may not provide full details about their substance use). In addition, clinicians may be reluctant to ask questions about tobacco, alcohol, or substance use if they fear that it will upset patients, if they lack the time or confidence in their ability to follow through with appropriate interventions, or if resources for treatment are unavailable in the community.
Statement 1. APA recommends (1C) that the initial psychiatric evaluation of a patient include assessment of the following: