History Taking in Psychiatry – Part 3

Introduction

In this section we highlight some of the essential basic principles of examining a patient with mental health problems. Each encounter with the patient is an opportunity for the treating physician to establish a rapport and further cement the therapeutic alliance — the working relationship — with the patient as well as the main caregiver and/or the next of kin chosen by the patient.

Each medical student, newly graduated doctor, and other health professional will develop their own personal methods of communication with patients, which work for them in all aspects of their clinical work. The basic principles of respect, privacy, and dignity for the patient must be maintained at all times. The patient must develop the belief that you care for them; that you will go the extra mile to help and support them; and that you are honest, caring, and accessible — especially when they really need you. At the same time, you must maintain a respectable professional distance and appropriate boundaries.

What follows is the method and approach that has worked well for the author in four decades of taking history and performing mental state examinations from patients with mental health disorders — which you may adapt to suit your own style and clinical practice.

Beginning the Interview: Finding a Suitable Room

Your first concern should be where to see your patient. Finding a suitable area is very difficult within NHS facilities. It is more difficult if you have been asked to see a patient as an emergency in an Accident & Emergency department or on a surgical ward. The first principle is to interview the patient when and wherever they can be made most comfortable in the given situation.

If you have been asked to visit a patient at home — usually an older person unable to travel — it is the patient who decides in which room you may interview them. In a hospital setting, it is your responsibility to find a suitable room, which is always challenging. In some clinical settings, there are clearly specified rooms available for medical consultations — please book them in advance, otherwise you will find them occupied by someone else.

Be Always on Time

There is nothing more upsetting for a patient than waiting for the doctor. If you are running late for any reason, it is courteous to let the patient know how long they will need to wait. A wait becomes more tolerable when the patient knows how long it will be. A comfortable waiting room with some privacy always helps, though this is not always the norm within the NHS.

Walking to the Consulting Room

If you have found a room to interview your patient and you are on time, you are doing well. It is always courteous — and helpful in establishing the essential rapport — if you yourself go to fetch the patient from the waiting area, rather than asking a secretary or nurse to send them in. This may not always be practical in a General Practice setting, but where it is possible, it offers benefits for both doctor and patient. Take this opportunity to ask the patient whether they would like their accompanying relative or friend to join them in the consulting room, or whether that person should be invited in towards the end of the interview for the final briefing about diagnosis and management.

The involvement of family members and others — only with the patient's consent — is very important in all branches of medicine and especially in psychiatry, where relatives want to understand the expected outcome of the proposed treatment and to know whether there are risks to the patient's personal safety or to others, and whom they can contact if things do not go as planned.

The Consultation

The patient should be seated first, then any person the patient has invited to accompany them, and finally the doctor takes their seat. Ideally, both the patient and the accompanying person are seated comfortably without a desk creating a barrier between you. After the initial greetings, check the patient's personal details (name, date of birth, address, GP details). Then introduce yourself and clearly state the purpose of the interview, who referred the patient, and approximately how long the interview is likely to last.

At this point, it is worth mentioning that if you are unable to complete the assessment in the allocated time, you will arrange to see them again soon — usually within two to three days — to complete the assessment and gather any additional information. Once again, take the patient's consent to contact others regarding their health issues.

The Start of the Interview

To relax the patient and also yourself, begin with open-ended questions that are low in emotional charge. For example:

• How does the patient feel about coming to see a doctor about their mental health?
• Does the patient feel they need to see a psychiatrist, or has someone else in the family encouraged them to come?
• Has the patient seen anyone else about their mental health problems in the past? What help was given?

Follow with further open-ended contextual questions where appropriate:

• How was the journey to the clinic?
• Was there any problem with traffic or parking?
• Do they need to return home or to work by a certain time?
• Who is looking after children at home?
• Are they currently off work?
• What are their current responsibilities towards others in the family?

All of the above are asked only where appropriate — not in a checklist fashion, but naturally as conversation allows.

The next step is to move to the patient's emotional and mental health issues. Follow the standard schema as outlined in History Taking in Psychiatry – Part 2. Your role is to ask the right questions to elicit the history; to listen; to facilitate and respond appropriately to the verbal and non-verbal expressions of the patient; to react empathically without making a judgement about how the patient is feeling; and to aim to understand the patient's feelings and suggest "how difficult this must have been for them." Never try to rush a patient into talking about difficult or traumatic material if they are not willing or ready to do so.

Take a hint from your patient and move on to the next part of the history, which is less emotionally charged. For example: "I know it is difficult for you to talk about that at the moment — let us leave it for now and come back to it later." This kind of transition statement is a skill that takes time to develop. Do not be discouraged if it takes practice.

While discussing the personal history, be mindful of others present in the room — this may be the opportune time to ask the patient once again whether they would prefer to talk to you alone or are happy for the accompanying person to stay. Often the relative themselves will offer to leave the room. Always take the lead from the patient.

As the interview progresses, take a brief moment to summarise the relevant information aloud, simply to check that you have correctly understood the patient's description of their problems. It is also useful to clarify the patient's wishes and expectations — what they hope to get from this contact and how they would like to be helped.

Remember that sometimes the patient may not wish you to communicate even with their referring GP or with the family member who accompanied them, and you should respect that — while documenting your decision clearly.

You will need to move backwards and forwards during the interview, asking relevant questions to elicit the key signs and symptoms, gather relevant information, and complete the Mental State Examination in your first meeting. The first interview should at least provide you with a primary working diagnosis and a management plan. Sometimes you will not have every piece of information needed — the patient may be uncooperative, you may have run short of time, or you may be faced with a patient who is very difficult to redirect. Cases like these require direction and transition statements, and the skill of keeping a patient on track and focused on the key issues of the assessment is one that develops over a career.

Finishing the History Taking and Closing the Interview

For the author, the close of the interview is as important as its beginning — and in many ways more important. Before addressing the specific elements of the closing, remember the basic principle of all meetings: keep to your agreed time. Overrunning with one patient will delay every other patient in the clinic and does not serve a useful purpose in the long run. Practise ending the interview a few minutes before the agreed time.

The last few minutes of the consultation must be spent discussing the following with the patient:

• The primary diagnosis (or working diagnosis if assessment is incomplete)
• The possible underlying causes
• Other possible diagnoses and how they will be distinguished
• What investigations will be carried out, by whom, where, and when
• How you plan to communicate with the patient's GP and other relevant professionals, and by when — seeking consent where required
• That you will copy any written correspondence to the patient (in psychiatry, use discretion about timing and content, bearing in mind that patients have the right to access all their medical notes)
• The proposed treatment plan and who will prescribe any medications
• What response the patient can expect and over what timescale
• Any side effects to watch out for
• Details of the next appointment and what to do if they are unable to attend
• Who the patient will see at their next appointment if you are not available
• And — most importantly — who the patient should contact in case of an emergency, including telephone numbers both during and outside of office hours

Make sure the patient leaves with all the relevant contact information. The success or failure of your treatment outcome often depends upon your follow-up arrangements and how accessible you are in case of emergency.

The next section in this series deals with the Mental State Examination in Psychiatry.