The psychiatric interview

The psychiatric interview is designed to obtain detailed information about past life, physical health, personality, relationships, and social circumstances, as well as past and present psychiatric symptoms. Such background information can help in making the diagnosis, choosing appropriate treatment, deciding whether the case should be managed on an inpatient or outpatient basis, and setting realistic goals.

In addition, experience of psychiatry affords a good opportunity to improve the practitioner's own interviewing and communication skills; training in consultation and interview skills may include the use of video recordings.

The first interview plays an important part in establishing the relationship between patient and psychiatrist, and therefore has a therapeutic function as well as an information-gathering one. The interviewer must reach the best compromise between listening to the patient's own concerns, and asking the requisite factual questions. Some patients, such as those who are very anxious, need some time to talk freely before they can cooperate with more structured enquiry. Open-ended questions ('How have you been sleeping lately?') are preferable to leading ones ('Have you been waking up early?').

The interview should start with the presenting complaint, though the order of the other components may vary. It is important to include all the sections, but a common-sense approach is called for; there is little use exploring the fine details of symptomatology but failing to find out that the patient has just been evicted from his accommodation or is about to appear in court. It is usual to take notes during the interview since there is too much material to recall accurately afterward.

Assessment may take place in an outpatient clinic, a general practice, the patient's home, a general hospital, or another site such as a police station. Occasionally, one may be asked to interview a patient across a video link; for example, the criminal justice system has a well-developed system allowing an inmate at a prison to be seen by a doctor, lawyer, or other party who attends by arrangement at a local police station. However, this is not fully satisfactory, as it is not a completely professional setting; it would be important, if it were used, that it be backed up by a face-to-face interview as soon as possible.

Privacy is important, and most psychiatrists prefer to see the patient alone, although occasional exceptions are necessary, for example, if the patient is potentially violent or likely to make allegations against the practitioner. Examination candidates are traditionally allowed 1 hour to assess a new case. Complex cases ideally need longer than this, whereas emergencies may have to be assessed more quickly.

If the patient is too ill or uncooperative to give a history, one should concentrate on the mental state examination. It is necessary to use the limited time available wisely; if it is a case of delirium caused by, say, acute infection, the interview will mainly consist of the mental state examination and physical examination. The history will be incoherent, and the priority is finding and diagnosing the underlying acute physical problem. By contrast, in a patient with neurosis, there may be little abnormality on the mental state examination, and physical examination will probably not be done. Therefore, the assessment will concentrate mainly on the history. A patient with psychosis will come somewhere in the middle; the history will be important to have, but more time will be spent on the mental state examination, and neurological or other physical examination may also be needed.

The assessment is often regarded as incomplete until another informant, usually a relative or friend, has been interviewed; this is especially true for cases of psychotic illness or organic brain disease. The patient's prior consent is required except in special circumstances. Where language barriers exist, the help of an interpreter may be required.

A letter summarizing the assessment interview is normally sent to the patient's GP, copies being filed in the case notes and sometimes sent to other professional agencies. Issues of confidentiality may cause problems, so it is important to ensure that the patient knows about the letter, who will receive a copy, and whether any sensitive personal material is to be included.

The status of medical notes has changed. For example, patients now have the right to read their medical notes. There never has been a place for pejorative or personal remarks about patients in the medical notes; this practice is now completely unsustainable.

Many mental health organizations now have computerized notes; there is a plan to have a national NHS information technology (IT) network, containing all patients' notes (although what the plan is intended to achieve, apart from enriching IT companies, is at present unclear). Many psychiatrists have reservations about these developments, but they are happening anyway. Inevitably, this means that there may be a trend toward highly sensitive information not being recorded in medical notes, as these are seen as less confidential than previously.

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