Psychiatric Interviews

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview: Evaluation and diagnosis.Chichester, England: John Wiley & Sons. Retrieved from http://www.ebrary.com

The Psychiatric Interview: Evaluation and Diagnosis, First Edition. Allan Tasman, Jerald Kay and Robert J. Ursano.

© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.

Psychiatric Interviews:

Special Populations

Randon Welton and Jerald Kay

5

There is a popular image of the psychiatric interview where the patient and clinician sit

comfortably in soft leather chairs in the psychiatrist’s office surrounded by objets d’art

and built-in bookshelves. The patient speaks clearly, honestly, and succinctly about his or

her problem. The psychiatrist listens intently and understands thoroughly what is being

said. This mutual understanding allows the therapy to begin effectively and proceed

quickly to its successful conclusion. All too often, the reality of psychiatric practice

reflects more challenging situations.

In this chapter, we shall be examining a number of special, but nonetheless common,

clinical circumstances and patient populations that tend to bend the frame of the traditional

psychiatric interview. There are an infinite number of special circumstances of

course, and this chapter could hardly list, much less discuss, them all. Instead we will be

looking at examples within two major themes. Sometimes the interview is extraordinary

because of the circumstances surrounding the interview. At other times, psychiatrists will

be interacting with a distinct population of patients; patients that inherently require an

alteration of our approach. These situations require extra thoughtfulness and adaptation

on the part of the clinician.

Included under the heading of Special Circumstances are patients located on

Inpatient Units, on Medical Wards, or in the Emergency Department (ED). The acuity of

these patients and the lack of privacy in these locations contribute to the difficulty of the

interview. Another set of special circumstances occurs in Mass Casualty or Disaster scenarios.

In those calamities, the psychiatrist may be responsible to assess large numbers of

patients in orthodox settings.

Even when the interview takes place in a more traditional setting, there are Special

Populations that may challenge the psychiatrist. These include patients with severe

Psychotic Symptoms or significant Suicidality. Interviewing Children and Adolescents

can pose a challenge for the non-subspecialist. Also included in these special populations

are those where there is a difference in language between the patient and the psychiatrist.

This creates the need to incorporate Interpreters into the psychiatric interview. Cultural

chapter

Tasman, A., Kay, J., & Ursano, R. J. (2013). <i>The psychiatric interview : evaluation and diagnosis</i>. Retrieved from http://ebookcentral.proquest.com

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104 The Psychiatric Interview

Barriers are invariably present with patients from different ethnic and racial backgrounds

even when they are fluent in English. These differences add difficulty to the psychiatric

interview. In these days of increasing demands and falling recruitment within psychiatry,

Telepsychiatry is becoming an increasingly common solution to providing access to

psychiatry. This new technology, however, often is accompanied by some unique issues

that, if not addressed, add complexity to the clinical interview.

Psychiatric Interview in Special Circumstances

Special Circumstances — Inpatient Units

Interviewing hospitalized psychiatric patients is a routine responsibility that may lead to

an insensitivity to the uniqueness of this environment. Because of the ubiquitous legal and

financial demands inherent in inpatient treatment, modifications to interview style are

necessary. Since a thorough history and physical examination must be documented within

the first 24 hours of admission, this first encounter is likely to be the longest one-on-one

interaction between the patient and psychiatrist.

This documentation of the history and physical examination must meet the standard

required by regulatory agencies such as the Joint Commission for the Accreditation of

Hospitals and includes, but is not limited to, assessments of the patient’s preferred method

of learning, patient strengths, risk to self, comprehensive psychiatric and medical history,

and risk to others. Diagnoses and treatment plans are required as well. In addition, the

psychiatrist will need enough information to satisfy utilization management and thirdparty

standards for hospitalization. The time pressure to get the necessary information as

quickly as possible shapes the psychiatrist’s interview. In the rush to obtain the requisite

information, clinicians often resort to simplified information-gathering tools such as

checklists and “Yes/No” questions, which must be carefully balanced with the development

of a doctor–patient relationship based on empathy and understanding.

Many inpatient units have adopted a team interview model where the psychiatrist is

the collator of information rather than the collector of that information. These units see it

as more cost-effective for nonphysicians to gather much of the background information.

So rather than asking traditional open-ended questions about the patient’s past experiences,

the psychiatrist simply “signs off” on the history obtained by other mental healthcare

providers. This may limit the engagement in the therapeutic relationship between the

patient and the psychiatrist.

The accuracy of a traditional psychiatric inpatient interview has been questioned.

Researchers looked for inter-rater reliability among providers assessing 56 patients using

three different methods. The methods included a traditional, unstructured diagnostic

assessment (TDA), the Structured Clinical Interview for the DSM – Clinical version

(SCID), and a Computer-Assisted Diagnostic Interview (CADI), which utilized questions

based on DSM-IV algorithms. Following the individual interviews, the interviewers met

to come up with a consensus diagnosis. Compared to the consensus diagnosis, the unstructured

TDA was in agreement 53.8% of the time, considerably less than the structured

approaches (SCID – 85.7%, CADI – 85.7%) (Miller et al., 2001). The same facility then

looked at agreement between the diagnosis in the ED and the ultimate diagnosis on the

Tasman, A., Kay, J., & Ursano, R. J. (2013). <i>The psychiatric interview : evaluation and diagnosis</i>. Retrieved from http://ebookcentral.proquest.com

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Chapter 5 • Psychiatric Interviews: Special Populations 105

inpatient unit. It used the same CADI to evaluate 39 patients in the ED and then reevaluated

them on the inpatient unit with another provider using the CADI. This was compared

to two groups who received TDAs in both the ED and the inpatient unit. The two TDA

arms combined had 66 patients. Looking at inter-rater reliability found “poor” to “fair”

agreement (45.5–54.5%) with the TDA, while using the CADI resulted in “excellent”

agreement (79.5%) (Miller, 2001).

A final study by this group looked at the impact the assessment had on patient care.

The use of the CADI ensured that the interview would cover all of the key criteria

necessary to screen for the major DSM-IV criteria. Because it was preloaded with the

DSM-IV algorithms, it would also cover all of the criteria when there had been a positive

screening. The interviewer using a traditional diagnostic assessment on average asked

only half of the key criteria screening questions and asked slightly less than half of the

DSM criteria for the likely diagnoses. In these patients, who had been randomly assigned

to the interviews based on their arrival at the hospital, the length of stay for those receiving

the CADI was an average of 4.8 days less than those receiving the TDA (Miller, 2002).

These studies did not address differences in long-term outcome nor the patients’ experiences

in the various approaches.

The challenge for the inpatient psychiatrist then is to obtain the diagnostic accuracy of

a structured or algorithmic interview while preserving the open-ended questions and empathic

connection of the traditional approaches. Working on an inpatient unit requires the psychiatrist

to perform a difficult balancing act. The pace, external accountability requirements, and

diagnostic precision required for the inpatient admission will challenge a slower-paced traditional

interview. Often relying on information provided by others and the use of more structured

and less engaging interviewing techniques is attractive. The cost of this accommodation

may be a decrease in the quality and significance of the relationships between the inpatient

provider and his or her patients. Although no simple solution exists to this tension, the inpatient

psychiatrist can utilize a few techniques to balance these positions:

• When possible, interview the patient after the other providers have collected their

information. The psychiatrist can then refer to the information that others have

obtained and ask the patient to expand on it. This demonstrates that the psychiatrist

has some basic understanding of the patient but wants additional information.

SS  Example – The previous interviewer recorded: Academic history – “Graduated High

School in 13 years; a few classes at community college”. The psychiatrist asks: “I

see that you needed an additional year to graduate high school and then went to

college for a while. Tell me about that”.

• Continue to ask open-ended questions, especially at the beginning of the interview.

Ignoring the patient’s perspective on why he or she was brought into the hospital can

damage the development of a therapeutic alliance and limit the clinician’s

understanding.

• Continue to make empathic statements rather than exclusively elicit symptoms.

SS  Example – The patient has a chronic history of highly critical auditory

hallucinations. “I see that you have heard voices for a long time and they say some

pretty bad things about you. That must be horrible. How have you managed to deal

with that for all of these years?”

• Aid in the development of a positive “institutional transference” by helping the patient

build trust in the entire team and not just the psychiatrist. Utilizing and praising the

Tasman, A., Kay, J., & Ursano, R. J. (2013). <i>The psychiatric interview : evaluation and diagnosis</i>. Retrieved from http://ebookcentral.proquest.com

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106 The Psychiatric Interview

work done by the other team members can aid in this. Stress the ongoing communication

among the team about the patient’s particular situation and treatment plan. If possible,

have them interact with multiple team members at a time along with the psychiatrist.

Summary of Recommendations

• Structured evaluations may be helpful.

• Do not neglect displays of empathy and opportunities to build rapport.

• Ask open-ended questions whenever possible.

• Purposefully develop a therapeutic alliance among the patient, the psychiatrist, and

the rest of the team.

Special Circumstance – Medical Wards

Although the consulting psychiatrist first and foremost has the patient’s best interest at

heart, the principle reason for the consultation, nevertheless, is to assist the medical or

surgical provider who initiated the consult. Depending on the culture of the hospital, these

providers may be asking for the psychiatrist to take over the management of the patient’s

psychiatric issues while on the medical ward. In other facilities, the consulting psychiatrist

is merely asked for advice on how to manage the patient and does not take an active

treatment role.

The patient must understand the role of the consulting psychiatrist and that

information obtained by the psychiatrist during an interview may be conveyed to the

treating team. If this is not clarified from the outset, the psychiatrist can be placed in an

awkward position of either knowing key elements of the patient’s history that he or she

does not relate to the treatment team request or of betraying the patient’s confidence.

There are often concerns about privacy. Although some patients will have single rooms

and can be assessed in privacy, the consult on the medical ward often takes place in a

room that is shared with at least one other patient. The patient’s medical condition may

make it impossible to move the consultation to a more private setting. These factors

necessitate significant changes in the initial interview. Both the patient and psychiatrist

must acknowledge and accept the lack of privacy and confidentiality as well as the dual

agency of the consulting psychiatrist.

The medically ill patient presents some other significant challenges. These include

gathering and understanding comprehensive details of the medical or surgical condition

that necessitated hospitalization. The consultant psychiatrist often returns to reading textbooks

or review articles. Drug–drug interactions in these patients may also be daunting.

The psychiatrist must appreciate the psychiatric manifestations of unfamiliar medications

and their interactions. Again, there must be a willingness to research these issues.

As part of the consult, the psychiatrist must routinely address behavioral medicine

issues in addition to elucidating specific psychiatric diagnoses. Assessing the patient’s

psychosocial adjustment and how it impacts on the patient’s health and response to

treatment falls squarely into the consulting psychiatrist’s purview.

• Example – A 55-year-old man was admitted to a medical ward on numerous occasions

for uncontrolled hypertension. While on the unit his blood pressure was well controlled

Tasman, A., Kay, J., & Ursano, R. J. (2013). <i>The psychiatric interview : evaluation and diagnosis</i>. Retrieved from http://ebookcentral.proquest.com

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Chapter 5 • Psychiatric Interviews: Special Populations 107

with medications, within days of discharge his blood pressure rose dangerously. When

asked, he insisted that he was taking his medication as prescribed and was following

the other behavioral suggestions of the treatment regimen. The frustrated treatment

team had asked for a consult to evaluate for malingering or factitious illness. The

psychiatrist took an empathic, nonjudgmental approach with the patient, openly

assuming that the patient was doing what he could to keep himself healthy. As the

patient became more comfortable with the psychiatrist, this proud man disclosed that

he did not have the financial resources to take his medication as prescribed and was in

fact only able to afford to take the prescription “every three or four days”. The

psychiatrist could then assume a liaison role to the team to help them negotiate the

financial aspects of his care.

The lack of comfort with managing psychiatric illnesses on the medical ward goes both

ways. Often the treatment team will be uncomfortable with the patient’s mental illness

and have only a vague idea of what he or she would like the psychiatrist to do for him or

her. This lack of clarity can be confusing for the patient and treatment team as well as for

the psychiatrist. The treatment team may even consult mental health without informing

the patients that they are doing so. When the psychiatrist shows up in the room, these

patients can be surprised and sometimes offended that their providers have consulted

mental health care without their knowledge.

There are some basic steps that the psychiatrist can take to improve the quality and

value of the interview on a medical or surgical ward.

• Specify the question to be answered – As a consultant, the psychiatrist assists the medical

team. The treatment team must, therefore, play a role in defining the focus of the

psychiatrist’s interview. No matter how brilliant the information obtained and relayed by

the psychiatrist is, if it does not answer the team’s question, then the consultation is not

successful. Often the team does not fully understand what they want and will send a

consult request that says in essence “See this patient”. In those situations, the consultant

should talk first with the team to clarify what information would be the most helpful. Are

they looking for help with diagnosis? Are they concerned about the patient’s current or

proposed medication regimen? Do they have questions about the patient’s capacity to

make informed decisions? Some authors have referred to this as the “center of gravity”

for the consult. The psychiatrist assists the patient by helping the medical team

understand what questions they have about the patient (Philbrick et al., 2012).

Frequently, the initial psychiatric consult may be inappropriate or impossible.

SS  Example – “35-year-old recently diagnosed with cancer. Patient is crying. Please

evaluate”.

SS  Example – “54-year-old chronic alcoholic. He has failed numerous rehabs. He

needs to stop drinking. Please assess and treat”.

One of the most important aspects of the consultation is helping the medical team

understand and accept the limits of what psychiatric consultation can provide them

and their patient (Nichita and Buckley, 2007; Perry and Viederman, 1981a).

• Dealing with Skeptical Staff Members – Unfortunately, the psychiatrist must

occasionally deal with medical and surgical staff that neither understand the impact

and importance of mental illness nor value the input of the psychiatrist. Often a

psychiatry consult appears to team members as the most expedient way to relieve

Tasman, A., Kay, J., & Ursano, R. J. (2013). <i>The psychiatric interview : evaluation and diagnosis</i>. Retrieved from http://ebookcentral.proquest.com

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108 The Psychiatric Interview

themselves of a difficult patient. Explaining the limitations and value of a psychiatric

interview and consultation can again be extremely helpful for the patient and the

consulting team. The psychiatrist does not want to remove a patient’s sadness over

tragic events (e.g., the diagnosis of metastatic cancer). A brief consultation will not

change chronic behavioral problems and cannot take the place of ongoing outpatient

therapy. The consultant can, however, point the team in the right direction while

recognizing that the bulk of the work must be completed elsewhere.

• Lack of Confidentiality – As the consulting team is the primary recipient of

information, the psychiatrist must explain the limits of confidentiality to the patient at

the beginning of the interview. The psychiatrist is there to help the medical team

provide care. The information obtained may be conveyed to the team if it is important

in the patient’s medical care. The consult will be included in the general medical

record and can be accessed by a host of personnel (Wise and Rundell, 2005). Of

course, the consulting psychiatrist still has some discretion. Issues that might unduly

embarrass the patient and will not directly impact patient care can usually be

expressed in a tactful fashion.

SS  Example – A 45-year-old female with metastatic breast cancer is being seen for

depression. She discloses that her marriage recently ended when her husband

announced that he was homosexual and left her for another man. The psychiatrist

records: “Discussed the painful ending of her marriage”.

• Lack of Privacy – When the interview takes place in a multi-bed room, the

psychiatrist may pull the curtain shut for the illusion of privacy but his or her voice

will easily carry to the other beds. If no private interview room is available or feasible,

the patient can be positioned so that he or she is turned away from his or her

roommate. The psychiatrist should speak softly but must ensure that the patient can

hear and understand him or her. The lack of privacy should not prevent the

psychiatrist from broaching potentially uncomfortable topics such as substance abuse

and suicidality. Euphemisms and generalities can be used to start the conversation, but

at some point the clinician will need to ask about them directly.

• Distractions – Although there is no way to prevent other medical personnel from

interrupting the interview, nursing staff can be asked if there is anything they need

from the patient before starting the interview. This should help minimize distractions.

Politely insist that the television and other entertainment be turned off during the

course of the interview.

• Visitors – Since some wards have restricted visiting hours and some visitors come

from long distances, it often seems uncaring to simply ask them to leave. Working

around the visitor’s schedule is a kind and compassionate thing to do if possible.

Those gestures can help create an instant therapeutic rapport with the patient. If,

however, the psychiatrist lacks such flexibility, he or she can apologize to the patient

and visitors and explain the need to interview the patient in private. Direct them to a

nearby waiting room and be sure to notify them when the interview is finished.

• Monitor Your Attitude – Because the medical/surgical ward is often unfamiliar and

uncomfortable to the psychiatrist, he or she can unconsciously adopt attitudes that are

not therapeutic. Being surrounded by a “medical” environment, the psychiatrist might

tend to function with a strictly biological focus. The psychiatrist adopting this

unempathic stance directs his or her attention only to pertinent positive and negative

Tasman, A., Kay, J., & Ursano, R. J. (2013). <i>The psychiatric interview : evaluation and diagnosis</i>. Retrieved from http://ebookcentral.proquest.com

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Chapter 5 • Psychiatric Interviews: Special Populations 109

signs and symptoms, gathering much of the information from the medical records and

staff members. This psychiatrist may stand by the bedside, simply confirming

information already obtained from the record and adopt an attitude of the detached,

benevolent authority. His or her recommendations would focus solely on laboratory

studies and medication changes, ignoring psychological or social interventions. On the

other hand, the psychiatrist, surrounded by poorly understood medical terminology,

can overly identify with the patient. He or she can become enraged by perceived

slights the patient has received from the staff and criticize the direction and pace of

treatment even when he or she does not have a good understanding of the medical

issues. The goal of the psychiatrist is to maintain a middle ground where he or she is

more medically focused and interactive than in a traditional interview but still takes

the time to let the patient explain his or her views (Perry and Viederman, 1981b).

• Mental Status – A significant number of psychiatry consultations center on the

cognitive functioning of the patient. Up to 25% of consultations may be for some

form of competency or capacity evaluation (Wise and Rundell, 2005). In addition, the

psychiatrist is often asked to evaluate for confusion and/or delirium. Although the

assessment of a patient’s mental status may not always require the formal

administration of a mental status examination, in these particular situations, the

formal cognitive exam plays a pivotal role. Moreover, cognitive impairment may go

undetected by nonpsychiatric medical personnel as well as by psychiatrists if there is

not a deliberate exploration of those issues. The patient’s social skills and polite

conversation can compensate for cognitive impairment unless attention, concentration,

memory, and executive functioning are specifically addressed. In order to assess

cognitive functioning in a systematic way, it is advised that the psychiatrist utilize a

standardized instrument such as the Folstein Mini-Mental Status Examination or the

Montreal Cognitive Assessment (Wise and Rundell, 2005).

• Collateral Information – Especially when there is a component of cognitive

impairment, patients may not be the best source of information about their current and

recent life experiences and mental functioning. Even the most impaired patient

deserves the psychiatrist’s best effort at establishing rapport and utilizing the patient

as the “expert on themselves”, but the consultant must be prepared to contact family

members or friends at times to clarify the patient’s situation (Wise and Rundell,

2005). Although Health Information Portability and Accountability Act concerns are

not raised when a sole psychiatrist gathers information, it is always best to gain the

patient’s consent before contacting outsiders. During these conversations with

collateral sources, the psychiatrist needs to be aware that the thrust of questions may

inadvertently convey personal health information to the other person. It is best

therefore to stick to general questions: “What changes have you noticed in the

patient?” “What other medical or mental health issues does he or she have?” “What

medications does he or she take regularly” Once the informant has brought up more

focused problems such as depression, confusion, or hallucination, the psychiatrist

should pursue those directly.

• The Surprised Patient – The psychiatrist should not be surprised that some patients will

be unaware that the medical team has consulted mental health. This surprised patient can

become resistant to the clinician. Hostility toward the consultant can arise through the

misconception that the psychiatrist believes that the patient’s problems are “all in his or

Tasman, A., Kay, J., & Ursano, R. J. (2013). <i>The psychiatric interview : evaluation and diagnosis</i>. Retrieved from http://ebookcentral.proquest.com

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110 The Psychiatric Interview

her head”. For this reason, many psychiatrists insist that the team’s consultation request

be explained to the patient before the first visit. The psychiatrist can sometimes assuage

the patient’s hostility by emphasizing that understanding and addressing the psychosocial

aspects of illness is an important aspect of the patient’s overall medical care.

SS  Example – A 43-year-old female has been admitted for unexplained abdominal pain.

The extensive workup has been negative. The consult request reads simply “43 y/o

with abdominal pain without medical cause. Evaluate and treat”. She is upset with her

team’s giving up on her and “calling in the shrink”. “That’s what they do when they

can’t find a cause. Rather than admit they are not that smart, they blame the patient”.

The psychiatrist explains that he or she has been invited to provide help to the team

beyond the extensive workup that has been done. “Obviously your team believes you

have pain or they would not have done those tests. Sometimes, though, the stress of

chronic unexplained pain or persisting illness might make the person sicker than they

were before. I’m wondering if you have noticed that your pain fluctuates with stress.

Is it worse when things are going poorly and better when things go well?”

• Complicated Medical/Surgical or Medication Issues – Do not be afraid to

acknowledge your ignorance. The psychiatrist can admit to the consulting team or

even the patient that additional research must be conducted to better appreciate the

clinical presentation. In addition to being honest, this interaction has other advantages.

It models an active style of learning to the patient that he or she can use. Asking the

consulting team for an explanation of the medical issues also sets a precedent for the

psychiatrist explaining some of the behavioral health or mental health aspects of the

case later on. Encouraging this type of interdisciplinary communication is an

important aspect of the liaison function.

Summary of Recommendations

• Clarify the question.

• Clarify the roles and responsibilities.

• Engage with the consulting team.

• Address behavioral medicine issues.

• Strive for a private, uninterrupted interview.

• Complete the mental status examination.

• Maintain an empathic relationship.

Special Circumstance – Emergency Department

Interviewing patients in the ED combines many of the difficulties found on the inpatient

unit and the medical ward. A significant number of patients presenting to the ED arrive

with complex and severe psychiatric issues such as psychosis, suicidality, dangerousness

to others, and/or aggressive behaviors. These issues are often compounded by medical

illnesses and the misuse of psychoactive substances. The psychiatrist may be called to

interview patients who are intoxicated or delirious. Many of these patients will be

uninterested in receiving help and can be openly confrontational. There are also patients

who present to the ED for what has been termed social reasons. They are homeless and

know that reporting severe psychiatric symptoms is a path to shelter and meals.

Tasman, A., Kay, J., & Ursano, R. J. (2013). <i>The psychiatric interview : evaluation and diagnosis</i>. Retrieved from http://ebookcentral.proquest.com

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Chapter 5 • Psychiatric Interviews: Special Populations 111

The setting of the ED interview complicates a patient evaluation. The ED often

lacks private, calming locations for the interview. The patient may be separated from

other patients by only a sheet that does not reach the floor. Without accompanying

records, the psychiatrist has nothing more than laboratory data, the physical examination,

and his or her psychiatric interview on which to base his or her assessment. The

evaluation may be further complicated by the ED’s attitudes toward many psychiatric

patients, especially when they are repeat visitors or so-called frequent flyers. These individuals

are very familiar to the ED staff, and often “getting the patient up to the ward” is

their sole priority.

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