The Initial Psychiatric Interview

I recently had a 30-minute Zoom call with a senior in medical school who told me that she was on her psychiatric inpatient rotation and she wanted to know, given my many years’ experience as a psychiatrist, how I went about interviewing a new patient. This exchange encouraged me to write this article. I believe that this article will be useful regardless of the theoretical orientation of the psychiatrist: psychodynamic, cognitive behavioral, psychopharmacologic, etc.

When I meet with a potential new patient for the first time (hereafter referred to as “the patient”), after an initial introduction, I use the standard initial medical interview as a template for the initial psychiatric interview. Although my practice has been entirely virtual since the COVID pandemic 6 years ago, the procedure I follow is the same as meeting with a patient in person. My goal is to collect enough information by the end of the interview to decide how to proceed next.

The initial psychiatric interview includes the chief complaint, history of the present illness, family history, social history, past psychiatric history, medical history, and the mental status examination. Toward the end of the interview, I summarize my formulation in layman’s terms to the patient, and, if the patient and I agree that we should meet a second time, I make initial treatment recommendations, and a second appointment is scheduled.

I have internalized this template after many years and I let the patient know that, during the interview, I will be looking away at times while I am taking (extensive, verbatim, hand-written) notes. I later transcribe and type my hand-written notes into my patient’s electronic file. I will now describe in more detail each of the components of the initial psychiatric interview.

Chief Complaint

After introducing myself to the patient, I often ask how they found me or got my name. If it was from a trusted colleague, for example, this will increase the likelihood of an early positive transference that will lay the groundwork for a solid physician patient relationship.

As an interesting counterexample, I recently received a voicemail message from a young adult who found me on the Psychology Today website, asking if I could meet with them and an elderly relative who was suffering from a terminal medical illness and cognitive impairment, and whose maternal tongue was different from my own. Somewhat astonished given the language and cultural difference, I commented that I appreciated the trust that was being placed in me. The caller would translate and the first appointment was scheduled for the next day.

When meeting with a new patient, I usually begin by asking the reason for contacting me. Their reply becomes the chief complaint. Most patients contact a psychiatrist because of a new onset or worsening of anxiety or depression, regardless of the cause of these affects. They may have had a failed relationship, a recent job loss, an illness in themselves or a relative, a problem with addiction, etc. We are always interested in “why now?,” ie, why are they seeking psychiatric help at this time, since something had to have changed and tipped the scales of their emotional equilibrium, either internally or externally, leading them to seek psychiatric care now.

History of the Present Illness

After I elicit the chief complaint, I ask them to tell me more about their current situation. This becomes the history of the present illness. During this early part of the interview, we are already obtaining crucial aspects of the mental status examination. That is, we are learning about the patient’s obsessive, histrionic, narcissistic, or sociopathic personality style; information about their educational and cultural background; their speech characteristics and thought processes; their affect and mood; their level of insight into their problems; and their psychological strengths and vulnerabilities.

If a person is flooding me with details, I may provide a brief summary of what they have just told me, whereas if they are speaking mostly in generalities, I ask them to give me examples of what they are saying. An analogy to dermatology can be made: “If it is dry, wet it; if it is wet, dry it.” The history of the present illness almost always includes other parts of the psychiatric history that will follow.

I sometimes tell the patient humorously while they are speaking that “I want to hit the pause button” and I ask them to say more about what they were just talking about. I try to use the patient’s own words as much as possible, rather than paraphrasing, since their spoken words have meanings specific to them alone. In the language of structural linguistics, their signifiers have their own specific signifieds, and patients will feel most understood if we use their own words, rather than paraphrase with our own.

The novice clinician may believe that taking the history of the present illness is simply data gathering to create a medical record. This is not the case. Taking the patient’s history while listening in a noncritical and empathic fashion is profoundly therapeutic in itself. The patient often feels better by the end of the interview.

When interviewing a patient, or later engaging the patient in psychotherapy, it is important to try to not interfere with the patient’s speech, or flow of associations, while they are talking. This is not an easy task and takes considerable experience. I think of myself as “actively keeping my mouth shut” rather than “passively listening” to the patient during the interview until I decide to say something.

Family History

“Tell me about…” are perhaps the 3 most important words in psychiatric interviewing. After obtaining the history of the present illness, I will ask a new patient to “Please tell me about your family” (for example). Generally, open-ended questions are best when gathering information since they prejudice the answers we get much less than questions that can be answered with a “yes” or “no.”

When asking about a patient’s family, I usually draw a family tree for myself, and, after telling me who is in their family in response to an open-ended question, I ask closed-ended questions to fill in the blanks. The names of family members and friends are important and often culturally and historically informative. I ask about the age of each family member and when deceased family members died, keeping in mind possible anniversary reactions.

Even though I might not remember most of these names, asking about them quickly brings me inside the patient’s internal familial world during the initial interview. In the “counterexample” I gave above, when I met with the patient online the next day, the person who contacted me to make the appointment was holding a 6-month-old infant and I immediately asked the name of this small child. This produced smiles all around—on the face of the parent, on that of the patient, then on the baby itself, and then for me as well. The family history can also provide information about genetic contributions to the patient’s psychiatric and medical symptoms.

Social History

I ask new patients to tell me about friends and friendships. This is an easy way to ask about the patient’s social world. I may then follow up with: “Tell me about important romantic relationships you have had.” This gives the patient the opportunity to talk about intimate relationships, marriages, divorce, etc. In this way, I learn about their capacity for enduring interpersonal relationships including the therapeutic relationship.

In my experience, psychiatrists avoid asking sexual questions of their patients like the plague, even though infantile sexuality is foundational in psychoanalysis and sex is consciously or unconsciously on everyone’s minds almost all the time. Asking about friendships and romantic relationships also has important diagnostic implications ranging from those who are “on the spectrum” with few or no friends, to those with a healthy cohort of close friendships, to those who are in emotionally painful sadomasochistic relationships.

Past Psychiatric History

Asking about previous psychotherapy and other past psychiatric treatment is crucial since this can provide insight into how treatment with you might evolve. Finding out what the patient found to be most helpful and what wasn’t in previous treatment is important for the same reason. Asking about past psychiatric hospitalizations, reasons for admission, medications and doses, and discharge outcomes—if relevant—is also important.

In this section of the interview, I also ask: “Tell me about your alcohol, tobacco and drug use (referring to illicit substances) in your lifetime. I often add the tag “in your lifetime” to my open-ended questions to gather the most information in the shortest amount of time.

The novice psychiatric interviewer might worry that such open-ended questions will elicit too much information that will never fit into the allotted time. However, the patient knows from the outset how long the initial interview will last (eg, an hour) and will usually make the length of their answers fit the amount of time of the interview. At the same time, the anamnesis may need to be completed in a follow-up visit.

Medical History

As a psychiatrist who is also a physician, I believe that I am more interested in the patient’s medical history than the nonphysician mental health clinician since I can better place this information in context. Thus, I ask patients to “tell me about” medical illnesses they are currently being treated for, and about serious illnesses or surgeries they have had “in their lifetime.” At the same time, I maintain clear boundaries between what I am trained to treat as a psychiatrist, and when patients need to be referred to their own general practitioner or to other specialists. I obtain a list of medications and doses and sometimes contact information for their other treating physicians.

Although I am writing these components of the psychiatric interview in a sequential manner, most interviews are rarely so. Patients go off on tangents, the interview takes detours, we may double back, and so on. At the same time, I keep my eye on the prize of obtaining as much of the information I need during the initial interview to arrive at a formulation and treatment plan by the end.

Mental Status Examination, Formulation, and Treatment Plan

After I transcribe my hand-written notes of the interview to a typed file later in the day, I add a mental status examination section as well as my formulation, diagnostic impression, and treatment plan. The mental status examination has been described by others at length, and I will not go into it here.

The formulation that I reflect back to the patient in layman’s terms toward the end of the interview pulls together the information I have collected, summarizes what I have heard, and determines how it likely contributes to the symptoms with which the patient presents, ie, the chief complaint. It is also helpful to ask the patient to describe why they think they are having the problems they are experiencing. This provides an assessment of their insight and lets them know that you are interested in how they think about themselves. I follow this by asking what they think might be helpful by way of treatment.

As you can see, I try to engage with the patient during the interview as much as possible. I sometimes quip to my patients (a tactful sense of humor can go a long way!) that: “I never help anyone; I try to help my patients help themselves.” If the patient agrees, we set up another appointment, usually the following week, unless the problem is more urgent, eg, including suicidal ideation not requiring hospitalization, and we schedule a follow-up in the days ahead.

Dr Perman is clinical professor in the Department of Psychiatry and the Behavioral Sciences at the George Washington University Medical Center in Washington, DC, and a clinical professor in the Department of Psychiatry at Creighton University Medical School in Omaha, Nebraska.