A psychiatric history is the result of a medical process where a clinician working in the field of mental health (usually a psychiatrist) systematically records the content of an interview with a patient.
This article mainly covers the initial assessment history taking of a patient presenting for the first time with a new complaint.
The clinician taking the history guides the process in an attempt to achieve a succinct summary of these relevant details.
Secondly, the questions are largely non threatening and provide a gentle introduction into the meeting of patient and clinician.
The severity of each complaint is assessed and this may include probing questions on sensitive issues such as suicidal thoughts or sexual difficulties.
[2] The substance (drug) history includes data about patterns of use (mode of administration, age of onset, frequency, amount, last use, medical or psychological complications, history of attempting to quit) for alcohol, tobacco, and illicit drugs.
Apart from the genetic factors, research has shown that illnesses in the parents such as depression and alcohol abuse are associated with a higher rate of some conditions in the children growing up in that environment.
It then looks at significant events in the patient's life such as parental separation, abuse, education, psychosexual development, peer relationships, behavioural aspects and any legal complications.
Major stresses and transitions such as marriage, parenthood, retirement, death or loss of a partner, and financial success and failure are all important, as is how the patient has dealt with them.
If the information has not already been obtained, the clinician then documents the social circumstances of the patient looking at factors such as finances, housing, relationships, drug and alcohol use, and problems with the law or other authorities.
A full review of systems should attempt to identify and list all of the relevant STRESSORS that may be impacting a patient's function and overall health.
Subsequent history taking on reviews concentrates on changes in the levels of symptoms and responses to treatment, including possible side-effects.