The psychiatric interview of a patient in an emergency setting is unique. Com-pared with a typical psychiatric interview, the emergency interview is usually shorter and frequently less private, and its primary goals are to assess the pa-tient’s safety and determine the appropriate disposition. It can be complicated by the fact that the patient may be unwilling to cooperate and may not have been the person who decided that psychiatric intervention was indicated. De-spite the compelling need to uncover complicating medical conditions and sources of collateral information, the interview need not be formulaic. Given that the clinician is trying to establish rapport and ask about intimate issues af-ter only a brief inaf-teraction, the clinician should always be flexible enough to switch the topic when necessary, follow the patient’s train of thought if indi-cated, and adapt to the patient’s personality style (Manley 2004).
An important part of the assessment occurs before the clinician even en-ters the room with the patient. Before initiating contact with the patient, the clinician should always find out 1) the reason for seeing the patient, 2) basic available demographic information, and 3) the patient’s behavior prior to the clinician’s arrival. If possible, brief covert observation of the patient’s behavior can also be extremely useful because it may uncover attempts at malingering or reveal behavior that the patient will attempt to hide during the interview itself. Clinicians should always begin an interview by clearly introducing them-selves, making the patient aware that they are conducting a psychiatric evalu-ation, and establishing a safe seating arrangement. It is also helpful to remind the patient that the purpose of the assessment is to figure out how best to help him or her in the given situation.
Components of the Interview
The components of an emergency psychiatric interview (Vergare et al. 2006) are similar to those of a more comprehensive diagnostic interview, but necessarily focus more on immediate medical and safety risk factors and on the events im-mediately preceding the patient’s arrival to the emergency department.
Patient Identification
The clinician first determines who the patient is and how he or she got to the emergency department. A brief sketch of the patient’s demographics contex-tualizes the patient for the rest of the assessment. How the patient arrived (i.e., on his or her own, with family, with police) is helpful for understanding the patient’s attitude toward treatment.
Chief Complaint
The clinician should then determine what the patient sees as the presenting problem.
History of Present Illness
A patient who is agitated, intoxicated, or psychotic may have difficulty clearly reconstructing how events unfolded before arriving at the emergency depart-ment. The patient may require specific redirection as to times, dates, events, and the chronology of symptoms, and the clinician may require data from collateral informants.
Past Psychiatric History
Information sought about the patient’s past psychiatric history should include 1) prior hospitalizations, last hospitalization, and age at first hospitalization;
2) prior suicide attempts or self-harming behaviors; 3) prior episodes of vio-lence or agitation; 4) prior trials of medications or therapies; and 5) history of arrests or incarceration.
Substance Use History
In questioning a patient about his or her history of substance use, the clinician should start by asking about tobacco, which is generally the most socially ac-ceptable. For each substance, a complete history should include the patient’s 1) prior use or experimentation, 2) highest level of use, 3) longest sober pe-riod, and 4) current level of use. In addition to questioning about alcohol, marijuana, cocaine, and opiates, the clinician should ask about hallucinogens, inhalants, club drugs, and prescription drugs. The clinician should also screen for history of withdrawal symptoms (e.g., delirium tremens and seizures) and prior treatment history (e.g., rehabilitation, outpatient programs, Alcoholics Anonymous).
Medical History
The medical history should include questions about the patient’s history of cardiac disease, hypertension, diabetes, epilepsy, head injury, hepatitis, cancer, and surgeries. A general reproductive history for women can also be helpful, specifically asking if the woman is menstruating regularly, is perimenopausal or postmenopausal, might be pregnant, or has undergone any reproductive surgeries. Because the Centers for Disease Control and Prevention (2006) has recommended that all adults be tested for HIV as a routine part of health maintenance, the clinician should routinely ask about HIV status in at-risk individuals. In at-risk populations, history of a positive PPD (purified protein derivative) or tuberculosis diagnosis or treatment is also important in deter-mining whether further evaluation by chest X ray or even respiratory isolation will be necessary.
Social Circumstances
In emergency presentations, instead of taking a detailed developmental his-tory, the clinician should focus on painting a picture of the patient’s current
social circumstances. The following information is helpful for making dispo-sition determinations: living situation, financial support, employment history, relocation history, social situation and supports, educational background, im-portant developmental events, and legal/immigration status.
Mental Status Examination
The mental status examination in the emergency psychiatric interview is sim-ilar to any other mental status examination, except that particular attention must be paid to documenting 1) active psychotic symptoms, 2) thoughts of self-injury or suicide and thoughts of harming others or homicide, 3) evidence of drug or alcohol intoxication, and 4) cognitive functioning.
Safety Alerts
Certain safety-related situations that may present during the emergency psy-chiatric interview should trigger more immediate action. These include the following:
• Children in the home or other persons for whom the patient is the primary caregiver (The interviewer should ascertain where these individuals are and who is caring for them, document this information carefully, and send authorities to retrieve anyone who is unsupervised while the patient is in the emergency department.)
• Medical conditions requiring immediate treatment
• Active alcohol or benzodiazepine intoxication and withdrawal
• Active suicidal ideation with intent and plan
• Active violent ideation with intent and plan Collateral Information
Collateral information can be helpful in forming a clear assessment in an emergency situation, and taking steps to obtain this information can be con-sidered a standard of care in certain circumstances. If possible, the clinician should obtain the patient’s consent to talk to collateral informants. However, in an emergency situation, the clinician is permitted, even with existing Health Insurance Portability and Accountability Act (HIPAA) regulations, to contact collateral sources of information if demanded by the patient’s emer-gency circumstances. Even though the clinician may obtain collateral
infor-mation, the physician is still not permitted to unnecessarily share information about the patient without the patient’s consent. (This point is discussed fur-ther in Chapter 12, “Legal and Ethical Issues in Emergency Psychiatry.”) All attempts to gain information via contacting collateral sources should be care-fully documented, including why it was deemed necessary to contact the source and whether the contact was made with or without the patient’s consent (U.S.
Department of Health and Human Services 2003b).