Clinical focus: Psychiatric history taking is a structured, empathic clinical interview. It establishes the patient’s story, symptoms, functioning, medical and substance contributors, risks, strengths and goals. It is not an interrogation or a substitute for physical examination; urgent safety and delirium assessment come first.
Learning objectives
- Build a therapeutic alliance and conduct a confidential, culturally safe interview.
- Structure the psychiatric clerking from presenting complaint to formulation and plan.
- Characterise symptoms by onset, duration, severity, course, triggers, function and associated features.
- Assess suicide, violence, abuse, neglect, vulnerability, psychosis, substances and medical emergencies.
- Obtain collateral history ethically and formulate biological, psychological and social contributors.
1. Preparation and engagement
- Ensure privacy, safety, adequate time, seating at eye level and a chaperone/interpreter when appropriate.
- Introduce yourself, confirm identity, explain confidentiality and its limits (imminent risk, safeguarding and lawful reporting).
- Ask how the patient would like to be addressed and whether they want a support person present.
- Start with an open invitation: “What has brought you in today?” Avoid premature diagnostic labels.
- Assess capacity to participate; if the patient is severely agitated, intoxicated, delirious or unsafe, stabilise and obtain help before a full interview.
2. Psychiatric clerking structure
| Section | Essential content |
|---|---|
| Identifying information | Name, age, gender, residence, occupation/school, relationship, informant and reliability. |
| Presenting complaint | Patient’s words and duration; record the reason for referral. |
| History of presenting illness | Timeline, symptom domains, severity, triggers, function, treatment, risks and patient perspective. |
| Past psychiatric history | Diagnoses, episodes, admissions, therapies, self-harm, violence, response, adherence and adverse effects. |
| Medical/neurological history | Illnesses, head injury, seizures, endocrine disease, pain, infections, pregnancy, medications and allergies. |
| Substance history | Alcohol, tobacco, cannabis, stimulants, opioids, sedatives, khat/other local substances, prescribed and traditional medicines. |
| Personal/developmental history | Pregnancy/birth, milestones, education, relationships, trauma, work, legal/financial stressors and strengths. |
| Family history | Mental illness, suicide, substance use, neurological/genetic illness, violence and support. |
| Social/forensic history | Housing, finances, dependants, safety, legal issues, violence, weapons, migration and services. |
| Mental state examination | Appearance, behaviour, speech, mood/affect, thought, perception, cognition, insight and judgement. |
| Risk assessment | Self-harm, harm to others, vulnerability, neglect, abuse, absconding, command hallucinations and access to means. |
| Formulation/plan | Biopsychosocial formulation, differential, investigations, immediate safety, treatment and follow-up. |
3. History of the presenting illness
Build a chronological narrative. Begin with the patient’s own account, then clarify.
| Dimension | Questions |
|---|---|
| Onset/course | When did it start? Sudden or gradual? First episode or recurrent? Continuous, episodic or fluctuating? |
| Precipitants | Loss, trauma, conflict, illness, medication, substance, sleep deprivation, pregnancy/postpartum or legal/financial stress? |
| Severity/function | What can the patient no longer do? Work, school, self-care, relationships, eating, sleep or finances? |
| Associated mood | Sadness, anhedonia, irritability, guilt, hopelessness, elevated/expansive mood, reduced need for sleep or impulsivity. |
| Anxiety/trauma | Excessive worry, panic, avoidance, intrusive memories, nightmares, hyperarousal or dissociation. |
| Psychosis | Hearing/seeing things, beliefs others do not share, thought interference, disorganisation and command content. |
| Cognition | Attention, memory, orientation and fluctuation; ask family about change from baseline. |
| Somatic/vegetative | Sleep, appetite, energy, libido, pain, weight, autonomic symptoms and menstrual/pregnancy changes. |
| Treatment response | What has been tried, dose/duration/adherence, benefit, adverse effects and barriers? |
4. Risk assessment: ask directly and calmly
Suicide and self-harm
- “Have you wished you were dead or thought life was not worth living?”
- “Have you had thoughts of killing yourself, a plan, intent or access to the means?”
- “Have you taken steps, rehearsed, written a note or made preparations?”
- Previous attempts, recent discharge, severe pain, intoxication, psychosis, agitation, losses and access to pesticides/firearms/medicines increase concern.
- Protective factors include relationships, responsibilities, beliefs, future goals and willingness to accept help—but never assume they cancel an active plan.
Harm to others and vulnerability
Ask about thoughts, target, intent, plan, access to weapons, command hallucinations, domestic violence, abuse, neglect, exploitation, homelessness, inability to eat/drink, wandering and unsafe dependence. A high-risk patient should not be left alone; involve senior staff, family only with consent/safety consideration, and emergency services according to law.
5. Past psychiatric and treatment history
- Age at first symptoms, number/duration of episodes, triggers, inter-episode recovery and previous diagnoses.
- Admissions, emergency visits, restraints, ECT, psychotherapy, traditional/faith support, community care and rehabilitation.
- Medication name, dose, timing, duration, adherence, therapeutic response, adverse effects, interactions, pregnancy and abrupt withdrawal.
- Past self-harm, suicide attempts, aggression, violence, safeguarding involvement and legal orders.
- What the patient found helpful or harmful; record their goals and preferences.
6. Medical, neurological and medication review
New psychiatric symptoms can be caused or worsened by physical illness. Ask about thyroid/adrenal disease, diabetes/hypoglycaemia, epilepsy, head injury, stroke, HIV/syphilis or other infection, autoimmune disease, liver/renal failure, pain, sleep disorders, pregnancy/postpartum state and menopause.
| Medication/exposure | Possible psychiatric effect |
|---|---|
| Corticosteroids | Insomnia, mood elevation, depression or psychosis. |
| Dopaminergic drugs/stimulants | Agitation, insomnia, mania or psychosis. |
| Anticholinergics/opioids/sedatives | Confusion, memory impairment, delirium or falls. |
| Thyroid medicines, interferon, some antimalarials | Mood, anxiety, sleep or psychotic symptoms in susceptible patients. |
| Withdrawal from alcohol/benzodiazepines | Tremor, autonomic instability, seizures, hallucinations and delirium. |
7. Substance-use history: non-judgemental detail
Ask about each substance separately: name, amount, frequency, route, timing, last use, cravings, tolerance, loss of control, consequences, attempts to stop, withdrawal, overdose, injecting/needle sharing and readiness to change. Include alcohol quantity in standard drinks when possible, tobacco/nicotine, cannabis, stimulants, opioids, sedatives, inhalants, prescription drugs and local substances.
Do not diagnose intoxication or withdrawal from behaviour alone. Check glucose, vital signs, temperature, oxygenation and neurological status, and consider toxicology or withdrawal scales according to local protocol.
8. Personal, developmental and social history
- Pregnancy/birth complications, developmental milestones, childhood illnesses and school performance.
- Attachment, caregivers, education, friendships, relationships, sexuality, identity and experiences of discrimination.
- Trauma, violence, sexual abuse, neglect, displacement, imprisonment or occupational exposure—ask with permission and do not force details before safety is established.
- Employment, finances, housing, food security, caregiving, transport, legal issues and access to medicines.
- Culture, language, faith, explanatory model, traditional healers and community resources.
- Strengths, coping strategies, goals and people the patient trusts.
9. Family history and collateral information
Ask about depression, bipolar disorder, psychosis, suicide, substance use, dementia, epilepsy, developmental disorders and relevant medical/genetic illness. With consent and explanation, collateral history can clarify baseline function, sleep, medication adherence, safety and fluctuating cognition. If the patient lacks capacity or immediate risk exists, share only necessary information under policy and document why.
10. Mental-state examination: link history to observation
| Domain | Document |
|---|---|
| Appearance/behaviour | Clothing, hygiene, eye contact, posture, cooperation, agitation/retardation, abnormal movements and response to unseen stimuli. |
| Speech | Rate, volume, tone, fluency, latency, pressure and poverty. |
| Mood/affect | Patient’s words and observed range, reactivity, congruence and stability. |
| Thought | Form (logical, tangential, disorganised), content (delusions, obsessions, guilt, hopelessness, risk) and passivity phenomena. |
| Perception | Hallucinations, illusions, depersonalisation/derealisation; ask about commands. |
| Cognition | Alertness, attention, orientation, memory, language and executive function; note fluctuation. |
| Insight/judgement | Understanding of experiences, treatment choices, consequences and ability to collaborate safely. |
11. Formulation and differential diagnosis
Use a biopsychosocial formulation rather than a label alone:
- Predisposing: genetics, temperament, childhood adversity, medical/neurological illness and prior episodes.
- Precipitating: recent loss, trauma, infection, medication change, substance use, sleep loss or postpartum change.
- Perpetuating: ongoing violence, poverty, insomnia, pain, substance use, stigma, non-adherence and poor access.
- Protective: relationships, housing, beliefs, skills, employment, goals and engagement.
Keep medical, substance-induced, trauma-related, mood, psychotic, neurocognitive, developmental and personality differentials open until the time course and examination support a conclusion.
12. Investigations: targeted, not automatic
- Physical examination and vital signs for every new or changed presentation.
- Glucose, full blood count, electrolytes/renal/liver tests, thyroid tests, pregnancy test, infection tests, B12/folate, toxicology, ECG or neuroimaging when history/examination indicates.
- Assess medication levels or interactions where relevant. A normal test does not exclude a primary psychiatric disorder, and an abnormal result does not prove causation.
- Document the clinical question, consent, result, interpretation and action; do not order broad panels without a plan.
13. Ending the interview
- Summarise the patient’s story and ask what you missed or got wrong.
- Explain your initial formulation in understandable language without premature certainty.
- Agree immediate safety steps, tests, treatment, referrals and follow-up date.
- Give crisis instructions and confirm a safe contact method.
- Document consent, risk discussion, capacity, collateral sources and decisions.
14. Worked cases
Case 1: First-episode psychosis
Clarify onset, hallucinations/delusions, command content, mood symptoms, substances, medications, seizures, infection, head injury and functioning. Assess suicide/violence risk, perform physical/neurological examination and arrange urgent specialist care; do not assume a primary psychotic disorder without medical review.
Case 2: “Depression” with fluctuating attention
Family reports rapid changes, fever and disorientation. This is delirium until proven otherwise. Check glucose, oxygenation, infection, medicines, withdrawal and metabolic causes; treat the medical emergency.
Case 3: Self-harm after relationship violence
Ask directly about current intent, access to means and safety at home, assess injuries and safeguarding, involve the survivor in a safety plan and arrange urgent mental-health and protection support.
15. Quick self-test
- What is the difference between an open question and a leading question?
- Name four domains that must be assessed in suicide risk.
- Why is collateral history useful?
- What does a biopsychosocial formulation include?
- Why must new psychosis or confusion receive a medical/substance assessment?
Answers
- An open question invites the patient’s story (“What has been happening?”); a leading question suggests an answer (“You were hearing voices, weren’t you?”).
- Thoughts, intent, plan/preparation, access to means, previous attempts, protective factors and immediate environment.
- It clarifies baseline, timeline, function, safety, adherence and fluctuation, with consent and minimum necessary disclosure.
- Predisposing, precipitating, perpetuating and protective biological, psychological and social factors.
- Delirium, intoxication/withdrawal, neurological, endocrine, infection and medication causes can be life-threatening and treatable.
Key take-home points
- Build alliance before asking sensitive questions; confidentiality and safety limits should be clear.
- Characterise timeline, symptoms, function, medical causes, substances, risk, context and strengths.
- Ask directly about suicide, violence, abuse and command hallucinations; direct questions do not cause suicide.
- Use collateral history ethically and keep a broad differential until medical and substance causes are considered.
- End with a shared formulation, immediate safety plan, referral and documented follow-up.
References and further reading
- WHO: mhGAP Intervention Guide, version 2.0
- WHO: mhGAP guideline 2023
- WHO: Guidance on mental-health policy and strategic action plans
- WHO: Mental health
Educational note: Follow current Ugandan mental-health law, safeguarding procedures and local referral protocols. This resource is for clinical education and does not replace specialist assessment.
