Psychiatric interview

Interview structure

Two main structures are accepted for the psychiatric interview. The fully structured interview follows a predetermined set of specific questions in a fixed order, designed to align with DSM-5 diagnostic criteria.

It relies on binary yes/no answers and requires the patient to have some insight into their condition; it can be administered by less experienced interviewers and aims for objective data. The conversational semi-structured interview uses a flexible format to cover a predetermined list of topics, with the interviewer deciding question order and format as the conversation progresses. This style demands an experienced interviewer and seeks the patient's full subjective narrative.

Components of the interview

The interview begins by establishing psychological safety, as the experience may cause shame. The interviewer elicits the chief complaint, current symptoms, and possible precipitating factors. Medical history is gathered, including past diagnoses, family medical history, current medications, and allergies.

Psychiatric history covers diagnoses, past medication trials, current medications, suicide attempts, hospitalizations, outpatient providers, and family psychiatric history. Social history includes drug and alcohol use, occupation, support systems, living situation, trauma, and stressors. A mental status exam or mini-mental status exam is performed.

Additional testing such as an IQ test, Minnesota Multiphasic Personality Inventory, or Rorschach test may be administered. In a fully structured interview, information is collected in a predetermined order; in a conversational interview, order is flexible. Diagnosis is based primarily on DSM-5-TR and ICD criteria.

Considerations

If a patient expresses homicidal ideation, the interviewer should take safety precautions and consider inpatient hospitalization. The provider must inquire about homicidal ideation, and per Tarasoff v. Regents of the University of California, credible threats require warning the intended subject. Suicidality must be evaluated in all patients, especially those with depression, bipolar disorder, schizophrenia, panic disorder, substance use disorders, or neurocognitive disorders.

Risk factors include male sex, white or Native American race, and older age. Active suicidal ideation with access to means warrants hospitalization. For agitated patients, the interviewer should prioritize safety and consider hospitalization, sedating medications, or restraints; the etiology of agitation should be determined. With delusional patients, the interviewer must not validate the delusion.

Challenges

Validity refers to how well data approximates an ideal truth. Patient-related challenges include shame, fear of judgment, lack of awareness or insight, cognitive deficits affecting recall, secondary gain or malingering, transference, education level affecting understanding, and language proficiency.

Interviewer-related challenges include countertransference, lack of experience, use of medical jargon causing confusion, and diagnostic bias (e.g., a schizophrenia researcher versus a bipolar disorder researcher diagnosing the same patient). Reliability concerns whether datasets collected by different interviewers or at different times are stable. Ideal reliability means the dataset remains consistent despite changes in data collection specifics.

Did You Know?

• The goals of the psychiatric interview include improving the patient's insight and fostering healing.
• Data collected through the psychiatric interview is mostly subjective and often cannot be corroborated by objective measurements.
• The interview aims to gather information from collateral sources.