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TheAmericanPsychiatricAssociationPracticeGuidelinesforthePsychiatricEvaluationofAdults

JoelJ.Silverman,M.D.,MarcGalanter,M.D.,MagaJackson-Triche,M.D.,M.S.H.S.,DouglasG.Jacobs,M.D.,JamesW.LomaxII,M.D.,MichelleB.Riba,M.D.,LowellD.Tong,M.D.,KatherineE.Watkins,M.D.,M.S.H.S.,LauraJ.Fochtmann,M.D.,M.B.I.,RichardS.Rhoads,M.D.,JoelYager,M.D.

AtitsDecembermeeting,TheAPABoardofTrusteesap-provedtheAPAWorkGrouponPsychiatricEvaluation’sPracticeGuidelinesforthePsychiatricEvaluationofAdults.[Thefullguidelineisavailableathttp:///doi/book/10.1176/appi.books.9780890426760].BACKGROUNDANDDEVELOPMENTPROCESSThesePracticeGuidelinesforthePsychiatricEvaluationofAdultsmarkatransitionintheAmericanPsychiatricAsso-ciation’sPracticeGuidelines.Sincethepublicationofthe2011InstituteofMedicinereportClinicalPracticeGuidelinesWeCanTrust,therehasbeenanincreasingfocusonusingclearlyde ned,transparentprocessesforratingthequalityofevi-denceandthestrengthoftheoverallbodyofevidenceinsystematicreviewsofthescienti cliterature.Theseguide-linesweredevelopedusingaprocessintendedtobeconsistentwiththerecommendationsoftheInstituteofMedicine(2011),thePrinciplesfortheDevelopmentofSpecialtySocietyClinicalGuidelinesoftheCouncilofMedicalSpecialtySocieties(2012),andtherequirementsoftheAgencyforHealthcareResearchandQuality(AHRQ)forinclusionofaguidelineintheNationalGuidelineClearinghouse.Parametersusedfortheguidelines’systematicreviewareincludedwiththefulltextoftheguidelines;thedevelopmentprocessisfullydescribedinadocumentavailableontheAPAwebsite:http:///File%20Library/Practice/APA-Guideline-Development-Process–updated-2011-.pdf.Tosupplementtheexpertiseofmembersoftheguidelineworkgroup,weuseda“snowball”surveymethodologytoidentifyexpertsonpsychiatricevaluationandsolicittheirinputonaspectsofthepsychiatricevaluationthattheysawaslikelytoimprovespeci cpatientoutcomes(Yager2014).Resultsofthisexpertsurveyareincludedwiththefulltextofthepracticeguideline.

Ratingthestrengthofresearchevidenceandrecommendations

ThenewguidelinerecommendationsareratedusingGRADE(GradingofRecommendationsAssessment,DevelopmentandEvaluation),anapproachadoptedbymultipleprofessionalorganizationsaroundtheworldtodeveloppracticeguidelinerecommendations(Guyattetal.,2013).WiththeGRADE

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approach,thestrengthofaguidelinestatementre ectsthelevelofcon dencethatpotentialbene tsofaninterventionoutweighthepotentialharms(Andrewsetal.,2013).Thislevelofcon denceisinformedbyavailableevidence,whichincludesevidencefromclinicaltrialsaswellasexpertopinionandpatientvaluesandpreferences.Evidenceforthebene tofaparticularinterventionwithinaspeci cclinicalcontextisidenti edthroughsystematicreviewandisthenbalancedagainsttheevidenceforharms.Inthisregard,harmsarebroadlyde nedandmightincludedirectandindirectcostsoftheintervention(includingopportunitycosts)aswellaspo-tentialforadverseeffectsfromtheintervention.Wheneverpossible,wehavefollowedtheadmonitiontocurrentguidelinedevelopmentgroupstoavoidusingwordssuchas“might”or“consider”indraftingtheserecommendationsastheycanbedif cultforclinicianstointerpret(Shiffmanetal.,2005).

Asdescribedunder“GuidelineDevelopmentProcess,”each nalratingisaconsensusjudgmentoftheauthorsoftheguidelinesandisendorsedbytheAPABoardofTrustees.A“recommendation”(denotedbythenumeral1aftertheguidelinestatement)indicatescon dencethatthebene tsoftheinterventionclearlyoutweighharms.A“suggestion”(denotedbythenumeral2aftertheguidelinestatement)indicatesuncertainty(i.e.,thebalanceofbene tsandharmsisdif culttojudge,oreitherthebene tsortheharmsareunclear).Eachguidelinestatementalsohasanassociatedratingforthe“strengthofsupportingresearchevidence.”Threeratingsareused:high,moderate,orlow(denotedbythelettersA,BandC,respectively)andre ectthelevelofcon dencethattheevidencere ectsatrueeffectbasedonconsistencyof ndingsacrossstudies,directnessoftheeffectonaspeci chealthoutcome,andprecisionoftheestimateofeffectandriskofbiasinavailablestudies(AHRQ2014;Balshemetal.2011;Guyattetal.2006).

Itiswellrecognizedthatthereareguidelinetopicsandclinicalcircumstancesforwhichhighqualityevidencefromclinicaltrialsisnotpossibleorisunethicaltoobtain(CouncilofMedicalSpecialtySocieties,2012).Forexample,itwouldnotbeethicaltorandomlyassignonlyhalfofpatientswithdepressiontobeaskedaboutsuicidalideas.Manyquestionsneedtobeaskedaspartoftheassessment,andinquiringaboutaparticularsymptomorelementofthehistorycannot

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beseparatedoutforstudyasadiscreteintervention.Itwouldalsobeimpossibletoseparatechangesinoutcomeduetoas-sessmentfromchangesinoutcomesduetoensuingtreatment.Researchonpsychiatricassessmentisalsocomplicatedbymultipleconfoundingfactorssuchastheinteractionbetweentheclinicianandthepatientorthepatient’suniquecircum-stancesandexperiences.Fortheseandotherreasons,thevastmajorityoftopicscoveredintheseguidelinesonpsychiatricevaluationhavereliedonformsofevidencesuchasconsensusopinionsofexperiencedcliniciansorindirect ndingsfromobservationalstudiesratherthanbeingbasedonresearchfromrandomizedtrials.TheGRADEworkinggroupandguidelinesdevelopedbyotherprofessionalorganizationshavenotedthatastrongrecommendationmaybeappro-priateevenintheabsenceofresearchevidencewhensensiblealternativesdonotexist(Andrewsetal.2013;Britoetal.2013;Djulbegovicetal.2009;Hazlehurstetal.2013).

Goalsandscopeofguidelinesforthepsychiatricevaluationofadults

Despitethedif cultiesinobtainingquantitativeevidencefromrandomizedtrialsforpracticeguidelinessuchaspsy-chiatricevaluation,guidancetoclinicianscanstillbebene- cialinenhancingcaretopatients.Thus,inthecontextofaninitialpsychiatricevaluation,amajorgoaloftheseguidelinesistoimprovetheidenti cationofpsychiatricsignsandsymptoms,psychiatricdisorders(includingsubstanceusedisorders),othermedicalconditions(thatcouldaffecttheaccuracyofapsychiatricdiagnosis),andpatientswhoareatincreasedriskforsuicidaloraggressivebehaviors.Additionalgoalsrelatetoidentifyingfactorsthatcouldin uencethetherapeuticalliance,enhanceclinicaldecisionmaking,enablesafeandappropriatetreatmentplanning,andpromotebettertreatmentoutcomes.Finally,thepsychiatricevaluationisthestartofadialogwithpatientsaboutmanyfactors,includingdiagnosisandtreatmentoptions.Furthergoalsoftheseguide-linesaretoimprovecollaborativedecisionmakingbetweenpatientsandcliniciansabouttreatment-relateddecisionsaswellastoincreasecoordinationofpsychiatrictreatmentwithotherclinicianswhomaybeinvolvedinthepatient’scare.Timerequiredtocompleteapsychiatricevaluation

Itisessentialtonotethattheseguidelinesarenotintendedtobecomprehensiveinscope.Manycriticalaspectsofthepsychiatricevaluationarenotaddressedbytheseguidelines.Forexample,itisassumedthatinitialpsychiatricorothermedicalassessmentswillneedtoidentifythereasonthatthepatientispresentingforevaluation.Itissimilarlyimportanttounderstandthepatient’sbackground,relationships,lifecircumstances,strengthsandvulnerabilities.

Furthermore,dependingonthecontext,recommendedareasofinquirymayneedtobepostponeduntillatervisits,andrecommendedquestionswillnotalwaysbeindicatedforaspeci cpatient.The ndingsoftheexpertsurveyreiteratethatexpertsvaryintheextenttowhichparticularelementsoftheinitialpsychiatricevaluationareassessed.Thisalso

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highlightstheimportanceofclinicaljudgmentintailoringthepsychiatricevaluationtotheuniquecircumstancesofthepatientandindeterminingwhichquestionsaremostim-portanttoaskaspartofaninitialassessment.

Properuseofguidelines

TheAmericanPsychiatricAssociationPracticeGuidelinesarenotintendedtoserveorbeconstruedasa“standardofmedicalcare.”Judgmentsconcerningclinicalcaredependontheclinicalcircumstancesanddataavailableforanindividualpatientandaresubjecttochangeasscienti cknowledgeandtechnologyad-vanceandpracticepatternsevolve.Theseguidelinestatementsweredeterminedonthebasisoftherelativebalanceofpotentialbene tsandharmsofaspeci cassessment,interventionorotherapproachtocare.Assuch,itisnotpossibletodrawconclusionsabouttheeffectsofomittingaparticularrecommendation,eitheringeneralorforaspeci cpatient.Furthermore,adherencetotheseguidelineswillnotensureasuccessfuloutcomeforeveryindividual,norshouldtheseguidelinesbeinterpretedasin-cludingallpropermethodsofevaluationandcareorexcludingotheracceptablemethodsofevaluationandcareaimedatthesameresults.Theultimaterecommendationregardingapar-ticularassessment,clinicalprocedure,ortreatmentplanmustbemadebythepsychiatristinlightofthepsychiatricevaluation,otherclinicaldata,andthediagnosticandtreatmentoptionsavailable.Suchrecommendationsshouldbemadeincollabo-rationwiththepatientandfamily,wheneverpossible,andin-corporatethepatient’spersonalandsocioculturalpreferencesandvaluesinordertoenhancethetherapeuticalliance,ad-herencetotreatment,andtreatmentoutcomes.

Organizationofthepracticeguidelinesforthepsychiatricevaluationofadults

Aspartofaligningthepracticeguidelines’developmentprocesswithnationalstandards,wehavetransitionedtoanewguidelineformat.EachsetofPracticeGuidelineswillconsistofmultiplediscretetopicsofrelevancetoanoverallsubjectarea.InthePracticeGuidelinesforthePsychiatricEvaluationofAdults,thesetopicsconsistofReviewofPsy-chiatricSymptoms,TraumaHistory,andPsychiatricTreat-mentHistory;SubstanceUseAssessment;AssessmentofSuicideRisk;AssessmentofRiskforAggressiveBehaviors;AssessmentofCulturalFactors;AssessmentofMedicalHealth;QuantitativeAssessment;InvolvementofthePatientinTreatmentDecisionMaking;andDocumentationofthePsychiatricEvaluation.Foreachtopic,guidelinestatementswillbefollowedbyadiscussionoftherationale,potentialbene tsandharms,andapproachestoimplementingtheguidelinestatements.ThisportionofthePracticeGuidelinesisexpectedhavethegreatestutilityforclinicians.AsecondsectionofthePracticeGuidelinesprovidesadetailedreviewoftheevidenceforguidelinestatementsinaccordwithnationalguidelinedevelopmentstandards.Thisreviewofresearchevidenceanddatafromtheexpertsurveyisfollowedbyadiscussionofqualitymeasurementconsiderations,in-cludingtheirappropriatenessforeachtopic.

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TABLE1.PracticeGuidelinesforthePsychiatricEvaluationofAdultsGuidelineTitle

IReviewofPsychiatricSymptoms,TraumaHistory,andPsychiatricTreatmentHistoryIISubstanceUseAssessmentIIIAssessmentofSuicideRisk

IVAssessmentofRiskforAggressiveBehaviorsVAssessmentofCulturalFactorsVIAssessmentofMedicalHealthVIIQuantitativeAssessment

VIIIInvolvementofthePatientinTreatmentDecision-Making

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DocumentationofthePsychiatricEvaluation

GUIDELINESANDSTATEMENTS

ThefollowingrepresentsasummaryoftherecommendationsandsuggestionscompiledfromallPracticeGuidelinesforthePsychiatricEvaluationofAdults(Table1),withsomestatementsbeingapartofmorethanoneoftheseguidelines.Inthecontextoftheseguidelinestatements,itisimportanttonotethatassessmentisnotlimitedtodirectexamina-tionofthepatient.Rather,itisde nedas“theprocessofobtaininginformationaboutapatientthroughanyofavarietyofmethods,includingface-to-faceinterview,reviewofmedicalrecords,physicalexamination(bythepsychiatrist,anotherphysician,oramedicallytrainedclinician),diagnostictesting,orhistory-takingfromcollateralsources.”Theevaluationmayalsorequireseveralmeetings,withthepatient,family,orothers,beforeitcanbecompleted.Theamountoftimespentdependsonthecomplexityoftheproblem,theclinicalset-ting,andthepatient’sabilityandwillingnesstocooperatewiththeassessment.

Thissummaryisorganizedaccordingtocommonhead-ingsofanevaluationnote.Asnotedabove,theguidelinesarenotintendedtobecomprehensive,andmanyaspectsofthepsychiatricevaluationarenotaddressedbytheserecom-mendationsandsuggestions.Thestrengthofsupportingre-searchevidencefortheserecommendationsandsuggestionsisgivenratingC(low)becauseofthedif cultiesinstudyingpsychiatricassessmentapproachesincontrolledstudiesasdescribedinthe“BackgroundandDevelopmentProcess.”Thespeci cguideline(s)inwhichtherecommendationorsuggestionisfoundisdenotedbyitsRomannumeralfromTable1.

Historyofpresentillness

Inadditiontoreasonsthatthepatientispresentingforeval-uation,APArecommends(1C)thattheinitialpsychiatricevaluationofapatientinclude:

Psychiatricreviewofsystems(I),includinganxietysymptomsandpanicattacks(III)

Assessmentofpastorcurrentsleepabnormalities,in-cludingsleepapnea(VI)

Assessmentofimpulsivity(III,IV)

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Psychiatrichistory

APArecommends(1C)thattheinitialpsychiatricevaluationofapatientincludeassessmentofthefollowing:

PastPriorandpsychoticcurrentorpsychiatricaggressivediagnosesideas,including(I,III)

thoughtsofphysicalorsexualaggressionorhomicide(IV)

Prioraggressivebehaviors(e.g.,homicide,domesticorwork-placeviolence,otherphysicallyorsexuallyaggressivethreatsoracts)(IV)

Priorsuicidalideas,suicideplans,andsuicideattempts,includingattemptsthatwereabortedorinterruptedaswellasthedetailsofeachattempt(e.g.,context,method,damage,potentiallethality,intent)(III)

Priorintentionalself-injuryinwhichtherewasnosuicidalintent(III)

APArecommends(1C)thattheinitialpsychiatricevalu-ationofapatientincludereviewofthefollowingaspectsofthepatient’spsychiatrictreatmenthistory:

Historyofpsychiatrichospitalizationandemergencyde-partmentvisitsforpsychiatricissues(I,III,IV)

Pastpsychiatrictreatments(type,duration,and,whereapplicable,doses)(I)

Responsetotopastpastpsychiatricandcurrenttreatmentspharmacological(I)

Adherenceandnon-pharmacologicalpsychiatrictreatments(I)

Substanceusehistory

APArecommends(1C)thattheinitialpsychiatricevaluationofapatientincludeassessmentofthefollowing:

Thepatient’suseoftobacco,alcohol,andothersubstances(e.g.,marijuana,cocaine,heroin,hallucinogens)andanymisuseofprescribedorover-the-countermedicationsorsupplements(II)

Currentorrecentsubstanceusedisorderorchangeinuseofalcoholorothersubstances(III,IV)

Medicalhistory(VI).APArecommends(1C)thattheinitialpsychiatricevaluationofapatientincludeassessmentofthefollowing:

Allergiesordrugsensitivities

Allmedicationsthepatientiscurrentlyorrecentlytakingandthesideeffectsofthesemedications(i.e.,bothpre-scribedandnonprescribedmedications,herbalandnu-tritionalsupplements,andvitamins)

Whetherornotthepatienthasanongoingrelationshipwithaprimarycarehealthprofessional

Pastorcurrentmedicalillnessesandrelatedhospitalizations Relevantpastorcurrenttreatments,includingsurgeries,otherprocedures,orcomplementaryandalternativemed-icaltreatments

Pastorcurrentneurologicalorneurocognitivedisordersorsymptoms(IV)

Physicaltrauma,includingheadinjuries Sexualandreproductivehistory

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APAsuggests(2C)thattheinitialpsychiatricevaluationofapatientalsoincludeassessmentofthefollowing:

Cardiopulmonarystatus

PastPastororcurrentcurrentinfectiousendocrinologicaldisease,disease

includingsexuallytrans-mitteddiseases,HIV,tuberculosis,hepatitisC,andlocallyendemicinfectiousdiseasessuchasLymedisease

Pastorcurrentsymptomsorconditionsassociatedwithsigni cantpainanddiscomfort

Reviewofsystems(VI).APArecommends(1C)thattheinitialpsychiatricevaluationofapatientincludeapsychiatricreviewofsystems(ifnotalreadyincludedwithhistoryofpresentillness)

Inadditiontoapsychiatricreviewofsystems,APAsug-gests(2C)thattheinitialpsychiatricevaluationofapatientincludeareviewofthefollowingsystems:

ConstitutionalEyes

symptoms(e.g.,fever,weightloss) Ears, CardiovascularNose,Mouth,Throat Respiratory Gastrointestinal Genitourinary Musculoskeletal

Integumentary Neurological(skinand/orbreast) Endocrine

Hematological/Lymphatic

Allergic/Immunological

Familyhistory

APArecommends(1C)thattheinitialpsychiatricevaluationofapatientwhoreportscurrentsuicidalideasincludeas-sessmentofhistoryofsuicidalbehaviorsinbiologicalrela-tives(forpatientswithcurrentsuicidalideas)(III)

Whenitisdeterminedduringaninitialpsychiatricevaluationthatthepatienthasaggressiveideas,APArec-ommends(1C)assessmentofhistoryofviolentbehaviorsinbiologicalrelatives(forpatientswithcurrentaggressiveideas)(IV)

Personalandsocialhistory

APArecommends(1C)thattheinitialpsychiatricevaluationofapatientincludeassessmentofthefollowing:

Presenceofpsychosocialstressors,(e.g. nancial,housing,legal,school/occupationalorinterpersonal/relationshipproblems;lackofsocialsupport;painful,dis guring,orterminalmedicalillness)(III,IV)

Reviewofthepatient’straumahistory(I,III)

Exposuretoviolenceoraggressivebehavior,includingcombatexposureorchildhoodabuse(IV)

Legalordisciplinaryconsequencesofpastaggressivebehaviors(IV)

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CulturalfactorsrelatedtothepatientPatient’sneedforaninterpreter(V)

’ssocialenvironment(V) APAsuggests(2C)thattheinitialpsychiatricevaluationofapatientincludeassessmentofthepatient’sPersonal/culturalbeliefsandculturalexplanationsofpsychiatricillness(V)

Examination,includingmentalstatusexamination

APAsuggests(2C)thattheinitialpsychiatricevaluationofapatientalsoincludeassessmentofthefollowing:

Height,weight,Skin,signsincluding(VI)

andbodymassindex(BMI)(VI) Vital anystigmataoftrauma,self-injury,ordruguse(VI)

APArecommends(1C)thattheinitialpsychiatricevalu-ationofapatientincludeassessmentofthefollowing: General Coordinationappearanceandnutritionalstatus(VI) Involuntary Sightmovementsandgait(VI)

orabnormalitiesofmotortone(VI) Speech,and

Mood,levelincludinghearing(VI)

ofanxiety, uencythoughtandarticulationcontentand(VI)

process,andperceptionandcognition(I,III) HopelessnessCurrentsuicidal(III)

ideas,suicideplans,andsuicideattempts,includingactiveorpassivethoughtsofsuicideordeath(III):Ifcurrentsuicidalideasarepresent,assess:

°Patient’sintendedcourseofactionifcurrentsymptomsworsen

°°AccessPatient’tospossiblesuicidemotivationsmethodsincludingforsuicide rearms

(e.g.attentionorreactionfromothers,revenge,shame,humiliation,de-lusionalguilt,commandhallucinations)

°Reasonsforliving(e.g.senseofresponsibilitytochildrenorothers,religiousbeliefs)

°Qualityandstrengthorpsychoticofthetherapeuticideas,includingalliance

Currentaggressivethoughtsofphysicalorsexualaggressionorhomicide(III,IV):Ifcurrentaggressiveideasarepresent,assess:

°Speci cindividualsorgroupstowardwhomhomicidaloraggressiveideasorbehaviorshavebeendirectedinthepastoratpresent

°°Impulsivity,Accessto rearms

includingangermanagementissuesImpressionandplan

APArecommends(1C)thattheclinicianwhoconductstheinitialpsychiatricevaluationdocument:

Anestimateofthepatient’ssuiciderisk,includingfactorsin uencingrisk(III)

Therationalefortreatmentselection,includingdiscus-sionofthespeci cfactorsthatin uencedthetreatmentchoice(IX)

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APArecommends(1C)thattheinitialpsychiatricevalu-ationofapatientwhoisseeninclude:

Askingthepatientaboutthetreatment-relatedpatientofthefollowing:preferencesthe(VIII) Anexplanationtodif-ferentialdiagnosis,risksofuntreatedillness,treatmentoptions,andbene tsandrisksoftreatment(VIII)

Collaborationbetweentheclinicianandthepatientaboutdecisionspertinenttotreatment(VIII)

APAsuggests(2C)thattheinitialpsychiatricevaluationofapatientinclude:

Quantitativemeasuresofsymptoms,leveloffunctioning,andqualityoflife(VII)

Documentationofanestimatedriskofaggressivebehavior(includinghomicide),includingfactorsin uencingrisk(IV) Documentationoftherationaleforclinicaltests(IX)

AUTHORANDARTICLEINFORMATION

FromtheAPAWorkgrouponPsychiatricEvaluation(JoelJ.Silverman,Chair).AddresscorrespondencetoKristinKroeger(kkroeger@http://).APAwishestoacknowledgethecontributionsoftheformerAPAstaff;RobertKunkle,M.A.,RobertPlovnick,M.D.,SaraReid,M.A.,Seung-HeeHong,andWilliamE.Narrow,M.D.,M.P.H.APAandtheWorkGrouponPsychiatricEvaluationespeciallythankLauraJ.Fochtmann,M.D.,M.B.I,andRobertKunkle,M.A.fortheiroutstandingworkandeffortonde-velopingtheseguidelines.APAalsothankstheAPASteeringCommitteeonPracticeGuidelinesandliaisonsfromtheAPAAssemblyfortheirinputandassistance.

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