Guideline Statements and Implementation

APA recommends (1C) that the initial assessment of a patient with a possible psychotic disorder include the reason the individual is presenting for evaluation; the patient’s goals and preferences for treatment; a review of psychiatric symptoms and trauma history; an assessment of tobacco use and other substance use; a psychiatric treatment history; an assessment of physical health; an assessment of psychosocial and cultural factors; a mental status examination, including cognitive assessment; and an assessment of risk of suicide and aggressive behaviors, as outlined in APA’s Practice Guidelines for the Psychiatric Evaluation of Adults (3rd edition).

Implementation

The importance of the psychiatric evaluation cannot be underestimated because it serves as the initial basis for a therapeutic relationship with the patient and provides information that is crucial to differential diagnosis, shared decision-making about treatment, and educating patients and family members about such factors as illness course and prognosis. APA’s Practice Guidelines for the Psychiatric Evaluation of Adults, 3rd edition (American Psychiatric Association 2016a) describe recommended and suggested elements of assessment for any individual who presents with psychiatric symptoms (Table 1). These elements are by no means comprehensive, and additional areas of inquiry will become apparent as the evaluation unfolds, depending on the responses to initial questions, the presenting concerns, the observations of the clinician during the assessment, the complexity and urgency of clinical decision-making, and other aspects of the clinical context. In many circumstances, aspects of the evaluation will extend across multiple visits (American Psychiatric Association 2016a).

• Reason that the patient is presenting for evaluation, including current symptoms, behaviors, and precipitating factors

• Hospitalization and emergency department visits for psychiatric issues, including substance use disorders

• Response and adherence to psychiatric treatments, including psychosocial treatments, pharmacotherapy, and other interventions such as electroconvulsive therapy or transcranial magnetic stimulation

Aggressive ideas or behaviors (e.g., homicide, domestic or workplace violence, other physically or sexually aggressive threats or acts)

Suicidal ideas, suicide plans, and suicide attempts, including details of each attempt (e.g., context, method, damage, potential lethality, intent) and attempts that were aborted or interrupted

• Use of tobacco, alcohol, and other substances (e.g., vaping, marijuana, cocaine, heroin, hallucinogens) and any misuse of prescribed or over-the-counter medications or supplements

• All medications the patient is currently taking or has recently taken and the side effects of these medications (i.e., both prescribed and nonprescribed medications, herbal and nutritional supplements, and vitamins)

• Relevant past or current treatments, including surgeries, other procedures, or complementary and alternative medical treatments

• Past or current infectious disease, including sexually transmitted diseases, HIV, tuberculosis, hepatitis C, and locally endemic infectious diseases such as Lyme disease

• Personal/cultural beliefs, sociocultural environment, and cultural explanations of psychiatric illness

• Presence of psychosocial stressors (e.g., financial, housing, legal, school/occupational, or interpersonal/relationship problems; lack of social support; painful, disfiguring, or terminal medical illness)

• Thought content, process, and perceptions, including current hallucinations, delusions, negative symptoms, and insight

• Current suicidal ideas, suicide plans, and suicide intent, including active or passive thoughts of suicide or death

If current suicidal ideas are present, assess patient’s intended course of action if current symptoms worsen; access to suicide methods, including firearms; possible motivations for suicide (e.g., attention or reaction from others, revenge, shame, humiliation, delusional guilt, command hallucinations); reasons for living (e.g., sense of responsibility to children or others, religious beliefs); and quality and strength of the therapeutic alliance

If current aggressive ideas are present, assess specific individuals or groups toward whom homicidal or aggressive ideas or behaviors have been directed in the past or at present, access to firearms, and impulsivity, including anger management issues

Source. Adapted from APA’s Practice Guidelines for the Psychiatric Evaluation of Adults, 3rd Edition. Arlington VA, American Psychiatric Association, 2016. Copyright © 2016 American Psychiatric Association. Used with permission.

The specific approach to the interview will depend on many factors, including the patient’s ability to communicate, degree of cooperation, level of insight, illness severity, and ability to recall historical details (American Psychiatric Association 2016a). Such factors as the patient’s health literacy (Clausen et al. 2016) and cultural background (Lewis-Fernández et al. 2016) can also influence the patient’s understanding or interpretation of questions. Typically, a psychiatric evaluation involves a direct interview between the patient and the clinician (American Psychiatric Association 2016a). The use of open-ended empathic questions about the patient’s current life circumstances and reasons for evaluation can provide an initial picture of the individual and serve as a way of establishing rapport. Such questions can be followed up with additional structured inquiry about history, symptoms, or observations made during the assessment.

Throughout the assessment process, it is important to gain an understanding of the patient’s goals, their view of the illness, and preferences for treatment. This information will serve as a starting point for person-centered care and shared decision-making with the patient, family, and other persons of support (Dixon et al. 2016; Hamann and Heres 2019). It will also provide a framework for recovery, which has been defined as “a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential” (Substance Abuse and Mental Health Services Administration 2012a, p. 3). Consequently, discussions of goals should be focused beyond symptom relief and may include goals related to schooling, employment, living situation, relationships, leisure activities, and other aspects of functioning and quality of life. Questions about the patient’s views may help determine whether the patient is aware of having an illness and whether the patient has other explanations for symptoms that are helpful to them (Saks 2009). Patients may have specific views about such topics as medications, other treatment approaches, mechanical restraints, or involuntary treatment based on prior treatment experiences. They may also be able to delineate strategies that have been helpful for them in coping with or managing their symptoms in the past (Cohen et al. 2017). Some patients will have completed a psychiatric advance directive (Murray and Wortzel 2019), which is important to review with the patient if it exists.

In addition to direct interview, patients may be asked to complete electronic or paper-based forms that ask about psychiatric symptoms or key aspects of the history (American Psychiatric Association 2016a). When available, prior medical records, electronic prescription databases, and input from other treating clinicians can add further details to the history or corroborate information obtained in the interview (American Psychiatric Association 2016a).

Family members, friends, and other individuals involved in the patient’s support network can be an important part of the patient’s care team and valuable sources of collateral information about the reason for evaluation, the patient’s past history, and current symptoms and behavior (American Psychiatric Association 2016a). Outreach to family, friends, and others in the support network will typically occur with the patient’s permission. In situations in which the patient is given the opportunity and does not object, necessary information can be shared with family members or other persons involved in the patient’s care or payment for care (Office for Civil Rights 2017b). For example, if a relative or person of support is present with the patient at an appointment, the clinician may discuss information about medications or give education about warning signs of a developing emergency.

In some instances, however, patients may ask that family or others not be contacted. When this is the case, patients can usually identify someone whom they trust to provide additional information, and they are often willing to reconsider contact as treatment proceeds. It is also useful to discuss the reasons that the patient has concerns about contacts with family members or other important people in the patient’s life. For example, a patient may wish to avoid burdening a loved one, may have felt unsupported by a particular family member in the past, or may be experiencing delusional beliefs that involve a family member or friend. The patient may also want to limit the information that clinicians receive about past or recent treatment, symptoms, or behaviors. Even when a patient does not want a specific person to be contacted, the clinician may listen to information provided by that individual, as long as confidential information is not provided to the informant (American Psychiatric Association 2016a). Also, to prevent or lessen a serious and imminent threat to the health or safety of the patient or others, The Principles of Medical Ethics (American Psychiatric Association 2013f) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA; Office for Civil Rights 2017b) permit clinicians to disclose necessary information about a patient to family members, caregivers, law enforcement, or other persons involved with the patient as well as to jails, prisons, and law enforcement officials having lawful custody of the patient. HIPAA also permits health care providers to disclose necessary information to the patient’s family, friends, or other persons involved in the patient’s care or payment for care when such disclosure is judged to be in the best interests of the patient and the patient either is not present or is unable to agree or object to a disclosure because of incapacity or emergency circumstances. Examples of such circumstances are not limited to unconsciousness and may also include such circumstances as temporary psychosis or intoxication with alcohol or other substances (Office for Civil Rights 2017b).

Although it is beyond the scope of this guideline to discuss the differential diagnosis and evaluation of psychotic disorders, many features and aspects of clinical course will enter into such a determination in addition to psychotic symptoms per se. Clinicians should also be mindful that biases can influence assessment and diagnosis, with disparities in diagnosis based on race being particularly common (Olbert et al. 2018; Schwartz and Blankenship 2014). The clinician should be alert to features of the history, including family, developmental, and academic history, that may suggest specific conditions or a need for additional physical or laboratory evaluation. Examples of conditions that can mimic schizophrenia in their initial presentation include neurosyphilis, Huntington’s disease, Wilson’s disease, and anti-N-methyl- d -aspartate (NMDA) receptor encephalitis (Lieberman and First 2018). Individuals with 22q11.2 deletion syndrome have a substantially increased risk of developing schizophrenia (Bassett et al. 2017; McDonald-McGinn et al. 2015; Van et al. 2017). In addition, the presence of a 22q11.2 deletion is associated with an increased likelihood of neurocognitive and physical health impairments (McDonald-McGinn et al. 2015; Moberg et al. 2018; Swillen and McDonald-McGinn 2015), which has implications for treatment (Fung et al. 2015; Mosheva et al. 2019). Psychotic symptoms can also occur in the context of other neurological and systemic illnesses, with or without delirium, and such acute states can at times be mistaken for an acute exacerbation of schizophrenia. Furthermore, because a significant fraction of individuals with psychosis will have a shift in diagnosis over time, the diagnosis may need to be reevaluated as new information about the patient’s illness course and symptoms becomes available (Bromet et al. 2011). Specialty consultation can be helpful in establishing and clarifying diagnosis (Coulter et al. 2019), particularly if the illness symptoms or course appear to be atypical or if the patient is not responding to treatment.

A thorough history is also important for identifying the presence of co-occurring psychiatric conditions or physical disorders that need to be addressed in treatment planning (American Psychiatric Association 2016a; Firth et al. 2019). For example, individuals with serious mental illness have higher rates of smoking, higher rates of heavy smoking, and lower rates of smoking cessation than do community samples (Cook et al. 2014; de Leon and Diaz 2005; Myles et al. 2012; Wium-Andersen et al. 2015). Furthermore, the use of cannabis may be more frequent in individuals with schizophrenia (Koskinen et al. 2010) and associated with greater symptom severity or earlier onset of psychosis (Carney et al. 2017; Large et al. 2011). Other substance use disorders, if present, can also produce or exacerbate symptoms of psychosis (American Psychiatric Association 2016a; Large et al. 2014). Thus, as part of the initial evaluation, it is important to determine whether the patient uses tobacco, cannabis, or other substances such as alcohol, caffeine, cocaine, opioids, sedative-hypnotic agents, stimulants, 3,4-methylenedioxymethamphetamine (MDMA), solvents, androgenic steroids, hallucinogens, or synthetic substances (e.g., “bath salts,” K2, Spice). The route by which substances are used (e.g., ingestion, smoking, vaping, intranasal, intravenous) is similarly important to document.

Mortality is increased in individuals with schizophrenia (Brown et al. 2000; Fazel et al. 2014; Olfson et al. 2015), and the average life span is shortened by a decade or more, with much of this decrease related to increased rates of co-occurring physical conditions (Laursen et al. 2013; Saha et al. 2007; Walker et al. 2015). Adverse health effects of smoking also contribute to an increased risk of mortality among individuals with schizophrenia (Lariscy et al. 2018; Reynolds et al. 2018; Tam et al. 2016). Many other conditions are more frequent in individuals with serious mental illness in general (Janssen et al. 2015; McGinty et al. 2016) and schizophrenia in particular (Henderson et al. 2015), including, but not limited to, poor oral health (Kisely et al. 2015), hepatitis C infection (Chasser et al. 2017; Hauser and Kern 2015; Hughes et al. 2016), HIV infection (Hobkirk et al. 2015; Hughes et al. 2016), cancer (Olfson et al. 2015), sleep apnea (Myles et al. 2016; Stubbs et al. 2016b), obesity (Janssen et al. 2015), diabetes mellitus (Vancampfort et al. 2016a), metabolic syndrome (Vancampfort et al. 2015), and cardiovascular disease (Correll et al. 2017c). These disorders, if present, can contribute to mortality or reduced quality of life, and some may be induced or exacerbated by psychiatric medications. Laboratory tests and physical examination as part of the initial evaluation can help to identify common co-occurring conditions and can serve as a baseline for subsequent monitoring during treatment (Table 2).