History Taking for Mentally Ill Patients
Comprehensive Guide for Nursing Assessment
Introduction
History taking is a fundamental skill in psychiatric nursing care. A thorough psychiatric history provides essential information for diagnosis, treatment planning, and establishing therapeutic rapport. This guide covers the comprehensive approach to gathering information from patients with mental health conditions, using evidence-based techniques and nursing considerations.
Key Points
- The psychiatric history is both a diagnostic tool and a therapeutic intervention
- A well-conducted interview can become the foundation of the therapeutic relationship
- Nurses must balance structured assessment with therapeutic communication
- Cultural sensitivity and individualized approaches are essential
Preparing for the Interview
Environmental Considerations
- Choose a quiet, private space free from distractions
- Ensure appropriate seating arrangements (accessible exit for both parties)
- Maintain comfortable room temperature and lighting
- Have tissues and water available
- Consider safety measures for potentially agitated patients
Personal Preparation
- Review available records before the interview
- Identify potential language barriers and arrange for interpreters if needed
- Be aware of your own biases and preconceptions
- Prepare necessary documentation tools
- Consider potential cultural factors that may influence the interview
Approach: Begin with less threatening topics before moving to more sensitive areas. This builds rapport and trust before exploring difficult subjects.
Therapeutic Communication Techniques
Effective communication is the foundation of psychiatric assessment. These techniques help establish rapport and gather accurate information.
| Technique | Description | Example |
|---|---|---|
| Active Listening | Focusing completely on the patient, demonstrating attention through verbal and nonverbal cues | Maintaining eye contact, nodding, leaning slightly forward |
| Open-Ended Questions | Questions that cannot be answered with “yes” or “no,” encouraging elaboration | “How would you describe your mood over the past week?” (instead of “Are you sad?”) |
| Reflection | Restating or paraphrasing what the patient has said to confirm understanding | “It sounds like you’ve been feeling overwhelmed by these thoughts.” |
| Validation | Acknowledging the patient’s feelings and experiences as understandable | “Given what you’ve been through, it makes sense that you would feel this way.” |
| Clarification | Asking for more information to ensure understanding | “Could you tell me more about what you mean by ‘feeling empty’?” |
| Empathic Responses | Demonstrating understanding of the patient’s emotional experience | “That must have been really frightening for you.” |
| Silence | Allowing comfortable pauses for reflection and processing | Waiting patiently after asking about a difficult topic |
NURSE Mnemonic for Empathic Responses
- Name the emotion: “It sounds like you’re feeling anxious.”
- Understand the emotion: “I can see why you would feel that way.”
- Respect the patient: “You’ve shown a lot of strength dealing with this.”
- Support the patient: “I’m here to help you work through this.”
- Explore the emotion: “Can you tell me more about when these feelings occur?”
Communication Barriers to Avoid
- Using medical jargon or complex terminology
- Asking multiple questions simultaneously
- Interrupting the patient
- Making judgmental comments or facial expressions
- Offering premature reassurance (“Everything will be fine”)
- Changing the subject abruptly
Components of Psychiatric History Taking
Basic demographic and background information forms the foundation of the assessment:
- Full name and preferred name
- Age, gender identity, and date of birth
- Contact information and emergency contacts
- Marital/relationship status
- Living situation and housing status
- Occupation and employment status
- Education level
- Cultural, religious, and ethnic background
- Primary language and need for interpreter
- Source of referral and reliability of information
The primary reason for seeking care, preferably in the patient’s own words.
Effective Questions to Elicit Chief Complaint:
- “What brings you here today?”
- “What concerns made you seek help at this time?”
- “How would you describe the main problem you’re experiencing?”
- “What’s been troubling you the most recently?”
Documentation tip: Record the chief complaint in quotation marks to capture the patient’s exact words, which often provide valuable diagnostic clues.
A detailed chronological account of the current problem from onset to present.
OPQRST-SAMPLER for Psychiatric HPI
Onset: When symptoms began and if they appeared gradually or suddenly
Precipitating/palliating factors: What makes symptoms better or worse
Quality: Nature and characteristics of symptoms
Region/radiation: How symptoms affect different aspects of life
Severity: Intensity on a scale of 1-10 or impact on functioning
Timing: Frequency, duration, and patterns of symptoms
Symptoms: Additional related symptoms
Allergies: Medication allergies and reactions
Medications: Current medications and adherence
Previous episodes: Similar episodes in the past
Last normal period: When the patient last felt “normal”
Events surrounding: Contextual factors around symptom onset
Response to previous treatment: What has/hasn’t worked
When assessing symptom severity, use concrete examples of functional impact rather than abstract ratings. For example: “How has this affected your ability to work?” or “Has this changed how you manage daily tasks?”
Complete history of previous mental health issues, treatments, and outcomes.
Areas to Cover:
- Previous psychiatric diagnoses
- Past psychiatric hospitalizations (voluntary and involuntary)
- History of self-harm or suicide attempts
- Previous outpatient treatment
- Past psychiatric medications and responses
- Psychotherapy experiences
- Electroconvulsive therapy (ECT) or other somatic treatments
- History of violence or aggression
Documentation Focus: For each past treatment, document:
- When it occurred (approximate dates)
- What specific treatment was provided
- How the patient responded
- Why treatment ended (completed, side effects, etc.)
Medical conditions can significantly impact mental health and treatment options.
Essential Elements:
- Current and chronic medical conditions
- Previous surgeries and hospitalizations
- Neurological history (seizures, head injuries, etc.)
- Current medications (prescribed and OTC)
- Allergies and adverse drug reactions
- Recent physical exams and findings
Medical Conditions with Psychiatric Symptoms:
- Thyroid disorders
- Vitamin deficiencies (B12, folate, D)
- Neurological conditions (MS, Parkinson’s)
- Autoimmune disorders
- Endocrine disorders
- Sleep disorders
- Chronic pain conditions
Always consider medical causes for psychiatric symptoms! Up to 10% of patients presenting with psychiatric symptoms have an underlying medical condition contributing to their presentation.
Many psychiatric disorders have genetic components, making family history crucial.
Areas to Explore in Family History
- Mental health diagnoses in first- and second-degree relatives
- Substance use disorders in the family
- Suicide attempts or completions
- Hospitalizations for psychiatric reasons
- Family patterns of behavior (e.g., impulsivity, mood instability)
- Treatment responses in family members
Approach Tip: Create a brief family genogram to visualize patterns of mental illness across generations. This can also serve as a tool for psychoeducation with the patient.
Understanding the patient’s life context and development provides essential background.
Key Areas:
- Early development: Pregnancy/birth complications, developmental milestones
- Childhood environment: Family dynamics, stability, early attachments
- Education history: Academic performance, learning difficulties, behavior issues
- Trauma history: Childhood adverse events, abuse, neglect, significant losses
- Occupational history: Work performance, job satisfaction, relationships with colleagues
- Relationship patterns: Quality of significant relationships, attachment style
- Social support: Current support network, isolation or connection
- Financial situation: Economic stressors, housing security
- Legal history: Past or pending legal issues
- Cultural factors: Cultural identity, religious/spiritual beliefs
Trauma-Informed Approach: When exploring trauma history:
- Provide clear rationale for asking about trauma
- Use a gradual approach, starting with less intrusive questions
- Respect boundaries if the patient is not ready to discuss trauma
- Monitor for signs of distress and offer grounding techniques
- Document trauma history sensitively and accurately
Substance use can cause, exacerbate, or mask psychiatric symptoms.
| Substance Category | Assessment Details |
|---|---|
| Alcohol | Frequency, quantity, pattern of use (daily, binge), longest period of sobriety, withdrawal symptoms, blackouts, impact on functioning, previous treatments |
| Tobacco/Nicotine | Type (cigarettes, e-cigarettes, chewing tobacco), amount per day, duration of use, quit attempts |
| Cannabis | Frequency, method of use, medical or recreational, effects experienced, impact on symptoms |
| Stimulants | Types used (cocaine, methamphetamine, prescription stimulants), pattern of use, route of administration, effects, withdrawal symptoms |
| Opioids | Prescription or illicit use, types, frequency, route of administration, withdrawal experiences, overdose history, MAT history |
| Sedatives | Benzodiazepines, sleep medications, frequency, prescribed vs. non-prescribed use, dependence symptoms |
| Hallucinogens | Types used (LSD, psilocybin, MDMA), frequency, setting of use, persistent perceptual effects |
| Caffeine | Daily intake, sources (coffee, energy drinks), impact on sleep and anxiety |
CAGE-AID Screening Questions
A quick screening tool for substance use disorders:
- Cut down: “Have you ever felt you ought to cut down on your drinking or drug use?”
- Annoyed: “Have people annoyed you by criticizing your drinking or drug use?”
- Guilty: “Have you ever felt bad or guilty about your drinking or drug use?”
- Eye-opener: “Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover?”
Two or more “yes” answers suggest a potential substance use problem requiring further assessment.
The psychiatric equivalent of the physical examination, assessing current mental functioning.
1. Appearance
- Grooming and hygiene
- Dress (appropriate, bizarre, disheveled)
- Posture and motor activity
- Apparent age vs. stated age
- Notable physical characteristics
2. Behavior
- Level of consciousness
- Psychomotor activity (agitation, retardation)
- Abnormal movements (tremors, dyskinesia)
- Eye contact
- Cooperation with interview
- Reaction to interviewer
3. Speech
- Rate, rhythm, volume
- Prosody (tone, inflection)
- Quantity (verbose, poverty of speech)
- Spontaneity
- Latency of response
- Articulation
4. Mood & Affect
- Mood: Subjective feeling state
- Affect: Observable emotional expression
- Range: Full, restricted, blunted, flat
- Appropriateness to content
- Stability vs. lability
- Congruence with stated mood
5. Thought Process
- Organization and logic
- Flow (linear, circumstantial, tangential)
- Flight of ideas
- Loose associations
- Thought blocking
- Perseveration
- Word salad
6. Thought Content
- Delusions (specify type and content)
- Obsessions or ruminations
- Phobias
- Suicidal ideation (passive vs. active)
- Homicidal ideation
- Preoccupations
- Ideas of reference
7. Perceptions
- Hallucinations (auditory, visual, tactile, etc.)
- Illusions
- Depersonalization/derealization
- Command hallucinations (content and response)
8. Cognition
- Orientation (person, place, time, situation)
- Attention and concentration
- Memory (immediate, recent, remote)
- Abstract thinking (proverb interpretation)
- Fund of knowledge
- Calculation ability
- Judgment and insight
The MSE should be an ongoing process throughout the interview, not just a checklist at the end. Observe the patient’s mental status while gathering other history components.
Risk Assessment
Evaluating safety risks is a critical component of psychiatric history taking.
Suicide Risk Assessment
Essential Questions:
- Current suicidal thoughts (passive vs. active)
- Specific plan (method, access to means)
- Intent (desire to die vs. escape pain)
- Previous suicide attempts (methods, context)
- Protective factors (support system, future goals)
Risk Factors (IS PATH WARM):
Ideation
Substance abuse
Purposelessness
Anxiety/Agitation
Trapped feeling
Hopelessness
Withdrawal
Anger
Recklessness
Mood changes
Approach to Asking About Suicide:
- Start with less direct questions: “Have you felt that life isn’t worth living?”
- Progress to more specific questions: “Have you been having thoughts about death or dying?”
- Ask directly about suicide: “Are you having thoughts of killing yourself?”
- If yes, assess for plan: “Have you thought about how you might do this?”
- Assess for intent: “How strong is your desire to act on these thoughts?”
- Explore protective factors: “What has kept you from acting on these thoughts so far?”
Violence Risk Assessment
Key Areas to Assess:
- Current thoughts of harming others
- Specific threats or targets
- Access to weapons
- History of violence or aggression
- Command hallucinations
- Paranoid or persecutory delusions
Warning Signs:
- Increasing agitation or restlessness
- Threatening statements or gestures
- Escalating voice volume
- Physical tension (clenched fists, rigid posture)
- Recent discontinuation of antipsychotics
- Substance intoxication or withdrawal
Duty to Warn/Protect: If a patient discloses specific threats toward an identifiable person, nurses may have legal obligations to warn the potential victim and/or notify authorities, depending on jurisdiction.
Special Considerations for Different Conditions
Mood Disorders
Focus Areas
- Pattern of mood episodes (frequency, duration)
- Neurovegetative symptoms (sleep, appetite, energy)
- Suicidal ideation and behavior
- Functional impact during episodes
- History of mania/hypomania
- Seasonal patterns
Anxiety Disorders
Focus Areas
- Specific triggers for anxiety
- Physical symptoms during anxiety episodes
- Avoidance behaviors
- Safety behaviors and coping mechanisms
- Course of symptoms over time
- Impact on daily functioning
Psychotic Disorders
Focus Areas
- Detailed description of hallucinations
- Content and conviction of delusions
- Negative symptoms
- Premorbid functioning
- Medication adherence history
- Age at first psychotic episode
- Insight into symptoms
Trauma-Related Disorders
Focus Areas
- Trauma history (with patient’s consent)
- Re-experiencing symptoms
- Avoidance patterns
- Hyperarousal symptoms
- Dissociative experiences
- Triggers and safety planning
Substance Use Disorders
Focus Areas
- Pattern of use for each substance
- Withdrawal symptoms and history
- Impact on functioning (work, relationships)
- Prior treatment attempts
- Last use of each substance
- Motivation for change
- Co-occurring mental health symptoms
Personality Disorders
Focus Areas
- Long-term patterns of behavior and relationships
- Self-image and identity
- Interpersonal difficulties
- Emotional regulation patterns
- Impulsivity and self-damaging behaviors
- Previous responses to treatment
When assessing a particular disorder, be careful not to develop tunnel vision. Comorbidity is common in psychiatric conditions, and symptoms often overlap across diagnostic categories. Maintain a broad perspective throughout the assessment.
The Nurse’s Role in Psychiatric History Taking
Core Nursing Responsibilities
- Establishing therapeutic rapport
- Systematically gathering comprehensive data
- Conducting ongoing assessments throughout care
- Identifying immediate safety concerns
- Contributing to multidisciplinary care planning
- Providing continuity of care
- Monitoring response to interventions
- Documenting findings accurately
Unique Nursing Perspective
- Holistic view that integrates physical and mental health
- Strengths-based approach to assessment
- Focus on functional impact of symptoms
- Attention to self-care abilities and deficits
- Family and community context assessment
- Identification of nursing-specific interventions
- Practical considerations for discharge planning
Nursing Process Application
1. Assessment
- Systematic collection of mental health data
- Identification of patterns and concerns
- Determination of risk factors
2. Diagnosis
- Formulation of nursing diagnoses
- Prioritization of patient problems
- Identification of contributing factors
3. Planning
- Development of individualized care plans
- Setting measurable goals and outcomes
- Collaboration with interdisciplinary team
4. Implementation & Evaluation
- Execution of therapeutic interventions
- Ongoing reassessment
- Modification of care plans as needed
PRESENT: Nursing Approach to Psychiatric History
- Privacy – Ensure confidential setting
- Rapport – Establish therapeutic relationship
- Exploration – Gather comprehensive information
- Safety – Assess for risks to self or others
- Empathy – Demonstrate understanding and validation
- Needs – Identify patient’s priorities and concerns
- Treatment history – Review previous interventions and outcomes
Cultural Considerations in Psychiatric Assessment
Cultural factors significantly influence how mental health symptoms are expressed, experienced, and interpreted.
Key Principles
- Cultural backgrounds influence symptom manifestation
- Cultural norms affect what is considered “abnormal”
- Help-seeking behaviors vary across cultures
- Stigma around mental illness differs among groups
- Traditional healing practices may be preferred
- Language barriers can affect assessment accuracy
LEARN Model for Cultural Assessment
- Listen with empathy to the patient’s perception of the problem
- Explain your understanding of the problem
- Acknowledge and discuss differences and similarities
- Recommend treatment while respecting cultural beliefs
- Negotiate a plan that incorporates both clinical needs and cultural expectations
Cultural Formulation Questions
- “How would people in your culture describe or explain the symptoms you’re experiencing?”
- “In your community, where would someone typically go for help with these issues?”
- “Are there specific treatments or approaches that would be important to include in your care?”
- “How do your family members view mental health treatment?”
- “Are there cultural or religious practices that help you cope with difficulties?”
Important: Avoid stereotyping based on perceived cultural background. Each patient is an individual with unique perspectives that may or may not align with cultural generalizations. Ask directly about personal beliefs rather than making assumptions.
Documentation Guidelines
Proper documentation of the psychiatric history is essential for quality care, continuity, and legal protection.
Documentation Principles
- Be objective and factual
- Use direct quotes when documenting symptoms
- Avoid judgmental or stigmatizing language
- Document time and date of assessment
- Note sources of information (patient, family, records)
- Include both positive and negative findings
- Document risk assessments in detail
- Note patient’s response to interventions
Critical Documentation Elements
- Suicidal/homicidal ideation, plan, intent
- Safety measures implemented
- Patient’s capacity for decision-making
- Refusal of assessment or treatment
- Changes in mental status
- Medication effects and side effects
- Education provided to patient/family
- Follow-up plans and instructions
Documentation Tips:
- Write clearly and concisely
- Avoid abbreviations not approved by your facility
- Document in chronological order
- Update assessments when significant changes occur
- Follow facility-specific documentation protocols
Case Examples
Patient: 42-year-old female presenting with persistent low mood for 3 months
Key Assessment Components:
- Chief Complaint: “I just don’t feel like myself anymore. Everything seems like too much effort.”
- History of Present Illness: Gradual onset following job loss 4 months ago. Reports persistent sadness, reduced interest in previously enjoyed activities, sleep disturbance (early morning awakening), decreased appetite with 10 lb weight loss, difficulty concentrating, and fatigue.
- Past Psychiatric History: One previous episode of depression following divorce 5 years ago. Responded well to sertraline and brief counseling.
- Substance Use: Reports increased alcohol consumption (2-3 glasses of wine nightly) to help with sleep.
- Risk Assessment: Passive suicidal ideation (“Sometimes I think it would be easier not to wake up”) but denies active ideation, plan, or intent.
- MSE Highlights: Psychomotor retardation, delayed responses, tearful at times, affect congruent with depressed mood, no psychotic symptoms, intact insight.
Nursing Approach:
- Begin with open-ended questions about mood and functioning
- Explore neurovegetative symptoms systematically
- Assess suicide risk thoroughly with progressive questioning
- Evaluate coping mechanisms and support system
- Explore connection between alcohol use and symptoms
- Discuss previous treatment response in detail
- Assess interest in resuming similar treatment
Patient: 24-year-old male brought to emergency department by police after unusual behavior in public
Key Assessment Components:
- Chief Complaint: “I need to warn everyone that they’re monitoring our thoughts.” (Per patient)
- Collateral Information: According to police, patient was found speaking loudly to himself and approaching strangers in a park, appearing agitated and disorganized.
- History of Present Illness: Gradual behavioral changes over 2 months per phone call with mother. Increasingly isolated, stopped attending college classes, neglecting hygiene, expressing paranoid beliefs about government surveillance.
- Past Psychiatric History: No previous psychiatric diagnosis or treatment. First known psychotic episode.
- Substance Use: Cannabis use several times weekly. Last use approximately 12 hours ago.
- MSE Highlights: Disheveled appearance, hypervigilant, intermittent poor eye contact, disorganized thought process, paranoid delusions, auditory hallucinations (voices commenting on his actions), impaired insight.
Nursing Approach:
- Establish rapport with non-threatening approach and clear communication
- Avoid challenging delusions directly while gathering information
- Assess safety risk (command hallucinations, dangerous delusions)
- Obtain collateral information when possible
- Explore timeline of symptom development
- Assess relationship between substance use and symptom onset
- Evaluate premorbid functioning and family history
- Focus on immediate needs and orientation to treatment
Patient: 35-year-old female self-referring to outpatient clinic for “panic attacks”
Key Assessment Components:
- Chief Complaint: “I keep having these terrible panic attacks where I feel like I’m dying.”
- History of Present Illness: First panic attack occurred 3 months ago while driving on highway. Now experiencing 2-3 attacks weekly, with symptoms including racing heart, chest tightness, shortness of breath, dizziness, fear of dying. Has begun avoiding driving on highways and other situations where attacks have occurred.
- Medical History: Hyperthyroidism diagnosed 6 months ago, currently treated with methimazole. No recent thyroid function tests.
- Substance Use: Increased caffeine consumption (4-5 cups of coffee daily) due to fatigue. No other substance use.
- Family History: Mother with generalized anxiety disorder.
- MSE Highlights: Anxious mood with congruent affect, hypervigilant to bodily sensations, thought content focused on health concerns, no suicidal ideation, intact cognition.
Nursing Approach:
- Obtain detailed description of panic attacks (frequency, duration, symptoms)
- Identify triggers and patterns
- Assess for avoidance behaviors and impact on functioning
- Consider medical contributions (thyroid condition, caffeine)
- Evaluate coping strategies currently employed
- Teach basic grounding techniques during assessment
- Screen for comorbid depression
- Review expectation for treatment and previous therapy experiences
Summary: The Effective Psychiatric History
Key Elements
- Therapeutic rapport as foundation
- Comprehensive data collection
- Systematic mental status examination
- Thorough risk assessment
- Cultural sensitivity throughout
- Concise, accurate documentation
- Integration with nursing process
Common Challenges
- Patients with limited insight
- Communication barriers
- Time constraints
- Patients in acute distress
- Managing countertransference
- Balancing direct questions with building rapport
- Obtaining collateral information appropriately
Remember that psychiatric history taking is not just a data collection exercise—it’s the beginning of the therapeutic relationship. The manner in which you conduct the assessment can set the tone for the entire treatment process. Approach each patient with empathy, respect, and genuine curiosity about their unique experience.
Practice Questions
During a psychiatric assessment, a patient tells the nurse, “Sometimes I hear my deceased mother calling my name when no one is there.” Which component of the Mental Status Examination does this information belong to?
A. Thought process
B. Thought content
C. Perceptions
D. Orientation
Answer: C. Perceptions
Rationale: This describes an auditory hallucination, which is an abnormal sensory perception occurring without external stimuli. Hallucinations are documented under the Perceptions component of the MSE.
Which of the following questions would be most appropriate when initially assessing for suicidal ideation?
A. “You’re not thinking about killing yourself, are you?”
B. “Have you been having thoughts about death or not wanting to live?”
C. “Do you have a plan to commit suicide?”
D. “How many suicide attempts have you made in the past?”
Answer: B. “Have you been having thoughts about death or not wanting to live?”
Rationale: This open-ended question begins the suicide assessment in a progressive manner, starting with broader thoughts about death before moving to more specific questions about suicide. Option A is leading and may discourage honest disclosure. Options C and D assume suicidal ideation or past attempts without first establishing if the patient is experiencing thoughts of death.
A nurse is interviewing a patient from a cultural background different from their own. Which approach reflects best practice in culturally sensitive assessment?
A. Assuming that the patient’s symptoms fit standard diagnostic criteria regardless of cultural background
B. Asking the patient about cultural beliefs and practices that may influence their understanding of their symptoms
C. Focusing exclusively on biological symptoms to avoid cultural misunderstandings
D. Using family members to interpret rather than professional interpreters to maintain cultural comfort
Answer: B. Asking the patient about cultural beliefs and practices that may influence their understanding of their symptoms
Rationale: This approach recognizes that culture influences how symptoms are experienced and expressed, while avoiding stereotyping by directly asking the patient about their personal beliefs. Option A ignores cultural influences. Option C neglects important psychological and social aspects of assessment. Option D can compromise confidentiality and lead to inaccurate interpretation.