History taking: psychiatry case
Mental health station is commonly tested in the OSCE as it makes up a large proportion of consultations in both primary care and also influences decisions in secondary care. The examiners want to ensure that the candidate has a sound understanding of the questions to ask, the red flags to rule out and the communication skills for a smooth consultation.
Important factors:
listening is far more important than talking.
show empathy with verbal and non verbal communication, whether that is with head nodding or saying “OK, I see”. Listening skills are important in ALL stations, but this one in particular!
if the patient cries, be silent and to break the silence say something empathetic “I can see that you are very upset”
ask about suicide, do not be afraid to ask this. Ask sensitively.
use the patients own words when reflecting what they have said. This shows you are listening and not making your own interpretation
“tell me more about ‘feeling alone and desperate’?”
Social history is just as important as all other components. Candidates often feel this doesn’t require as much attention, but this is not true. Knowing who the patient lives with, their support network, if they go to university/work will firstly allow safety netting (if they were suicidal) and also builds rapport.
Below is a summary of the questions to ask and why (as knowing the ‘why’ makes it a whole lot easier to remember!) I have focused the history on low mood to make it easier to discuss.
PRESENTING COMPLIANT
“How can I help you today?’
Let the patient talk and express themselves. The first 1 minute (‘golden minute”) will tell you mostly what you need to know. Listen to them, make a mental note/physical note of the important statements they used
HISTORY OF PRESENTING COMPLIANT
Core symptoms
This is where you want to know if they have the specific “core symptoms” of depression.
"Have you in the last month felt persistently low in mood?”
“Have you in the last 1 month lost interest in things that used to interest you?”
“Have you in the last 1 month felt low in energy?”
Biological symptoms
With depression, patients also have other ‘biological symptoms” along with the core symptoms.
“Are you sleeping?” “Have you had issues with your sleep?”
This may be OVER sleeping or UNDER sleeping.
“How is your appetite?” “Are you eating less/more”
They may over eat/under eat. Remember depression can go hand in hand with an eating disorder. Of course this is something you will not be able to cover in a 10 minute station.
“Have you noticed a change in your libido?”
Remember low mood doesn’t just affect the patient, but also loved ones. It has a significant impact on relationships.
Cognitive symptoms
change in concentration
how they feel about themselves and the world around them
Associated psychiatric conditions
With depression, patients can suffer from associated psychiatric conditions ie eating disorder or psychosis. Here you need to ask questions to rule this out:
“Have you ever worried about your weight?” - eating disorder
“Have you ever felt euphoric?” - Mania (bipolar)
“Have you ever heard voices when no one is ever around?” psychosis (auditory hallucinations)
“ Have you ever seen something that you couldn't explain?” psychosis (visual hallucinations)
“Do you ever feel like people are talking about you behind your back?” psychosis
Candidates find it odd asking the above questions, so you can always start with
“these questions may sound odd, but it is important we discuss them” This also gives a warning shot to the patient.
The above questions may need examples if the patient is not understanding you ie “Do you feel like like people are speaking about you negatively, ie you feel like people are out to get you?”
RISK ASSESSMENT
Vital questions that have to be asked in a patient presenting with suicidal thoughts/deliberate self harm:
ask about suicide, do not be afraid to ask this. Ask sensitively. There are lots of different ways ie
“have you ever thought life was not worth living"?”
“do you ever wish you weren’t here"?”
“do you feel the world would be better without you”
Ask about self harm
“Do you have thoughts about harming yourself?
“Have you ever harmed yourself”
If they say they DO have thoughts of harming themselves or DO have thoughts of wanting to end their lives, the next best step is to ask about protective factors: essentially what would STOP them from hurting/killing themselves. Working as a GP, this question is essential for me to evaluate “risk” and my next step. Also, having an idea of the patients social set up will help me, ie do they live alone, do they have lots of friends around them.
“I really appreciate you being open with me about these thoughts you are having, it must have been so difficult to say this” “What stops you from actually ending your life"?”
Most patients will say ‘oh i don’t actually want to, its just fleeting thoughts” some say “my family, my children, my dog, religion”.
PAST PSYCHIATRIC HISTORY
You want to find out if they have 1) seen their GP for their mental health in the past 2) Been on medications for mental health issues 3) been admitted into hospital for mental health issues
This will put the above information into context. Is this is a patient who has been sectioned for mental health problems? - this is more worrying than a patient who has never been on any medications.
PAST MEDICAL HISTORY
The same questions as other history taking stations
DRUG HISTORY
Same as other history taking stations
additional factors:
If they have taken antidepressants/anti psychotics in the past /currently, you need to know 1) what medications 2) the dose 3) for how long.
FAMILY HISTORY
Same questions as other stations but with additional questions around mental health issues in the family. Many mental health problems run in the family. Also you want to know if the patient grew up around a parent with depression, or a parent who committed suicide.
SOCIAL HISTORY
alcohol, drugs, smoking
forensic- have they ever been in trouble with the police
student/working - how has their mood impacted this
relationship - are they single? do they find it difficult to form relationships
who do they live with?
Do they speak to their friends and family? (support network)
INSIGHT
You may want to ask this if the patient has come with a relative who is worried. Does the patient actually see that they may have depression? Having insight makes the management different to someone who is not aware they they have a mental health problem.
ICE
Same questions as other history taking station
I hope you found this information useful. It is not a comprehensive guide and there to just get you thinking and reflecting on your own style of history taking.
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