APA OFFICIAL ACTIONS

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults

Joel J. Silverman, M.D., Marc Galanter, M.D., Maga Jackson-Triche, M.D., M.S.H.S., Douglas G. Jacobs, M.D., James W. Lomax II, M.D., Michelle B. Riba, M.D., Lowell D. Tong, M.D., Katherine E. Watkins, M.D., M.S.H.S., Laura J. Fochtmann, M.D., M.B.I., Richard S. Rhoads, M.D., Joel Yager, M.D.

At its December meeting, The APA Board of Trustees ap- approach, the strength of a guideline statement reflects the proved the APA Work Group on Psychiatric Evaluation’s level of confidence that potential benefits of an intervention Practice Guidelines for the Psychiatric Evaluation of Adults. outweigh the potential harms (Andrews et al., 2013). This [The full guideline is available at http://psychiatryonline.org/ level of confidence is informed by available evidence, which doi/book/10.1176/appi.books.9780890426760]. includes evidence from clinical trials as well as expert opinion and patient values and preferences. Evidence for the benefitof fi BACKGROUND AND DEVELOPMENT PROCESS a particular intervention within a speci cclinicalcontextis identified through systematic review and is then balanced These Practice Guidelines for the Psychiatric Evaluation of against the evidence for harms. In this regard, harms are Adults mark a transition in the American Psychiatric Asso- broadly defined and might include direct and indirect costs of ciation’s Practice Guidelines. Since the publication of the 2011 the intervention (including opportunity costs) as well as po- Institute of Medicine report Clinical Practice Guidelines We tential for adverse effects from the intervention. Whenever Can Trust, there has been an increasing focus on using clearly possible, we havefollowed the admonitiontocurrent guideline defined, transparent processes for rating the quality of evi- development groups to avoid using words such as “might” or dence and the strength of the overall body of evidence in “consider” in drafting these recommendations as they can be systematic reviews of the scientific literature. These guide- difficult for clinicians to interpret (Shiffman et al., 2005). lines were developed using a process intended to be consistent As described under “Guideline Development Process,” with the recommendations of the Institute of Medicine (2011), each final rating is a consensus judgment of the authors of the the Principles for the Development of Specialty Society Clinical guidelines and is endorsed by the APA Board of Trustees. Guidelines of the Council of Medical Specialty Societies (2012), A “recommendation” (denoted by the numeral 1 after the and the requirements of the Agency for Healthcare Research guideline statement) indicates confidence that the benefits of and Quality (AHRQ) for inclusion of a guideline in the National the intervention clearly outweigh harms. A “suggestion” Guideline Clearinghouse. Parameters used for the guidelines’ (denoted by the numeral 2 after the guideline statement) systematic review areincludedwith the full textof theguidelines; indicates uncertainty (i.e.,the balance of benefitsand harms is the development process is fully described in a document difficult to judge, or either the benefits or the harms are available on the APA website: http://www.psychiatry.org/File% unclear). Each guideline statement also has an associated 20Library/Practice/APA-Guideline-Development-Process– rating for the “strength of supporting research evidence.” updated-2011-.pdf. To supplement the expertise of members Three ratings are used: high, moderate, or low (denoted by of the guideline work group, we used a “snowball” survey the letters A, B and C, respectively) and reflect the level of methodology to identify experts on psychiatric evaluation confidence that the evidence reflects a true effect based on and solicit their input on aspects of the psychiatric evaluation consistency of findings across studies, directness of the effect that they saw as likely to improve specific patient outcomes on a specific health outcome, and precision of the estimate of (Yager 2014). Results of this expert survey are included with effect and risk of bias in available studies (AHRQ 2014; the full text of the practice guideline. Balshem et al. 2011; Guyatt et al. 2006). It is well recognized that there are guideline topics and Rating the strength of research evidence and clinical circumstances for which high quality evidence from recommendations clinical trials is not possible or is unethical to obtain (Council The new guideline recommendations are rated using GRADE of Medical Specialty Societies, 2012). For example, it would (Grading of Recommendations Assessment, Development not be ethical to randomly assign only half of patients with and Evaluation), an approach adopted by multiple professional depression to be asked about suicidal ideas. Many questions organizations around the world to develop practice guideline need to be asked as part of the assessment, and inquiring recommendations (Guyatt et al., 2013). With the GRADE about a particular symptom or element of the history cannot

798 ajp.psychiatryonline.org Am J Psychiatry 172:8, August 2015 APA OFFICIAL ACTIONS be separated out for study as a discrete intervention. It would highlights the importance of clinical judgment in tailoring the also be impossible to separate changes in outcome due to as- psychiatric evaluation to the unique circumstances of the sessment from changes in outcomes due to ensuing treatment. patient and in determining which questions are most im- Research on psychiatric assessment is also complicated by portant to ask as part of an initial assessment. multiple confounding factors such as the interaction between the clinician and the patient or the patient’s unique circum- Proper use of guidelines stances and experiences. For these and other reasons, the vast The American Psychiatric Association Practice Guidelines are majority of topics covered in these guidelines on psychiatric not intended to serve or be construed as a “standard of medical evaluation have relied on forms of evidence such as consensus care.” Judgments concerning clinical care depend on the clinical opinions of experienced clinicians or indirect findings from circumstances and data available for an individual patient and are observational studies rather than being based on research subject to change as scientific knowledge and technology ad- from randomized trials. The GRADE working group and vanceandpracticepatternsevolve.Theseguidelinestatements guidelines developed by other professional organizations were determined on the basis of the relative balance of potential have noted that a strong recommendation may be appro- benefits and harms of a specific assessment, intervention or other priate even in the absence of research evidence when sensible approach to care. As such, it is not possible to draw conclusions alternatives do not exist (Andrews et al. 2013; Brito et al. 2013; about the effects of omitting a particular recommendation, either Djulbegovic et al. 2009; Hazlehurst et al. 2013). in general or for a specificpatient.Furthermore,adherenceto these guidelines will not ensure a successful outcome for every Goals and scope of guidelines for the psychiatric individual, nor should these guidelines be interpreted as in- evaluation of adults cluding all proper methods of evaluation and care or excluding Despite the difficulties in obtaining quantitative evidence other acceptable methods of evaluation and care aimed at the from randomized trials for practice guidelines such as psy- same results. The ultimate recommendation regarding a par- chiatric evaluation, guidance to clinicians can still be bene- ticular assessment, clinical procedure, or treatment plan must be ficial in enhancing care to patients. Thus, in the context of an made by the psychiatrist in light of the psychiatric evaluation, initial psychiatric evaluation, a major goal of these guidelines other clinical data, and the diagnostic and treatment options is to improve the identification of psychiatric signs and available. Such recommendations should be made in collabo- symptoms, psychiatric disorders (including substance use ration with the patient and family, whenever possible, and in- disorders), other medical conditions (that could affect the corporate the patient’s personal and sociocultural preferences accuracy of a psychiatric diagnosis), and patients who are at and values in order to enhance the therapeutic alliance, ad- increased risk for suicidal or aggressive behaviors. Additional herence to treatment, and treatment outcomes. goals relate to identifying factors that could influence the therapeutic alliance, enhance clinical decisionmaking, enable Organization of the practice guidelines for the safe and appropriate treatment planning, and promote better psychiatric evaluation of adults treatment outcomes. Finally, the psychiatric evaluation is the As part of aligning the practice guidelines’ development start of a dialog with patients about many factors, including process with national standards, we have transitioned to diagnosis and treatment options. Further goals of these guide- a new guideline format. Each set of Practice Guidelines will lines are to improve collaborative decisionmaking between consist of multiple discrete topics of relevance to an overall patients and clinicians about treatment-related decisions as subject area. In the Practice Guidelines for the Psychiatric well as to increase coordination of psychiatric treatment with Evaluation of Adults, these topics consist of Review of Psy- other clinicians who may be involved in the patient’scare. chiatric Symptoms, Trauma History, and Psychiatric Treat- ment History; Substance Use Assessment; Assessment of Time required to complete a psychiatric evaluation Suicide Risk; Assessment of Risk for Aggressive Behaviors; It is essential to note that these guidelines are not intended Assessment of Cultural Factors; Assessment of Medical to be comprehensive in scope. Many critical aspects of the Health; Quantitative Assessment; Involvement of the Patient psychiatric evaluation are not addressed by these guidelines. in Treatment DecisionMaking; and Documentation of the For example, it is assumed that initial psychiatric or other Psychiatric Evaluation. For each topic, guideline statements medical assessments will need to identify the reason that the will be followed by a discussion of the rationale, potential patient is presenting for evaluation. It is similarly important benefits and harms, and approaches to implementing the to understand the patient’s background, relationships, life guideline statements. This portion of the Practice Guidelines circumstances, strengths and vulnerabilities. is expected have the greatest utility for clinicians. A second Furthermore, depending on the context, recommended section of the Practice Guidelines provides a detailed review areas of inquiry may need to be postponed until later visits, of the evidence for guideline statements in accord with and recommended questions will not always be indicated for national guideline development standards. This review of a specific patient. The findings of the expert survey reiterate research evidence and data from the expertsurvey is followed that experts vary in the extent to which particular elements by a discussion of quality measurement considerations, in- of the initial psychiatric evaluation are assessed. This also cluding their appropriateness for each topic.

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TABLE 1. Practice Guidelines for the Psychiatric Evaluation Psychiatric history of Adults APA recommends (1C) that the initial psychiatric evaluation Guideline Title of a patient include assessment of the following: I Review of Psychiatric Symptoms, Trauma History, and • Past and current psychiatric diagnoses (I, III) Psychiatric Treatment History • II Substance Use Assessment Prior psychotic or aggressive ideas, including thoughts of III Assessment of Suicide Risk physical or sexual aggression or homicide (IV) IV Assessment of Risk for Aggressive Behaviors • Prior aggressive behaviors (e.g., homicide, domestic or work- V Assessment of Cultural Factors place violence, other physically or sexually aggressive VI Assessment of Medical Health threats or acts) (IV) VII Quantitative Assessment • VIII Involvement of the Patient in Treatment Decision- Prior suicidal ideas, suicide plans, and suicide attempts, Making including attempts that were aborted or interrupted as well IX Documentation of the Psychiatric Evaluation as the details of each attempt (e.g., context, method, damage, potential lethality, intent) (III) • Prior intentional self-injury in which there was no suicidal GUIDELINES AND STATEMENTS intent (III) APA recommends (1C) that the initial psychiatric evalu- The following represents a summary of the recommendations ation of a patient include review of the following aspects of and suggestions compiled from all Practice Guidelines for the patient’s psychiatric treatment history: the Psychiatric Evaluation of Adults (Table 1), with some statements being a part of more than one of these guidelines. • History of psychiatric hospitalization and emergency de- In the context of these guideline statements, it is important partment visits for psychiatric issues (I, III, IV) to note that assessment is not limited to direct examina- • Past psychiatric treatments (type, duration, and, where tion of the patient. Rather, it is defined as “the process of applicable, doses) (I) obtaining information about a patient through any of a variety • Response to past psychiatric treatments (I) ofmethods,includingface-to-faceinterview,reviewofmedical • Adherence to past and current pharmacological and non- records, physical examination (by the psychiatrist, another pharmacological psychiatric treatments (I) physician, or a medically trained clinician), diagnostic testing, or history-taking from collateral sources.” The evaluation Substance use history may also require several meetings, with the patient, family, or APA recommends (1C) that the initial psychiatric evaluation others, before it can be completed. The amount of time spent of a patient include assessment of the following: depends on the complexity of the problem, the clinical set- • The patient’s use of tobacco, alcohol, and other substances ’ ting, and the patient s ability and willingness to cooperate (e.g., marijuana, cocaine, heroin, hallucinogens) and any with the assessment. misuse of prescribed or over-the-counter medications or This summary is organized according to common head- supplements (II) ings of an evaluation note. As noted above, the guidelines • Current or recent substance use disorder or change in use are not intended to be comprehensive, and many aspects of of alcohol or other substances (III, IV) the psychiatric evaluation are not addressed by these recom- mendations and suggestions. The strength of supporting re- Medical history (VI). APA recommends (1C) that the initial search evidence for these recommendations and suggestions psychiatric evaluation of a patient include assessment of the is given rating C (low) because of the difficulties in studying following: psychiatric assessment approaches in controlled studies • Allergies or drug sensitivities as described in the “Background and Development Process.” • All medications the patient is currently or recently taking The specific guideline(s) in which the recommendation or and the side effects of these medications (i.e., both pre- suggestion is found is denoted by its Roman numeral from scribed and nonprescribed medications, herbal and nu- Table 1. tritional supplements, and vitamins) • Whether or not the patient has an ongoing relationship History of present illness with a primary care health professional In addition to reasons that the patient is presenting for eval- • Pastorcurrentmedicalillnessesandrelatedhospitalizations uation, APA recommends (1C) that the initial psychiatric • Relevant past or current treatments, including surgeries, evaluation of a patient include: other procedures, or complementary and alternative med- • Psychiatric review of systems (I), including anxiety ical treatments symptoms and panic attacks (III) • Past or current neurological or neurocognitive disorders or • Assessment of past or current sleep abnormalities, in- symptoms (IV) cluding sleep apnea (VI) • Physical trauma, including head injuries • Assessment of impulsivity (III, IV) • Sexual and reproductive history

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APA suggests (2C) that the initial psychiatric evaluation of • Culturalfactorsrelatedtothe patient’s social environment (V) a patient also include assessment of the following: • Patient’s need for an interpreter (V) • Cardiopulmonary status APA suggests (2C) that the initial psychiatric evaluation • Past or current endocrinological disease of a patient include assessment of the patient’sPersonal/ • Past or current infectious disease, including sexually trans- cultural beliefs and cultural explanations of psychiatric mitted diseases, HIV, tuberculosis, hepatitis C, and locally illness (V) endemic infectious diseases such as Lyme disease • Past or current symptoms or conditions associated with Examination, including mental status examination fi signi cant pain and discomfort APA suggests (2C) that the initial psychiatric evaluation of a patient also include assessment of the following: Review of systems (VI). APA recommends (1C) that the initial psychiatric evaluation of a patient include a psychiatric review • Height, weight, and body mass index (BMI) (VI) of systems (if not already included with history of present • Vital signs (VI) illness) • Skin, including any stigmata of trauma, self-injury, or drug In addition to a psychiatric review of systems, APA sug- use (VI) gests (2C) that the initial psychiatric evaluation of a patient APA recommends (1C) that the initial psychiatric evalu- include a review of the following systems: ation of a patient include assessment of the following: • Constitutional symptoms (e.g., fever, weight loss) • General appearance and nutritional status (VI) • Eyes • Coordination and gait (VI) • Ears, Nose, Mouth, Throat • Involuntary movements or abnormalities of motor tone (VI) • Cardiovascular • Sight and hearing (VI) • Respiratory • Speech, including fluency and articulation (VI) • Gastrointestinal • Mood, level of anxiety, thought content and process, and • Genitourinary perception and cognition (I, III) • Musculoskeletal • Hopelessness (III) • Integumentary (skin and/or breast) • Current suicidal ideas, suicide plans, and suicide attempts, • Neurological including active or passive thoughts of suicide or death • Endocrine (III): If current suicidal ideas are present, assess: • Hematological/Lymphatic ∘ Patient’s intended course of action if current symptoms • Allergic/Immunological worsen ∘ Access to suicide methods including firearms Family history ∘ Patient’spossible motivations forsuicide (e.g. attention or APA recommends (1C) that the initial psychiatric evaluation reaction from others, revenge, shame, humiliation, de- of a patient who reports current suicidal ideas include as- lusional guilt, command hallucinations) sessment of history of suicidal behaviors in biological rela- ∘ Reasons for living (e.g. sense of responsibility to children tives (for patients with current suicidal ideas) (III) or others, religious beliefs) When it is determined during an initial psychiatric ∘ Quality and strength of the therapeutic alliance evaluation that the patient has aggressive ideas, APA rec- • Current aggressive or psychotic ideas, including thoughts ommends (1C) assessment of history of violent behaviors in of physical or sexual aggression or homicide (III, IV): If biological relatives (for patients with current aggressive current aggressive ideas are present, assess: ideas) (IV) ∘ Specific individuals or groups toward whom homicidal or aggressive ideas or behaviors have been directed in the Personal and social history past or at present APA recommends (1C) that the initial psychiatric evaluation ∘ Impulsivity, including anger management issues of a patient include assessment of the following: ∘ Access to firearms • Presence of psychosocial stressors, (e.g. financial, housing, Impression and plan legal, school/occupational or interpersonal/relationship APA recommends (1C) that the clinician who conducts the problems; lack of social support; painful, disfiguring, or initial psychiatric evaluation document: terminal medical illness) (III, IV) • Review of the patient’s trauma history (I, III) • An estimate of the patient’s suicide risk, including factors • Exposure to violence or aggressive behavior, including influencing risk (III) combat exposure or childhood abuse (IV) • The rationale for treatment selection, including discus- • Legal or disciplinary consequences of past aggressive sion of the specific factors that influenced the treatment behaviors (IV) choice (IX)

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APA recommends (1C) that the initial psychiatric evalu- No. 10(14)-EHC063-EF. Rockville, MD: Agency for Healthcare Research ation of a patient who is seen include: and Quality. Jan 2014. Chapters available at: www.effectivehealthcare. ahrq.gov. • Asking the patient about treatment-related preferences (VIII) Andrews JC, Schünemann HJ, Oxman AD, et al: GRADE guidelines: • An explanation to the patient of the following: the dif- 15. Going from evidence to recommendation-determinants of a rec- ommendation’s direction and strength. J Clin Epidemiol 2013; 66: ferential diagnosis, risks of untreated illness, treatment – fi 726 735 options, and bene ts and risks of treatment (VIII) Balshem H, Helfand M, Schünemann HJ, et al: GRADE guidelines: • Collaboration between the clinician and the patient about 3. Rating the quality of evidence. J Clin Epidemiol 2011; 64:401–406 decisions pertinent to treatment (VIII) BritoJP, DomecqJP,MuradMH,et al:TheEndocrineSocietyguidelines: when the confidence cart goes before the evidence horse. J Clin APA suggests (2C) that the initial psychiatric evaluation of Endocrinol Metab 2013; 98:3246–3252 a patient include: Council of Medical Specialty Societies (CMSS): Principles for the Development of Specialty Society Clinical Guidelines. Chicago, IL. • Quantitative measures of symptoms, level of functioning, 2012 and quality of life (VII) Djulbegovic B, Trikalinos TA, Roback J, et al: Impact of quality of evi- • Documentation of an estimated risk of aggressive behavior dence on the strength of recommendations: an empirical study. BMC (including homicide), including factors influencing risk (IV) Health Serv Res 2009; 9:120 • Guyatt G, Eikelboom JW, Akl EA, et al: A guide to GRADE guidelines for Documentation of the rationale for clinical tests (IX) the readers of JTH. J Thromb Haemost 2013; 11:1603–1608 Guyatt G, Gutterman D, Baumann MH, et al: Grading strength of rec- ommendations and quality of evidence in clinical guidelines: report AUTHOR AND ARTICLE INFORMATION from an american college of chest physicians task force. Chest 2006; From the APA Workgroup on Psychiatric Evaluation (Joel J. Silverman, 129:174–181 Chair). Address correspondence to Kristin Kroeger ([email protected]). Guyatt GH, Oxman AD, Kunz R, et al: GRADE Working Group: Going – APA wishes to acknowledge the contributions of the former APA staff; from evidence to recommendations. BMJ 2008; 336:1049 1051 Robert Kunkle, M.A., Robert Plovnick, M.D., Sara Reid, M.A., Seung-Hee Hazlehurst JM, Armstrong MJ, Sherlock M, et al: A comparative quality Hong, and William E. Narrow, M.D., M.P.H. APA and the Work Group on assessment of evidence-based clinical guidelines in endocrinology. Clin – Psychiatric Evaluation especially thank Laura J. Fochtmann, M.D., M.B.I, Endocrinol (Oxf ) 2013; 78:183 190 and Robert Kunkle, M.A. for their outstanding work and effort on de- Institute of Medicine (IOM): Clinical Practice Guidelines We Can Trust. veloping these guidelines. APA also thanks the APA Steering Committee on Washington, DC, The National Academies Press, 2011 Practice Guidelines and liaisons from the APA Assembly for their input and Shiffman RN, Dixon J, Brandt C, et al: The GuideLine Implement- assistance. ability Appraisal (GLIA): development of an instrument to identify obstacles to guideline implementation. BMC Med Inform Decis Mak – Am J Psychiatry 2015; 172:798 802; doi: 10.1176/appi.ajp.2015.1720501 2005; 5:23 YagerJ,KunkleR,FochtmannLJ,etal:Who’syourexpert?Useof REFERENCES an expert opinion survey to inform development of American Psy- Agency for Healthcare Research and Quality: Methods Guide for chiatric Association practice guidelines. Acad Psychiatry 2014; 38: Effectiveness and Comparative Effectiveness Reviews. AHRQ Publication 376–382

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