Past Psychiatric History: Framework and Essential Components

This is Part 1 in our series on Past Psychiatric History.
This post establishes the framework for understanding and gathering a comprehensive psychiatric history.

In the introduction, we outlined the six domains of history taking. The Past Psychiatric History, our first domain, is substantial enough to merit numerous detailed guides. This post establishes the framework and essential components that subsequent posts will explore in depth.

What This Domain Covers

The Past Psychiatric History documents a patient’s journey through the mental health system: the diagnoses they’ve received, the treatments they’ve tried, the crises they’ve survived, and the providers who’ve walked alongside them. This account shows how their illness has responded to intervention over time.

Think of this as the treatment narrative, distinct from the symptom narrative you’ll gather in the History of Present Illness. In contrast, the HPI explores what the patient has experienced internally (symptoms, onset, course), while the Past Psychiatric History explores what has happened externally (hospitalizations, medications, therapy, life events).

Learning Objectives

After reading this section, you should be able to:

• Identify the nine elements of a comprehensive Past Psychiatric History
• Distinguish Past Psychiatric History content from the History of Present Illness
• Explain why each element informs diagnostic reasoning and risk assessment

The Essential Components

A comprehensive Past Psychiatric History includes nine core components:

Once you’ve gathered these nine elements, the next step is understanding why they matter clinically.

Why This Information Matters

Each element provides unique clinical value that shapes your understanding of the patient and guides treatment decisions.

Past diagnoses reveal how others have conceptualized the patient’s illness. Understanding diagnostic evolution over time shows whether the formulation has remained stable or shifted, whether diagnoses were data-driven or impressionistic, and whether diagnostic uncertainty exists. This historical perspective prevents anchoring bias and encourages fresh diagnostic consideration.

Hospitalization history marks the most severe points of decompensation. The precipitants, frequency, and outcomes of hospitalizations reveal illness severity, response to crisis intervention, and patterns in symptom exacerbation. Multiple brief admissions suggest different pathology than rare but prolonged stays. Understanding what has required inpatient care calibrates your risk assessment for the current presentation.

Treatment provider information ensures continuity and provides collateral sources. Knowing who is actively involved allows care coordination and prevents fragmented treatment. Understanding past therapeutic relationships reveals patterns of engagement, rupture, or sustained alliance that inform current treatment planning.

Support systems identify protective factors and practical resources. Strong social supports improve outcomes and reduce hospitalization risk. Understanding who helps the patient at home, who provides emotional support, and what community connections exist reveals resilience factors and identifies isolation as a risk factor.

Psychotherapy history demonstrates which approaches have been tried and whether therapeutic relationships have been sustained. Multiple brief therapies ending in conflict suggest different dynamics than long-term stable therapy. Understanding what has helped psychologically prevents repeating failed approaches and builds on previous gains.

Medication and ECT trials prevent repeating failed interventions and identify what has worked. Knowing which medications were tried at adequate doses for sufficient duration distinguishes true treatment resistance from inadequate trials. Understanding side effect patterns guides future prescribing. Prior successful treatments often work again when symptoms recur.

Suicide attempt history informs current risk assessment with the most powerful predictor available. Past attempts are the strongest risk factor for future attempts and completed suicide. Understanding method, intent, precipitants, and frequency reveals patterns essential for safety planning and intervention.

Self-harm patterns reveal coping mechanisms and emotional regulation strategies. Non-suicidal self-injury indicates distress tolerance deficits and often predicts future suicide risk. Understanding the function self-harm serves guides treatment selection toward skills training and affect regulation interventions.

Trauma history contextualizes symptoms and informs treatment approach. Many psychiatric symptoms make sense only when understood through a trauma lens. Hypervigilance appears as adaptive scanning after assault. Emotional detachment represents dissociation from overwhelming memories. Trauma history transforms symptoms from disorders to understandable responses requiring trauma-focused intervention.

Together, these components create a comprehensive picture of how the patient’s illness has unfolded and how the mental health system has responded. This historical perspective reveals treatment patterns, identifies what works, prevents repeating failures, and grounds risk assessment in longitudinal data rather than single-point-in-time evaluation.

What’s Coming in This Series

With this framework established, the parts that follow in this series will provide detailed, practical guidance for each component: showing how to gather, interpret, and document each element of the Past Psychiatric History.

Part 2: How to Assess Past Psychiatric Diagnoses
Specific questions to ask, how to assess diagnostic accuracy, and what hospitalization details matter most.

Part 3: How to Take a Hospitalization History That Actually Predicts Risk
Knowing what to ask about prior inpatient treatment.

Part 4: Understanding the Patient’s Current Treatment Providers
Who is actively involved in their care and who has been in the past.

Part 5: Understanding the Patient’s Support System
How to identify and evaluate family, friends, and community supports that influence recovery.

Part 6: How to Take a Psychotherapy History
And Why It Reveals Personality.

Part 7: Medication History
How to Identify Treatment Resistance and Avoid Repeating Failed Trials.

Part 8: Suicide Attempt History
Getting It Right Without Losing the Relationship.

Part 9: Trauma History
How to Ask Without Re-Traumatizing.

Each guide will include specific interview questions, clinical pearls, documentation strategies, and common pitfalls to avoid. Each subsequent post will guide you step-by-step through these components, from diagnostic history to trauma assessment.

Once we complete the Past Psychiatric History series, we’ll move on to Substance Use History, the second major domain in comprehensive psychiatric evaluation.

A note on scope: This series focuses on treatment history rather than syndromal history (onset, premorbid functioning, illness course). Those temporal elements of symptom progression naturally belong in the History of Present Illness, where symptom-focused conversation is already happening. This separation keeps the interview conversational and prevents redundancy.

Next in this series: Part 2 – How to Assess Past Psychiatric Diagnoses

How to Assess Past Psychiatric Diagnoses (Correctly)

This is Part 2 in our series on Past Psychiatric History.
Read Part 1: Framework and Essential Components to understand how this domain fits into comprehensive psychiatric evaluation.

Past diagnoses shape treatment decisions and how patients understand themselves. Your job is to systematically extract what diagnoses exist in the chart and in the patient’s memory, document their sources, and note any discrepancies. This creates the foundation for clinical reasoning – but that reasoning comes later. Right now, focus on accurate extraction.

Learning Objectives

After reading this section, you should be able to:

• Identify reliable sources for extracting previous psychiatric diagnoses
• Differentiate between chart-documented and patient-reported diagnoses
• Evaluate diagnostic discrepancies for accuracy and context
• Document diagnoses with clear source attribution (“per chart” vs. “per patient”)

Start With Chart Review

Before interviewing the patient, review available documentation:

Previous psychiatric notes – Diagnostic impressions from psychiatrists, psychologists, therapists

Problem lists – Active and inactive diagnoses in the electronic medical record

Discharge summaries – Hospital and partial hospitalization diagnoses often reflect more thorough evaluation

Psychological testing reports – May identify ADHD, autism, learning disorders not documented elsewhere

💡 Clinical Pearl: Pay attention to diagnostic inconsistencies. If one provider diagnosed major depression and another diagnosed bipolar disorder, this discrepancy warrants exploration with the patient.

Interview the Patient

After chart review, interview the patient to confirm, clarify, and add to documented diagnoses.

Core Questions to Ask

• “Has a doctor or therapist ever given you a mental health diagnosis?”
• “Are you aware of having any diagnoses like depression, anxiety, or bipolar disorder?”
• If chart diagnoses weren’t mentioned: “I see you’ve been diagnosed with [diagnosis]. Were you aware of that?”
• After they name one: “Have you been given any other diagnoses?”

When They Say “No” or “I Don’t Know”

Many patients do not spontaneously report certain conditions such as neurodevelopmental disorders (ADHD, autism), substance use disorders, personality disorders, or neurocognitive conditions when asked whether they have “psychiatric diagnoses.” While I have not found specific research describing this as a studied phenomenon, it reflects my clinical experience. Patients often readily report diagnoses like depression, anxiety, bipolar disorder, or schizophrenia, but conditions such as ADHD or autism may only emerge later in the interview, often when reviewing current or past medications. On several occasions, I have discovered an ADHD diagnosis only after asking why a patient was prescribed a stimulant medication. They might casually reply, “Oh, I was diagnosed with ADHD as a kid,” even though they had not mentioned it earlier. The same is often true for substance use disorders, which patients may not volunteer until asked directly or until a medication such as buprenorphine, methadone, or naltrexone appears in their record. Because substance use history is a core component of every psychiatric evaluation, these diagnoses are less likely to be missed, but the pattern still illustrates the value of probing beyond initial answers and reviewing medication history carefully.

Ask specifically:

• “Has anyone mentioned ADHD or autism?”
• “Do you have any diagnoses related to learning, attention, or development?”
• “Have you been told about substance use problems or addiction?”

Follow-Up for Context

Once a patient names a diagnosis, gather context:

• “Who gave you this diagnosis – a psychiatrist, therapist, or primary doctor?”
• “About how long ago?”
• “Do you remember how old you were when you received the diagnosis?”
• “What was happening when you got this diagnosis – were you in the hospital or in crisis?”
• “Are you still being treated for this?”

💡 Clinical Pearl: The reliability of a past diagnosis depends greatly on who made it, in what setting, and under what circumstances. A diagnosis established by a psychiatrist after longitudinal evaluation carries more weight than one made during an emergency visit or acute crisis. The American Psychiatric Association emphasizes documenting both source and context—including clinician type, setting, and timing—since diagnostic stability and accuracy vary widely across clinical environments.

Diagnosis Drift: Bipolar Disorder (DSM-IV vs DSM-5)

Why this matters: Bipolar disorder diagnoses made before 2013 (under DSM-IV) require special scrutiny.

The key change: DSM-IV allowed diagnosis based on mood symptoms alone (elevated, expansive, or irritable mood). DSM-5 requires BOTH abnormal mood AND persistently increased energy or activity. This stricter criterion reduced bipolar diagnoses by 30 to 50% across all age groups – one of the few adult psychiatric diagnoses to decrease under DSM-5.

In children specifically: DSM-IV criteria were often applied to chronic, severe irritability without true episodic changes. DSM-5 introduced Disruptive Mood Dysregulation Disorder (DMDD) for chronic irritability and clarified that bipolar disorder requires episodic presentations.

Clinical implication: When you see bipolar disorder diagnosed before 2013, especially in children or during crisis presentations, explore: Was this based on true episodic changes in mood AND energy? Or chronic irritability? Crisis diagnosis or longitudinal observation?

What to Document

Your documentation should specify both the diagnoses and their sources, creating a clear baseline for diagnostic reasoning.

Consistently documenting the source and context of prior diagnoses prevents circular reasoning and supports accurate formulation later in the evaluation.

Why This Information Matters

Diagnostic labels map how others have understood the patient’s struggles. Your role is to extract and document these labels precisely; interpretation comes later. Right now, your job is accurate extraction and documentation of what diagnoses exist and where they came from.

Understanding past diagnoses provides several critical functions. First, it reveals diagnostic consensus or uncertainty. When multiple providers across time agree on a diagnosis, this strengthens diagnostic confidence. When diagnoses shift frequently or conflict, this signals diagnostic uncertainty requiring careful reassessment. Second, it identifies documentation gaps. When patients report diagnoses not in the chart, this may indicate treatment elsewhere, documentation failures, or the patient’s interpretation of symptoms rather than formal diagnoses. Third, it prevents anchoring bias. Seeing how others conceptualized the illness doesn’t determine your formulation – it provides one data point among many. Your independent assessment may confirm, refine, or revise prior diagnoses.

Source attribution – documenting who made the diagnosis and when – is essential for both clinical reasoning and medicolegal documentation. A bipolar diagnosis from an emergency physician during a single crisis encounter requires different interpretation than the same diagnosis from a psychiatrist following months of careful observation. Crisis diagnoses may reflect acute presentations that don’t represent the patient’s longitudinal course. Outpatient diagnoses based on sustained observation typically carry more weight.

This foundation prepares you for the next component: understanding when and why those diagnoses led to psychiatric hospitalizations. Hospitalization history reveals illness severity, treatment response, and crisis patterns that further contextualize the diagnostic picture.

Next in this series: Part 3 – Psychiatric Hospitalization History: When, Where, Why, and What It Reveals About Illness Severity

Previous post: Part 1 – Framework and Essential Components: Understanding the Scope of Past Psychiatric History

How to Gather Psychiatric Hospitalization History

This is Part 3 in our series on Past Psychiatric History.
Read Part 2: Past Psychiatric Diagnoses for the previous component.

Hospitalization history reveals the severity and trajectory of psychiatric illness more clearly than almost any other data point. The pattern of admissions – frequency, timing, and circumstances – shows how sick someone has been, what interventions worked, and what risks may re-emerge. Your job is to systematically extract this information from the chart and from the patient, focusing on patterns rather than exhaustive detail.

Learning Objectives

After reading this section, you should be able to:

• Identify reliable chart sources for documenting hospitalization history
• Elicit accurate hospitalization timelines from patient interviews
• Recognize clinically significant admission patterns (e.g., rapid readmissions, long-term stays)
• Document hospitalization history clearly, emphasizing severity, frequency, and context

Start With Chart Review

Before interviewing the patient, review available documentation:

Admission/discharge dates – Many EHRs display hospitalization history chronologically

Discharge summaries – Primary diagnoses, length of stay, admission circumstances, discharge disposition

Previous psychiatric notes – Often reference recent or significant past admissions

Document what you find: dates, facilities, admission reasons, and any details suggesting severity. This will be utilized as a timeline you can have in your mind before speaking with the patient.

💡 Clinical Pearl: For patients recently discharged, note the specific hospital name and location immediately. You can request discharge documentation without delay – these records can often take days and sometimes weeks to arrive and can transform your understanding of the case.

Summarize what you find chronologically. This will be your framework for patient questioning.

Interview the Patient

After chart review, interview the patient to confirm, clarify, and add missing admissions.

Opening Questions

• “Have you ever been hospitalized for psychiatric reasons?”
• “How many times have you been in a psychiatric hospital?”
• “When was your most recent hospitalization?”
• “When was your first hospitalization?”

If chart shows admissions the patient doesn’t mention:

• “I see you were hospitalized at [facility] in [year]. Do you remember that admission?”

For Patients With Multiple Admissions

When someone has had numerous hospitalizations, focus your detailed questions on three priorities:

1. The most recent admission – This is usually most relevant to current presentation and treatment planning
2. Any state hospital admissions – These indicate a different level of severity and warrant specific inquiry
3. Frequency over time – Understanding admissions per year helps identify patterns without documenting every single admission exhaustively

Then shift to pattern recognition rather than exhaustive detail on each admission.

Gathering Detail on Key Admissions

For the most recent admission (and state hospital admissions), gather:

Basic facts:

• “Which hospital were you at?”
• “How long were you there – days, weeks, months?”
• “Did you go voluntarily or were you committed?”

Circumstances:

• “What brought you to the hospital that time?”
• “What were you struggling with most – suicidal thoughts, psychosis, depression, mania?”
• “How were you feeling when you left – much better, somewhat better, about the same?”

Treatment received:

• “Did they change your medications while you were there?”
• “Did you have ECT or any other treatments?”

💡 Clinical Pearl: Voluntary vs. involuntary status matters. Involuntary admissions suggest more severe illness, greater acute risk, or impaired insight at the time.

Understanding State Hospital Admissions

If the patient mentions state psychiatric hospital admissions, explore these specifically. State hospitals typically indicate greater illness severity, treatment resistance, or need for specialized services not available in community settings.

Ask:

• “Have you ever been in a state psychiatric hospital?”
• “How many times?”
• “How long did each admission last – days, weeks, months?”
• “Were you in a short-term crisis unit or a longer-term treatment unit?”

State Hospitals: Acute vs. Long-Term Units

Many state hospital systems have different units with vastly different clinical implications:

Acute stabilization units (short-term):

• Length of stay: Days to a couple of weeks
• Purpose: Crisis stabilization, medication adjustment, immediate safety
• May function similarly to community hospital acute units
• Patients cycle through relatively quickly

Long-term/chronic care units:

• Length of stay: Weeks to months (or longer)
• Purpose: Extended stabilization, treatment of persistent symptoms, complex medication management
• Indicates more severe, persistent, or treatment-resistant illness
• May involve specialized programming (forensic, neurobehavioral)

Clinical implication: Two state hospital admissions for 4 days each suggests brief crisis stabilization and relatively quick response to treatment. Two admissions lasting 6 months each indicates severe, treatment-resistant illness requiring extended specialized care – a fundamentally different clinical picture.

💡 Clinical Pearl: State hospital discharge summaries are invaluable but take longer to obtain. They often contain detailed medication trials, comprehensive treatment histories, and specialized testing results. Request them immediately.

Assessing Frequency and Timeline

Once you’ve established the key hospitalizations, shift focus from individual episodes to overall frequency and trends.

For patients with many admissions, establish the overall pattern without exhaustive detail on each one:

• “How many hospitalizations would you say you’ve had in the past year?”
• “In the past 5 years?”
• “When did the hospitalizations start becoming more frequent?”

This gives you the frequency data needed for pattern recognition without getting bogged down in details of every single admission.

For patients with multiple admissions, pattern recognition matters more than documenting every single hospitalization.

Key Patterns and What They Mean

When timing matters more than total number:

Long Stable Period, Then Readmission

Question: 

“It looks like you hadn’t been hospitalized in years, then went in recently. What changed?”

Clinical meaning: Signals a significant shift. Investigate what changed – new stressor, medication discontinuation, loss of supports, substance relapse, or natural illness progression.

Recent Discharge Followed by Rapid Readmission

Questions:

• “You were just discharged [timeframe]. What happened between then and now?”
• “Did you make it to your follow-up appointment?”
• “Were you able to get your medications filled?”

Clinical meaning: Suggests inadequate stabilization before discharge, gaps in discharge planning, systemic barriers (housing, transportation, medication access), or that the treatment plan didn’t address actual needs. Requires careful analysis of what went wrong.

Frequent Short Admissions (“Revolving Door”)

Question: 

“These admissions seem to happen pretty regularly. What usually brings you in?”

Clinical meaning: Points to unmet psychosocial needs, inadequate outpatient support intensity, chronic suicidality requiring different interventions, personality dynamics, active substance use, or housing instability. The hospital becomes a recurring safety net rather than definitive treatment.

🚩 Pitfall: Accepting Summary Numbers Without Context

A patient reports “3 psychiatric hospitalizations.” Without further questioning, you note this and move on.

What you missed: The number “3” could mean entirely different clinical pictures:

• Three admissions 15 years ago (remote history, less relevant now)
• One admission 15 years ago, then two in the past month (dramatic change, highly relevant)
• Three admissions in the past year (ongoing instability)

In this patient’s case, detailed inquiry reveals two hospitalizations occurred 15 years ago during a brief crisis period that fully resolved. The patient was stable for over a decade. The third hospitalization was yesterday – and today they’re seeking readmission within 24 hours of discharge.

The lesson: The summary number “3 hospitalizations” obscures the real story. The remote admissions are historical context, but the immediate pattern (discharge → readmission within 24 hours) is the critical clinical information.

Always establish when hospitalizations occurred and look for pattern changes.

What to Document

Tailor your documentation detail to clinical relevance and available time.

State hospital admissions should be documented separately:

“Two prior state hospital admissions: State Psychiatric Center 2020 (3 weeks, acute unit) and 2022 (4 months, long-term unit) for treatment-resistant psychosis.”

The key is documenting enough to understand severity and pattern without exhaustive detail on every admission.

Why This Information Matters

Hospitalization history reveals illness severity and helps predict future risk in ways that outpatient symptom history cannot. Past admissions are among the strongest predictors of future admissions – understanding the pattern allows evidence-based risk assessment rather than impressionistic judgment.

Pattern Recognition Informs Treatment Planning: Understanding what has triggered past crises helps you anticipate vulnerabilities and intervene preventively. A patient whose admissions consistently follow medication discontinuation needs intensive medication adherence support. One whose admissions cluster around anniversary dates of trauma needs trauma-focused care and safety planning during high-risk periods. Another with admissions following relationship conflicts may benefit from interpersonal therapy or couples work.

Discharge Planning Requires Historical Context: Knowing what stabilized the patient in previous admissions guides current treatment. If the patient improved with ECT during a prior admission but was never continued on maintenance ECT, this suggests a missed opportunity. If multiple admissions ended with rapid readmission, this reveals systemic discharge planning failures that must be addressed – medication access, housing stability, outpatient appointment scheduling, or family support coordination.

Treatment Response Patterns Emerge: Hospitalization frequency over time shows whether illness is stable, worsening, or improving with treatment. Decreasing admission frequency suggests effective outpatient management. Increasing frequency indicates treatment inadequacy or illness progression requiring intervention escalation. The length of stays also matters – briefer admissions suggest rapid treatment response, while prolonged stays indicate treatment resistance or severe symptoms.

Risk Stratification Becomes Data-Driven: Rather than relying on the patient’s current presentation alone, hospitalization history provides longitudinal risk data. A patient with no prior hospitalizations despite years of depression presents different risk than one with ten admissions over the same period. Recent discharge followed by ED presentation within days is one of the highest-risk patterns, associated with suicide attempts and completed suicide.

Combined with your diagnostic history from Part 2, you’re building a comprehensive picture of this patient’s psychiatric journey – what they’ve been diagnosed with, how severe it’s become, and what has (or hasn’t) helped stabilize them. This longitudinal perspective prevents reactive crisis management in favor of informed, pattern-based treatment planning.

Next in this series: Part 4 – Treatment Providers and Psychotherapy History: Who Has Been Involved in Care

Previous post: Part 2 – Past Psychiatric Diagnoses: Gathering and Evaluating Diagnostic History

How to Gather Current Treatment Provider Information

This is Part 4 in our series on Past Psychiatric History. 
Read Part 3: Psychiatric Hospitalization History for the previous component.

Most patients receive care within a network of providers managing different aspects of their health. Identifying this treatment team is essential for coordination, preventing medication errors, avoiding conflicting recommendations, obtaining collateral information, and planning discharge. Your task is to determine who is involved, how long they’ve been engaged, and when they were last seen.

Learning Objectives

After reading this section, you should be able to:
• Identify chart sources that reveal a patient’s active provider network.
• Conduct interview questions that clarify provider roles, frequency, and recent changes.
• Recognize warning signs of fragmented or low-intensity care.
• Document provider continuity and gaps relevant to risk formulation and discharge planning.

Start With Chart Review

Before interviewing the patient, review available documentation:

• Recent clinical notes – Look for references to outside providers (therapists, psychiatrists, PCPs)
• Medication lists – Prescriber names indicate active relationships with providers
• Referral records – Recent referrals show newly established care
• Release of information forms – Who has the patient authorized for communication?
• Appointment records – Scheduled or completed visits with external providers

Document provider names, specialties, and contact information when available. This creates your baseline before speaking with the patient.

💡 Clinical Pearl: Check medication prescriber names carefully. If three different psychiatrists prescribed the current medication regimen, this suggests provider changes and potential continuity issues worth exploring.

Interview the Patient

After chart review, interview the patient to confirm, clarify, and add providers not documented in the system.

Opening Questions

• “Who are you currently seeing for mental health treatment?”
• “Do you have a therapist? A psychiatrist? What are their names?”
• “Are you involved with any programs like day treatment or intensive outpatient?”
• “Who is your primary care doctor?”

Confirm and Clarify from the Chart:

• “I see Dr. [Name] prescribed your medication. Are you still seeing them?”

Identifying the Full Treatment Team

Cast a wide net. The current care team may include:

Mental health specialists:

• Psychiatrist or psychopharmacologist
• Therapist, psychologist, or counselor
• Psychiatric nurse practitioner or physician assistant
• Case manager or care coordinator

Specialized programs:

• Day treatment or partial hospitalization program
• Intensive outpatient program
• Residential program or group home staff
• Substance use treatment programs

Other medical providers:

• Primary care physician
• Neurologist (for seizure disorders, dementia, movement disorders)
• Pain management specialist

Gathering Detail on Each Provider

For each provider identified, ask:

Contact and identification:

• “What’s their full name?”
• “Where is their office located?”
• “Do you have their phone number?”

Nature of involvement:

• “What do they help you with – medications, therapy, both?”
• “How long have you been seeing them?”
• “How often do you meet – weekly, monthly?”

Recent contact:

• “When was your last appointment with them?”
• “When is your next appointment scheduled?”
• “Have you missed any appointments recently?”

Recent changes:

• “Has anything changed with this provider recently – like seeing them less often or stopping?”
• “Have you switched providers or stopped seeing anyone in the past few months?”

🚩 PITFALL: Assuming Stability Without Checking for Changes

A patient reports seeing a therapist and psychiatrist regularly for “years” – sounds like strong, stable engagement.

What you missed: Detailed questioning reveals that until 3 months ago, the patient saw the therapist weekly and psychiatrist monthly. The treatment team recently reduced frequency to every 3 months due to perceived stability. Since this change, the patient has been hospitalized 3 times.

The lesson: The reduction in care intensity directly correlates with clinical deterioration. Always ask not just WHO is involved, but HOW LONG, HOW OFTEN, and WHETHER ANYTHING HAS CHANGED RECENTLY. Stable provider relationships don’t guarantee stable intensity of services.

Assessing Engagement Through Appointment Timing

The timing of recent and upcoming appointments reveals critical information about engagement, access, and continuity:

Last appointment timing shows:

• Recent contact suggests active engagement
• Long gaps may indicate disengagement, access barriers, or provider availability issues
• Missed appointments may indicate symptom severity or ambivalence

Next appointment timing shows:

• Appointments scheduled within days/weeks suggest good continuity
• Long gaps before next visit may require interim care (IOP, partial hospitalization, bridge appointments)
• No scheduled appointment suggests discharge planning needs

What to Document

Documentation should balance completeness with practicality.

When providers have changed:

• “Previous psychiatrist: Dr. Adams (2020-2023, stopped due to insurance change). Current psychiatrist: Dr. Smith (since January 2024, seen 3 times)”

The key is capturing provider continuity, recent contact, and any changes or gaps that explain current presentation.

Why This Information Matters

The treatment provider network reveals several things:

Engagement capacity: Long-standing relationships suggest ability to engage. Frequent provider changes may indicate personality dynamics, geographic instability, or treatment dissatisfaction.

Care coordination needs: Multiple prescribers require medication reconciliation. Fragmented care increases risk of conflicting advice or duplicated services.

Discharge planning: Knowing who will continue care after your evaluation determines whether recommendations can be implemented. A patient without outpatient providers needs different discharge planning than one with weekly therapy scheduled.

Collateral information sources: Current providers can offer longitudinal perspectives on symptoms, treatment response, and baseline functioning that transform your understanding of the case.

This foundation prepares you for the next component: understanding what actually happens in therapy and what psychotherapeutic approaches have been tried.

By mapping the treatment network, you’re identifying both the patient’s safety net and its weak points – information that directly shapes your risk formulation and discharge plan.

Next in this series: Part 5: Understanding Support Systems – Types of therapy, duration, frequency, and therapeutic benefit.

Previous post: Part 3: Psychiatric Hospitalization History – Gathering admission patterns and frequency.

Understanding Support Systems

This is Part 5 in our series on Past Psychiatric History. 
Read Part 4: Current Treatment Providers for the previous component.

Beyond formal healthcare providers, patients exist within networks of family, friends, and community supports that profoundly influence recovery. Additionally, information from these supports and from current providers offers perspectives your patient may not be able to provide themselves. Your job is to identify who comprises the support system and determine what collateral information may be valuable.

Learning Objectives
After reading this section, you should be able to:
• Identify key chart sources for existing family or community supports.
• Conduct structured interviews to elicit informal supports and assess support quality.
• Distinguish between emotional, practical, and crisis supports.
• Document support systems clearly and understand their relevance to risk assessment and discharge planning.

Start With Chart Review

Before interviewing the patient, review available documentation:

• Emergency contact information – Names, relationships, phone numbers
• Release of information forms – Who is authorized for communication?
• Previous clinical notes – References to involved family members, friends, or supports
• Social work assessments – Often document support systems in detail
• Legal documentation – Healthcare proxy, power of attorney, guardianship papers

Document who appears to be involved and in what capacity. This gives you starting points for the interview.

💡 Clinical Pearl: Pay attention to who brought the patient to the appointment or hospital. This person is likely a key support and potential collateral source.

Interview the Patient

After chart review, explore the patient’s support network and permission for collateral contact.

Identifying Informal Supports

Family involvement:

• “Is there family involved in helping you with your mental health care?”
• “Who in your family knows about your treatment?”
• “Does anyone help you remember appointments or medications?”

Friends and community:

• “Do you have close friends who support you?”
• “Are you involved in any support groups or community programs?”
• “Is there anyone outside of family who you’d want us to contact if needed?”

Living situation supports:

• “Who do you live with?”
• “Do your housemates or roommates know about your mental health treatment?”
• “Is anyone helping you manage daily tasks?”

Legal arrangements:

• “Do you have a healthcare proxy or power of attorney for medical decisions?”
• “Does anyone have guardianship or legal authority over your care?”

Assessing Support Quality and Involvement

Not all “supports” are actually supportive. Assess the quality:

• “How helpful has [person] been with your mental health?”
• “Do they understand what you’re going through?”
• “Have there been any conflicts with family or friends about your treatment?”
• “Has anyone been critical or unsupportive of you getting help?”

Understanding What Supports Provide

Different supports serve different functions:

Emotional support:

• Listening, validation, encouragement

Practical support:

• Transportation to appointments
• Help with medications
• Reminders about appointments
• Financial assistance

Crisis support:

• Who to call when struggling
• Safety planning involvement
• Emergency contacts

Ask:

“When things get difficult, who do you reach out to first?”

Current support people are often valuable sources of collateral information about longitudinal course, treatment response, and baseline functioning. However, obtaining and interpreting collateral information requires attention to consent, context, and reliability. *For detailed guidance on when to seek collateral information, how to obtain permission, what to ask, and how to interpret what you learn, see [Collateral Information](#).*

What to Document

Support system documentation:

• “Patient lives with sister who is supportive and aware of treatment. Sister provides transportation to appointments.”
• “Limited support system – estranged from family, no close friends. Lives alone.”
• “Mother is healthcare proxy. Attends appointments regularly and manages medications.”

Why This Information Matters

Support systems and collateral information serve multiple functions:

Discharge planning: Robust supports allow for more confident outpatient management, whereas limited supports may necessitate higher levels of care.

Safety assessment: Collateral sources may reveal concerning behaviors the patient minimizes or doesn’t recognize.

Treatment engagement: Involved, supportive family or friends improve treatment adherence and outcomes.

Longitudinal understanding: Providers and long-term supports offer perspective on what’s typical for this patient versus what represents change.

Understanding who comprises the support network and what information they can provide creates a more complete picture of the patient’s life, resources, and vulnerabilities.

Next in this series: Part 6: Psychotherapy History – Types of therapy tried, duration, and therapeutic benefit.

Previous post: Part 4: Current Treatment Providers – Identifying the formal treatment team.

How to Take a Psychotherapy History (And Why It Reveals Personality)

This is Part 6 in our series on Past Psychiatric History.
Read Part 5: Understanding Support Systems for the previous component.

Psychotherapy history reveals something distinct from medication or hospitalization history. It captures how a person has engaged in the work of psychological change, their ability to build trust, reflect on experience, and tolerate discomfort in relationships. Each therapy experience leaves a trace, whether it strengthened insight, ended abruptly, or failed to take hold at all.

Your goal in this part of the evaluation is to reconstruct those experiences in a structured way, identifying what types of therapy were attempted, how the patient participated, what helped or hindered progress, and what patterns emerge across time. Understanding those patterns does more than clarify treatment history; it provides a window into relational style, personality organization, and readiness for future therapy.

Learning Objectives

After reading this section, you should be able to:

• Identify relevant chart sources for previous psychotherapy records
• Gather structured information about prior therapy experiences
• Recognize engagement patterns that reflect personality and relational capacity
• Document psychotherapy history clearly and interpret it for treatment planning

Start With Chart Review

Before interviewing the patient, review available documentation for clues about previous therapy experiences:

Past mental health notes – Look for therapy types, frequency, duration, and clinician names. Previous psychiatric evaluations often summarize therapy history.

Discharge summaries – Inpatient notes sometimes document scheduled/previous outpatient psychotherapy or therapy engagement during hospitalization.

Prior psychological evaluations – Often list therapist names, describe therapy response, and note engagement quality.

Collateral information – Family members, case managers, or primary care providers may document therapy attendance and engagement patterns.

💡 Clinical Pearl: Therapy notes often reveal how patients interacted with providers. If multiple therapists document “limited engagement,” “frequent no-shows,” or “therapy discontinued after conflict,” this pattern may be diagnostically meaningful even before your interview.

Interview the Patient

After chart review, explore psychotherapy experiences directly with the patient. A psychotherapy history reveals something distinct from other interventions – it illuminates relational capacity, insight, and the patient’s ability to engage in psychological healing.

Opening Questions

Begin broadly to establish the overall therapy experience:

• “Have you ever been in therapy or counseling?”
• “Can you tell me about your experiences with therapy?”
• “What kinds of therapy have you tried?”

Information to Gather

For each significant therapy experience, explore the following dimensions:

Type and Duration

• “What kind of therapy was it?” (Individual, group, family, couples)
• “How long did you see this therapist?”
• “How often did you meet?” (Weekly, biweekly, monthly)

Content and Focus

• “What did you work on in therapy?”
• “What was the therapist’s approach or style?”
• “Did the therapist give you homework or specific exercises?”

Outcome and Experience

• “What was helpful about that therapy?”
• “What wasn’t helpful?”
• “Why did therapy end?” (Completed goals, moved, insurance issues, therapeutic rupture)

💡 Clinical Pearl: How therapy ended matters enormously. Planned endings suggest capacity for healthy separation and goal completion. Abrupt terminations, especially after conflict with the therapist, may suggest personality dynamics that will affect future therapeutic relationships.

Common Therapy Modalities

Patients rarely know technical terms. Help them identify therapy types by describing approaches. Clarifying the therapy type helps interpret what skills or insights a patient may have already developed and what gaps remain.

Cognitive Behavioral Therapy (CBT):

“Did your therapist focus on changing your thoughts and behaviors? Did you work on identifying negative thought patterns?”

Dialectical Behavior Therapy (DBT):

“Were you in therapy that taught skills like distress tolerance, emotion regulation, or mindfulness? Did you attend both individual and group sessions?”

Psychodynamic/Insight-Oriented Therapy:

“Did you explore your past and how childhood experiences affect your present? Did you talk about patterns in your relationships?”

Supportive Therapy:

“Was it more about having someone to talk to and get support from, rather than learning specific skills or techniques?”

Trauma-Focused Therapy (EMDR, Prolonged Exposure, CPT):

“Did you specifically work on traumatic memories? Did therapy involve revisiting difficult experiences in a structured way?”

Red Flags and Patterns

Patterns in therapy engagement often reveal more about personality structure and relational capacity than the therapy content itself. Watch for:

Multiple brief therapies: May indicate difficulty engaging, personality dynamics interfering with therapeutic relationships, practical barriers (transportation, finances), or repeated mismatches between patient needs and therapeutic approach.

Repeated therapeutic ruptures: A pattern of therapy ending after conflict with the therapist suggests potential for splitting, idealization/devaluation cycles, or difficulty tolerating the discomfort inherent in therapeutic work.

Long-term therapy with limited progress: May indicate that therapy provides support but not change, wrong modality for the condition, treatment-resistant pathology, or that the patient values the relationship over behavioral change.

Never engaged despite recommendations: Assess for practical barriers, beliefs about therapy effectiveness, cultural factors that stigmatize mental health treatment, or ambivalence about change.

Special Considerations

Therapy During Childhood/Adolescence

Therapy experienced in childhood often shapes later attitudes toward mental health treatment – either as a trusted refuge or as an imposed burden. These early experiences often color how adults later perceive therapists and therapy itself.

When patients report therapy as children, explore:

• Was it voluntary or mandated? (School-based, court-ordered, parent-initiated)
• What was the focus? (Behavior problems, trauma, family conflict)
• Did the patient understand why they were there?
• How did it end?

Mandated childhood therapy often leaves negative associations that affect adult treatment engagement and willingness to participate.

Family or Couples Therapy

These modalities add relational complexity. Explore:

• Who initiated the therapy?
• Who participated consistently? Who dropped out?
• What was the stated goal?
• Did it help or harm relationships?
• Is the patient still in contact with other participants?

🎯 When to Go Deeper: Therapy Ruptures

If a patient describes multiple therapies ending in conflict or dissatisfaction, this pattern becomes diagnostically important and should be explored thoughtfully.

Consider asking:

“I’m noticing you’ve mentioned that several therapy relationships ended after disagreements or feeling misunderstood. What tends to happen in your relationships with therapists over time?”

Naming the pattern collaboratively can itself be therapeutic and helps plan for similar dynamics in future treatment. This exploration provides critical information about:

• Transference patterns likely to emerge
• Countertransference risks for future therapists
• Need for specific therapeutic approaches (e.g., mentalization-based therapy for personality pathology)
• Realistic expectations for treatment duration and outcomes

What to Document

Your documentation should capture not just what therapy occurred, but the quality of engagement and meaningful patterns.

Why This Information Matters

A patient’s psychotherapy history reveals their capacity for introspection, relational stability, and treatment engagement. This information is essential for several clinical reasons:

Predicting Therapeutic Alliance: Patterns of therapy rupture, idealization, or premature termination often mirror broader personality organization and predict challenges in forming new therapeutic relationships.

Tailoring Treatment Recommendations: Understanding what has helped (or failed) before allows you to recommend therapy types aligned with the patient’s psychological readiness and learning style. A patient who thrived in structured CBT but struggled with open-ended psychodynamic therapy needs different recommendations than the reverse.

Anticipating Countertransference: When a patient has repeatedly experienced conflict with therapists, future clinicians need this information to recognize their own emotional reactions and maintain appropriate boundaries.

Formulating Personality Structure: The quality of therapy engagement – capacity to reflect, tolerate discomfort, maintain consistency, manage endings – provides rich information about personality organization that supplements formal diagnostic criteria.

Setting Realistic Expectations: A history of treatment resistance or dependency helps frame realistic timelines and goals for future interventions, preventing both patient and clinician frustration.

Psychotherapy history is not just a list of past treatments – it’s a window into how patients form relationships, manage vulnerability, and approach psychological change. This understanding directly shapes your formulation and guides future treatment planning.

Next in this series: Part 7 – Medication History: How to Identify Treatment Resistance and Avoid Repeating Failed Trials

Previous post: Part 5 – Understanding Support Systems

Medication History: How to Identify Treatment Resistance and Avoid Repeating Failed Trials

This is Part 7 in our series on Past Psychiatric History.
Read Part 6: Psychotherapy History – How to Assess Engagement and Relational Patterns for the previous component.

Having explored how relational interventions shape healing, we now turn to pharmacologic approaches: biological interventions targeting symptoms directly. Medication history reveals the patient’s unique pharmacological story: what has silenced symptoms, what has failed despite adequate trials, and what side effects have proven intolerable.

A detailed medication history is essential because it avoids repeating failures, builds on successes, identifies tolerability issues, reveals adherence patterns, assesses treatment resistance, and informs realistic expectations. How patients describe medication experiences also reveals cognitive style and engagement patterns that inform your formulation.

Learning Objectives

After reading this section, you should be able to:

• Identify relevant chart sources for previous medication trials
• Gather structured information about each medication trial including dose, duration, response, and tolerability
• Distinguish adequate trials from inadequate trials
• Recognize patterns of treatment resistance and side effect sensitivity
• Document medication history accurately at the level appropriate for each clinical scenario

Start With Chart Review

Before interviewing the patient, review available documentation for medication history:

Past medication lists – Look for psychiatric medications, doses, and dates. Note gaps that may indicate discontinuation periods.

Pharmacy fill records – Reveal actual adherence patterns. Multiple early refills or long gaps between fills provide adherence data the patient may not volunteer.

Prior psychiatric evaluations – Often include detailed medication trials with response and side effect information.

Discharge summaries – Document medication changes during hospitalizations, responses to acute interventions, and discharge regimens.

Laboratory records – Therapeutic drug monitoring (lithium, valproate levels), metabolic monitoring (weight, glucose, lipids), and genetic testing results (pharmacogenomic panels).

Consultation notes – Medical specialists often document psychiatric medication side effects (e.g., cardiology notes about QTc prolongation, endocrinology notes about metabolic effects).

💡 Clinical Pearl: Chart review identifies objective data about adherence, therapeutic doses, and documented side effects before the interview. Pharmacy records showing 90-day supplies picked up every 120 days reveal non-adherence the patient may not report.

Interview the Patient

After chart review, explore medication experiences directly with the patient. This conversation reveals not just what was tried, but how the patient understands their pharmacological journey.

Opening Questions

Start broadly to establish the medication history scope:

• “What psychiatric medications have you tried in the past?”
• “What medications are you currently taking?”
• “Have you ever taken medication for depression, anxiety, sleep, or other mental health concerns?”

For current medications:

• “What dose are you taking?”
• “How long have you been on this dose?”
• “How well is it working?”
• “Any side effects you’ve noticed?”

Information to Gather for Each Medication

For every medication tried, document these essential elements:

Basic Identification

• Medication name (generic and brand – patients often remember brand names)
• Indication (what it was prescribed for)
• Prescriber and treatment setting

Dosing Details

• Starting dose and final dose achieved
• Frequency of administration
• Duration of trial at therapeutic dose
• Whether dose was adequately titrated

Response

• Did it help? Which symptoms improved?
• How much improvement? (Percentage or descriptive scale)
• How quickly did it work?
• How long did benefit last?

Tolerability

• Any side effects experienced?
• Were they tolerable or intolerable?
• Did side effects improve over time?
• Did side effects lead to discontinuation?

Discontinuation

• Why was it stopped? (Lack of efficacy, side effects, practical reasons, feeling better)
• Who made the decision? (Patient, prescriber, collaborative)
• Was discontinuation gradual or abrupt?
• Any withdrawal symptoms?

💡 Clinical Pearl: How a medication was ended matters enormously. Medications stopped because “I felt better” differ from those stopped due to intolerable side effects or lack of response. The former suggests potential for relapse; the latter informs future medication selection.

Critical Concept: Adequate Trials

A medication trial is only meaningful if it was adequate. An adequate trial requires three elements:

Appropriate Dose – Within therapeutic range for the condition being treated. Subtherapeutic doses cannot be considered failed trials.

Sufficient Duration – Long enough for the medication to work:

• Antidepressants: 4 to 8 weeks at therapeutic dose
• Mood stabilizers: 3 to 6 months for full effect
• Antipsychotics: 2 to 4 weeks for acute symptoms, longer for negative symptoms
• Anxiolytics: 2 to 4 weeks for SSRIs/SNRIs; benzodiazepines work immediately

Good Adherence – Actually taking the medication as prescribed. Missing multiple doses weekly means the trial was not adequate.

💡 Clinical Pearl: Many patients report a medication “didn’t work” when they took subtherapeutic doses briefly. A patient who took sertraline 25 mg for 2 weeks has NOT had an adequate trial – they’ve demonstrated intolerance to initiation side effects, which differs from true non-response. Document whether trials were adequate, not just whether medications were tried.

Common Pitfalls in Medication History

🚩 Pitfall: Accepting “I’ve Tried Everything”

A patient reports they’ve “tried everything” and “nothing works.” Detailed questioning reveals multiple trials at subtherapeutic doses for insufficient durations, stopped due to side effects before reaching therapeutic window.

The lesson: This patient hasn’t “tried everything” – they’ve had multiple inadequate trials. Rather than moving to complex augmentation strategies, recommend an adequate trial at therapeutic dose with proper expectation-setting about initial side effects and time to benefit.

Always document:

• Whether trials were adequate
• Specific reasons for inadequacy (dose, duration, adherence)
• Whether the pattern suggests treatment resistance or treatment intolerance

Organizing Medication History by Class

For clarity in documentation and pattern recognition, organize medications by pharmacologic class:

Antidepressants – SSRIs, SNRIs, TCAs, MAOIs, bupropion, mirtazapine, others

Anxiolytics – Benzodiazepine receptor agonists, buspirone, gabapentin, hydroxyzine

Sleep Medications – Benzodiazepine receptor agonists, sedating antidepressants, melatonin, orexin antagonists, quetiapine

Mood Stabilizers – Lithium, valproate, carbamazepine, lamotrigine, oxcarbazepine

Antipsychotics – First-generation (typical) and second-generation (atypical)

Stimulants and ADHD Medications – Methylphenidate, amphetamines, atomoxetine, guanfacine

Side Effect Medicating Medications – Benztropine, Valbenazine, Deutetrabenazine

Substance Use Disorder Medications – Naltrexone, Acamprosate, Disulfiram, Suboxone, Methadone

This organization reveals patterns: “Patient has tried six SSRIs with minimal benefit but responded well to bupropion” suggests different pathophysiology than “Patient responded to multiple SSRIs but could not tolerate side effects.”

Special Considerations

Adherence Patterns

Explore not just what was prescribed but whether it was actually taken:

• “How consistent were you about taking it?”
• “Did you ever miss doses or stop taking it without telling your doctor?”
• “What made it hard to take the medication regularly?”

Patterns of non-adherence inform formulation and future treatment planning. Some patients stop medications when feeling better (lack of illness insight). Others stop due to side effects but don’t report this to prescribers. Some face practical barriers (cost, pharmacy access, complex regimens).

Medication-Induced Adverse Effects

Some patients have experienced serious adverse effects that profoundly shape willingness to try medications:

• Severe akathisia or dystonia
• Serotonin syndrome
• Lithium toxicity
• Neuroleptic malignant syndrome
• Severe weight gain (>20% of body weight)
• Sexual dysfunction leading to relationship problems
• Cognitive impairment affecting work or school

Document these carefully – they represent red lines the patient may not cross again. These experiences appropriately increase caution about future medication trials and require extensive informed consent and monitoring.

Electroconvulsive Therapy (ECT) History

If the patient has received ECT, document:

• When administered (dates of treatment course)
• Number of treatments in the series
• Electrode placement (bilateral, right unilateral, bitemporal)
• Response and duration of improvement
• Side effects experienced (memory impairment, cognitive effects, headache)
• Maintenance ECT (if applicable – frequency and ongoing response)

💡 Clinical Pearl: Patients who responded well to ECT previously are likely to respond again if depression recurs. This history is invaluable for treatment planning in severe, treatment-resistant depression. Prior ECT response is one of the strongest predictors of future ECT response.

Cognitive Style Revealed Through Medication Descriptions

How patients describe medication experiences reveals thinking patterns:

• Rigid, black-and-white thinking: “It didn’t work at all” vs. nuanced reflection “It helped my sleep but not my depression”
• Catastrophizing: “The side effects were unbearable” for mild, transient nausea
• Health anxiety: Detailed recall of every dose change and minor side effect
• Disengagement: Vague responses, inability to recall medication names or doses
• External locus of control: “The doctor kept changing my medications” vs. “We worked together to find the right one”

These patterns inform your understanding of personality structure, health literacy, and capacity for collaborative treatment planning.

What to Document

Your documentation should capture not just what medications were tried, but the quality of each trial and patterns that emerge.

Why This Information Matters

A patient’s medication history is far more than a list of drugs tried. It reveals their unique biological response profile, treatment resistance patterns, side effect vulnerabilities, and capacity for adherence. This information is essential for several critical clinical functions:

Avoiding Futile Repetition: Without detailed medication history, clinicians risk repeating failed trials. A patient who has completed adequate trials of five SSRIs is unlikely to respond to a sixth. Understanding this pattern directs treatment toward mechanistically different interventions – MAOIs, TCAs, augmentation strategies, or ECT – rather than cycling through similar medications indefinitely.

Building on Previous Success: Medications that worked before often work again. A patient who responded well to bupropion in the past but stopped it due to life circumstances may respond again. Knowing what has helped provides a pharmacological roadmap when symptoms recur.

Predicting Tolerability: Side effects that caused discontinuation previously will likely recur with rechallenge. A patient who developed severe akathisia on risperidone faces similar risk with other high-potency antipsychotics. This knowledge guides medication selection and monitoring intensity.

Assessing True Treatment Resistance: Multiple failed medication trials do not necessarily indicate treatment-resistant illness. Many apparent “failures” reflect inadequate trials – subtherapeutic doses, insufficient duration, or poor adherence. Distinguishing inadequate trials from true non-response fundamentally changes the treatment approach. True treatment resistance (multiple adequate trials without response) suggests more severe pathophysiology and warrants consideration of advanced interventions like ECT, esketamine, or specialized augmentation strategies.

Understanding Adherence Capacity: Patterns of medication adherence reveal critical information about illness insight, practical barriers, health literacy, and motivation for treatment. A patient who stops medications when feeling better lacks illness awareness. One who can’t afford medications faces practical barriers requiring social work intervention. Another who fears side effects needs extensive psychoeducation and close monitoring. These patterns inform not just what to prescribe, but how to support treatment adherence.

Informing Diagnostic Clarity: Medication response patterns sometimes clarify diagnosis. A patient diagnosed with unipolar depression who became manic on antidepressants may have bipolar disorder. One who responded robustly to stimulants for “depression” may have had unrecognized ADHD. Antipsychotic response at low doses sometimes suggests underlying psychotic process not apparent in initial presentation.

Medication history transforms from a rote checklist into a window on treatment resistance, biological vulnerabilities, and future treatment trajectories. A carefully gathered medication history turns patterns of pharmacologic response into actionable formulation, directly shaping evidence-based prescribing and realistic expectations for patients and families.

Next in this series: Part 8 – Substance Use History: Understanding Self-Medication and Comorbidity

Previous post: Part 6 – Psychotherapy History: How to Assess Engagement and Relational Patterns

Suicide Attempt History: Getting It Right Without Losing the Relationship

This is Part 8 in our series on Past Psychiatric History.
Read Part 7: Medication History – How to Identify Treatment Resistance and Avoid Repeating Failed Trials for the previous component.

Having explored pharmacologic interventions that shape recovery, we now turn to the most critical dimension of safety: understanding the patient’s relationship with death itself. Suicide history sits at the crossroads of safety and understanding. Each attempt represents a moment when distress overwhelmed all coping, when death seemed like the only escape. Understanding these moments is both a safety imperative and a window into the patient’s internal world.

Assessing suicide attempt history is one of the most critical components of any psychiatric evaluation. It enables risk stratification, lethality assessment, pattern identification, and safety planning. Beyond protecting the patient, asking compassionately about suicide strengthens rather than damages the therapeutic relationship. Your approach determines whether patients will be honest about the most vulnerable moments of their lives.

Learning Objectives

After reading this section, you should be able to:

• Identify key chart sources for prior suicide attempt documentation
• Gather structured data about method, timing, intent, and medical outcome for each attempt
• Differentiate lethality from intent and recognize protective factors
• Identify patterns across multiple attempts that inform prevention strategies
• Document suicide attempt history with clinical clarity and compassion

Start With Chart Review

Before interviewing the patient, review available documentation for suicide attempt history:

Emergency department records – Look for chief complaints like “overdose,” “self-harm,” “suicidal ideation,” or medical codes for intentional self-harm. Note method, medical treatment provided, and disposition.

Inpatient psychiatric records – Admission notes often detail the precipitating attempt, including circumstances, method, intent, and patient’s description of the event.

Discharge summaries – Document treatment course, risk assessment at discharge, safety planning, and follow-up recommendations after suicide attempts.

Prior psychiatric evaluations – Often include comprehensive suicide history with dates, methods, and outcomes of previous attempts.

Medical records from intensive care or trauma services – Reveal medical severity of attempts requiring advanced interventions (intubation, dialysis, surgical repair).

Safety plans and crisis response documents – Show what interventions were tried after previous attempts and what worked or didn’t work.

Collateral documentation – Family reports, case manager notes, or crisis team documentation may describe attempts the patient doesn’t remember or minimizes.

💡 Clinical Pearl: Chart review reveals objective severity data the patient may not recall or may minimize. A patient who says they “took some pills” may have required ICU admission for life-threatening overdose. Understanding medical facts before the interview helps calibrate your assessment and frame questions appropriately. This review ensures that when you speak with the patient, you begin informed rather than reactive.

Interview the Patient

After chart review, explore suicide attempt history directly with the patient. This conversation requires particular sensitivity, as many patients fear judgment, hospitalization, or loss of autonomy.

Creating Safety to Disclose

Many patients fear being honest about suicidal thoughts and behaviors. They worry about involuntary hospitalization, being judged, losing custody of children, losing jobs, or being seen as weak or manipulative. Your approach determines whether patients feel safe enough to be honest.

Frame questions with empathy and normalization:

• “Have there been times when things felt so overwhelming that you thought about ending your life?”
• “Many people who struggle with depression have thoughts about suicide. Has that been true for you?”
• “Have you ever done anything to try to end your life?”

Provide reassurance about confidentiality with honest limits:

• “I want you to feel comfortable being honest with me. Everything we discuss is confidential, with some important exceptions – if I’m concerned about immediate safety, we may need to make a plan together to keep you safe.”

Acknowledge the courage it takes to discuss this:

• “I appreciate you being willing to talk about this with me. I know these are difficult things to discuss.”

Opening Questions

Start with broad screening questions:

• “Have you ever tried to hurt yourself or end your life?”
• “Have there been times you’ve acted on thoughts of suicide?”
• “Tell me about times you’ve done something to try to die.”

Essential Information to Gather for Each Attempt

For every suicide attempt, explore these dimensions systematically:

Timing

• When did this happen? (Date or approximate timeframe)
• How old were you?
• How long ago was this?

Method

• What did you do?
• Can you walk me through exactly what happened?
• What did you use? (Medication name and amount, weapon type, height of fall, etc.)

Intent and Planning

• Did you plan this or was it impulsive? How long had you been thinking about it?
• Did you expect to die?
• Did you take steps to avoid being found? (Locked doors, chose isolated location, timed it when alone)
• Did you tell anyone beforehand or leave a note?
• How did you feel when you survived? (Relieved, disappointed, ambivalent)

Context and Precipitants

• What was happening in your life at that time?
• What made you feel like you couldn’t go on?
• Had you been using alcohol or drugs at the time?
• Were you in psychiatric treatment? Taking medications?
• Had anything changed recently? (Relationship loss, job loss, trauma, medication change)

Medical Severity

• What happened after? Who found you?
• Did you require medical treatment?
• Were you hospitalized? For how long?
• How serious were the injuries? (ICU admission, intubation, surgery, dialysis)

Aftermath and Reflection

• What happened after you were medically stable?
• Did you receive psychiatric treatment? (Inpatient, partial hospitalization, outpatient)
• How do you feel about it now, looking back?
• What kept you alive or helped you recover?
• What would you do differently if you felt that way again?

💡 Clinical Pearl: The ratio of intent to medical lethality is crucial for risk assessment. A patient who took 10 aspirin fully expecting to die demonstrates high suicidal intent despite low medical lethality. Conversely, a patient who impulsively took 50 pills “just to sleep” but didn’t want to die shows low intent despite high lethality. Both high intent and high lethality are concerning, but they require different prevention approaches. High intent with low lethality may reflect poor knowledge about lethality but serious wish to die. High lethality with low intent may reflect impulsivity, intoxication, or ambivalence.

Assessing Lethality and Intent

Understanding both the medical dangerousness of the method and the psychological intent to die provides a complete risk picture.

High-Lethality Methods

• Firearms
• Hanging or suffocation
• Jumping from significant height
• Severe overdoses (tricyclic antidepressants, opioids, acetaminophen in large quantities)
• Carbon monoxide poisoning
• Drowning in isolated locations

Lower-Lethality Methods

• Superficial cutting to arms or legs
• Small overdoses of over-the-counter medications (few pills)
• Low-dose overdoses of less dangerous medications

High Intent Indicators

• Detailed planning over days or weeks
• Final arrangements (wills, goodbye letters, giving away possessions)
• Efforts to avoid discovery (timing when alone, remote locations, locked doors)
• Disappointment or anger at survival
• Belief the method would be lethal

Low Intent Indicators

• Impulsive action with minimal planning
• Ambivalence about dying
• Relief at survival
• Actions taken in view of others or with high likelihood of discovery
• Recognition the method was unlikely to be lethal

🚩 Important Note: Never assume low-lethality methods indicate low risk. Patients may simply lack knowledge about lethality. A patient who takes 20 acetaminophen tablets thinking it won’t kill them may still have high suicidal intent. Similarly, superficial cutting can escalate to more lethal methods. Always assess intent separately from method.

Patterns Across Attempts

When patients have multiple suicide attempts, patterns often emerge that inform both formulation and prevention strategies.

Escalating Lethality

Multiple attempts with progressively more dangerous methods suggest increasing desperation and treatment resistance. This pattern requires urgent intervention and consideration of intensive treatment modalities.

Consistent Method

Repeated use of the same method may indicate strong method preference shaped by access, cultural factors, or perceived effectiveness. This pattern is critical for safety planning – restricting access to the preferred method becomes paramount.

Impulsive Attempts During Intoxication

Attempts that occur exclusively or primarily when intoxicated suggest substance use is a major risk factor. This pattern indicates need for substance use treatment as a suicide prevention strategy.

Attempts During Specific Triggers

Some patients attempt suicide consistently in response to particular triggers – relationship conflicts, anniversary dates, seasonal patterns, or medication changes. Identifying these triggers allows for targeted prevention during high-risk periods.

Attempts with Similar Precipitants

When attempts consistently follow certain life events (rejection, loss, humiliation), this reveals core psychological vulnerabilities. Treatment can then address these underlying sensitivities.

🎯 What Patterns Reveal: Multiple attempts don’t simply add up – they reveal qualitative patterns about coping capacity, impulsivity, substance use, and relationship with death. A patient with five impulsive attempts during intoxication has a fundamentally different clinical picture than someone with five carefully planned attempts while sober. The former needs addiction treatment and impulsivity management; the latter needs intensive psychiatric intervention for treatment-resistant illness and unremitting suicidal ideation. Identifying these themes transforms data points into insight for formulation and prevention.

Aborted and Interrupted Attempts

Not all suicide attempts are completed. Two types of near-attempts provide important risk information:

Aborted Attempts

The patient prepared to act but changed their mind at the last moment:

• “I had the gun in my hand but put it down.”
• “I stood at the edge of the bridge but stepped back.”
• “I had the pills in my hand but didn’t take them.”

Clinical significance: Aborted attempts indicate high risk (preparation occurred) but also reveal protective factors (something stopped the patient). Understanding what changed their mind provides crucial information for safety planning.

Interrupted Attempts

The patient began to act but someone or something intervened:

• “I was about to jump but someone walked by.”
• “I had started taking pills but my roommate came home.”
• “I was tying the rope but got a phone call.”

Clinical significance: Interrupted attempts show the patient was actively attempting suicide. The intervention was external, not an internal decision. This may indicate higher risk than aborted attempts because internal protective factors didn’t engage.

How to Ask About Near-Attempts

• “Have there been times you were planning or preparing to kill yourself but didn’t go through with it?”
• “Have there been times you were about to act but changed your mind or were stopped?”
• “What stopped you or changed your mind?”

These questions often reveal suicidal crises the patient doesn’t count as “real attempts” but which represent significant risk periods and protective factor information.

Special Considerations

Attempts in Childhood or Adolescence

Early suicide attempts shape adult relationship with suicide and treatment:

• Assess developmental context – what was happening in family, school, peer relationships
• Determine if attempt was understood as potentially lethal at the time
• Explore how family responded – supportive treatment vs. punishment vs. minimization
• Consider how early attempts influence current help-seeking and disclosure

Early attempts, especially in context of trauma or family dysfunction, may predict chronic suicidal ideation and repeated attempts across lifespan.

Non-Suicidal Self-Injury (NSSI)

Distinguish suicide attempts from self-injury without intent to die:

• NSSI typically involves superficial cutting for emotional regulation, not death
• Patients usually distinguish clearly: “I cut to feel better, not to die”
• However, NSSI increases suicide risk and can transition to attempts
• Document separately but recognize NSSI as important risk factor

Cultural and Religious Context

Cultural beliefs about suicide shape how patients describe and understand attempts:

• Some cultures stigmatize suicide heavily, affecting disclosure
• Religious beliefs about afterlife may influence attempt methods or interpretation
• Family shame may lead patients to minimize or conceal attempts
• Understanding cultural context helps interpret patient’s narrative

What to Document

Your documentation should capture both objective facts and the patient’s subjective experience, balancing clinical precision with compassionate language.

Why This Information Matters

Suicide attempt history is far more than a safety checklist. It reveals the patient’s relationship with death, their capacity to tolerate distress, the severity of their illness, and the effectiveness of their coping strategies. This information serves multiple essential clinical functions that directly shape care.

Risk Stratification and Safety Planning: Past suicide attempts are the single strongest predictor of future attempts and completed suicide. Understanding the number, timing, methods, and circumstances of previous attempts allows evidence-based risk assessment. A patient with multiple recent high-lethality attempts requires more intensive intervention than someone with a single remote low-lethality attempt. This history determines appropriate level of care, need for hospitalization, frequency of outpatient monitoring, and intensity of safety planning. Knowing a patient’s preferred method allows targeted means restriction – removing firearms, limiting medication quantities, addressing access to heights or bridges.

Pattern Recognition for Prevention: Patterns across attempts reveal modifiable risk factors. Attempts that occur exclusively when intoxicated indicate substance treatment is suicide prevention. Attempts following relationship conflicts suggest need for interpersonal skills or couples therapy. Attempts during mixed episodes point to need for mood stabilization. Attempts after medication changes warrant careful monitoring during future adjustments. Understanding these patterns allows clinicians to intervene preventively rather than reactively during the patient’s highest-risk moments.

Diagnostic Clarity: Suicide attempt history often clarifies diagnosis. Multiple impulsive attempts may suggest borderline personality disorder rather than recurrent depression. Attempts during distinct mood episodes support bipolar diagnosis. Psychotic content surrounding attempts points to schizophrenia spectrum illness. Command hallucinations prompting self-harm indicate need for antipsychotic treatment. The relationship between symptoms and suicidal behavior helps refine the diagnostic formulation.

Understanding Intent and Ambivalence: The distinction between intent and lethality reveals critical psychological information. High intent with low lethality may reflect poor knowledge about methods but genuine wish to die, warranting intensive psychiatric intervention. High lethality with low intent may indicate impulsivity, intoxication, or a “cry for help” that accidentally became medically serious. Some patients remain profoundly ambivalent about living, demonstrated by rescue behaviors (calling 911 after overdose) or survival actions (calling out for help while attempting). This ambivalence is a therapeutic foothold – something within the patient wants to live. Identifying and strengthening that part becomes central to treatment.

Identifying Protective Factors: Understanding what stopped aborted attempts or what helped recovery after attempts reveals protective factors to strengthen. Did religious beliefs intervene? Thoughts of family? Fear of pain? Therapeutic relationship? Future plans? These factors become anchors in safety planning and reasons for living to revisit during crises. A patient who aborted an attempt because “I thought about my daughter” needs treatment that strengthens that relationship and explores parenthood as meaning.

Strengthening Therapeutic Alliance: Asking about suicide attempts with genuine curiosity and compassion rather than fear or judgment communicates that the patient’s most desperate moments matter and can be understood. Patients often expect clinicians to be uncomfortable with suicide discussion or to respond punitively with hospitalization. When clinicians instead explore attempts with empathy, seeking to understand rather than control, trust deepens. This allows ongoing honest communication about suicidal thoughts, which is itself protective. Patients who believe they can tell their therapist about suicidal ideation without automatic hospitalization are more likely to disclose – and disclosure allows intervention.

Suicide attempt history transforms from a crisis-focused safety screening into a window on the patient’s suffering, coping capacity, illness trajectory, and potential for recovery. Gathering this history with depth and compassion transforms moments of crisis into opportunities for understanding and prevention.

Next in this series: Part 9 – Self-Harm History: Understanding the Distinction from Suicidal Behavior

Previous post: Part 7 – Medication History: How to Identify Treatment Resistance and Avoid Repeating Failed Trials

Understanding Self-Harm: Function, Pattern, and Treatment Implications

This is Part 9 in our series on Past Psychiatric History.
Read Part 8: Suicide Attempt History: Getting It Right Without Losing the Relationship for the previous component.

With suicide risk assessed, we turn to a related but distinct phenomenon: self-harm as coping mechanism. Self-harm often functions as the body’s language for unspoken distress, a physical outlet for overwhelming emotional pain. Unlike suicide attempts, self-harm typically serves to relieve tension, express anguish, or punish oneself rather than to end life.

Understanding self-harm requires careful assessment of intent, function, and pattern. Non-suicidal self-injury (NSSI) reveals critical information about emotion regulation capacity, distress tolerance, and underlying psychopathology. While the intent differs from suicide attempts, self-harm significantly increases future suicide risk and requires targeted therapeutic intervention.

Learning Objectives

After reading this section, you should be able to:

• Distinguish non-suicidal self-injury from suicide attempts based on intent and function
• Identify common self-harm methods and their clinical significance
• Assess the psychological functions self-harm serves for individual patients
• Recognize patterns that increase risk or indicate severity
• Document self-harm history accurately with attention to function and treatment implications

Start With Chart Review

Before interviewing the patient, review available documentation for self-harm history:

Emergency department records – Look for chief complaints involving lacerations, burns, or wounds described as “self-inflicted” or “intentional.” Note wound patterns, locations, and whether suicidal intent was documented.

Prior psychiatric evaluations – Search for terms like “cutting,” “self-injury,” “self-harm,” “superficial wounds,” or “non-suicidal self-injury.” Note whether function was assessed.

Inpatient psychiatric records – Often document self-harm behaviors observed during admission or restrictions placed due to self-harm risk.

School or college counseling records – May contain early documentation of self-harm, particularly in adolescents and young adults.

Medical records from primary care or dermatology – Sometimes document unexplained scars, burns, or wounds that raise concern for self-harm.

Collateral documentation – Family reports, therapist notes, or case manager observations may describe visible injuries or self-harm disclosures.

💡 Clinical Pearl: Even brief mentions of “scratching,” “minor cuts,” or “superficial wounds” in medical records may signal significant emotional dysregulation. The medical severity of injuries doesn’t always correlate with psychological severity. Always verify the context and intent behind any documented injuries.

Interview the Patient

After chart review, explore self-harm history directly with the patient. This requires creating safety for disclosure, as many patients feel shame about self-harm or fear judgment.

Opening Questions

Begin with direct but nonjudgmental screening:

• “Have you ever hurt yourself on purpose – like cutting, burning, or hitting yourself – but not to end your life?”
• “Some people hurt themselves when they’re overwhelmed as a way to cope. Has that been true for you?”
• “Have you ever engaged in self-harm or self-injury?”

Follow-Up Questions

If the patient endorses self-harm, explore systematically:

Methods Used

• “What ways have you hurt yourself?”
• “Have you tried different methods at different times?”

Timing and Frequency

• “When did you first start hurting yourself?”
• “How often does it happen now?”
• “When was the most recent time?”
• “Was there a period when it was more frequent?”

Function and Motivation

• “What does self-harm do for you?”
• “What are you feeling right before you hurt yourself?”
• “How do you feel afterward?”
• “What would happen if you didn’t do it?”

Severity and Medical Care

• “How severe are the injuries typically?”
• “Have you ever needed medical attention – stitches, wound care, burn treatment?”
• “Has self-harm ever been more dangerous than you intended?”

Context and Triggers

• “Are there specific situations or feelings that lead to self-harm?”
• “Does it happen more at certain times or places?”
• “Is anyone else usually aware when it happens?”

💡 Clinical Pearl: How patients describe the function of self-harm guides treatment selection. “I cut to release tension” suggests emotion regulation deficits requiring DBT skills. “I do it to punish myself” points to self-critical cognitions requiring cognitive therapy. “It helps me feel something when I’m numb” may indicate dissociation requiring trauma-focused treatment. Understanding function transforms self-harm from a behavior to be eliminated into a communication about underlying needs.

Distinguishing Self-Harm from Suicide Attempts

The fundamental distinction lies in intent, though this boundary can sometimes blur:

Non-Suicidal Self-Injury (NSSI)

Intent: Relieve emotional pain, regulate affect, express distress – not to die

Function:

• Affect regulation: Release tension, interrupt numbness
• Self-punishment: Express self-hatred or guilt
• Communication: Show others the depth of distress
• Sensation-seeking: Feel real or alive

Lethality: Usually low-lethality methods (superficial cutting, minor burns)

Patient’s Description: “I did it to feel better,” “It helps me cope,” “I needed to release the pressure”

Typical Pattern: Repeated episodes over time, relatively consistent severity

Suicide Attempt

Intent: End one’s life, escape existence

Function: Permanent solution to unbearable suffering

Lethality: Can range from low to very high

Patient’s Description: “I wanted to die,” “I thought it would kill me,” “I hoped I wouldn’t wake up”

Typical Pattern: May be single catastrophic event or escalating attempts

The Blurred Boundary

This distinction is not always clear-cut:

• Some self-harm carries unintended lethal risk (deep cuts near arteries, severe burns)
• Patients may engage in both NSSI and suicide attempts at different times
• Chronic self-harm can transition to suicidal behavior
• Ambivalence exists: “I didn’t want to die, but I didn’t care if I did”
• Impulsive escalation during self-harm episodes can become life-threatening

🚩 Important Note: Never assume that self-described “non-suicidal” self-injury carries no suicide risk. History of NSSI is itself a significant risk factor for future suicide attempts. The presence of self-harm always warrants careful suicide risk assessment, regardless of stated intent.

Common Self-Harm Methods

Document all forms of self-injury, as method diversity correlates with severity:

Cutting – Most common method; usually forearms, thighs, abdomen. Depth varies from superficial scratches to deep lacerations requiring sutures.

Burning – Using cigarettes, lighters, hot objects, or chemicals. Can cause significant scarring and infection risk.

Hitting or Bruising – Punching walls, hitting oneself, head-banging. May cause fractures, concussions, or internal injuries.

Scratching or Picking – Compulsive skin-picking, scratching until bleeding. Can become chronic and disfiguring.

Interfering with Wound Healing – Picking at scabs, reopening cuts. Maintains visible evidence of distress.

Hair-Pulling (Trichotillomania) – May serve self-harm function in some patients, though diagnostically distinct.

Other Methods – Swallowing dangerous objects, self-poisoning with non-lethal intent, excessive risk-taking.

💡 Clinical Pearl: Use of multiple methods is associated with more severe psychopathology and increased suicide attempt risk. A patient who engages in cutting, burning, and hitting represents higher clinical acuity than someone using a single method. Method escalation over time (superficial scratches progressing to deep cuts) suggests worsening emotion dysregulation.

Functions of Self-Harm

Understanding why patients self-harm is essential for treatment planning. Different functions require different interventions:

Affect Regulation

Description: “I do it to release tension,” “It helps calm me down,” “The pain distracts from emotional pain”

Psychological Mechanism: Self-harm provides temporary relief from overwhelming negative emotions through physiological mechanisms (endorphin release, arousal reduction) or psychological distraction.

Treatment Implications: Requires emotion regulation skills (DBT), alternative coping strategies, distress tolerance training.

Managing Numbness or Dissociation

Description: “I need to feel something,” “It makes me feel real,” “Cutting brings me back”

Psychological Mechanism: Self-harm generates sensation during dissociative states, providing grounding through physical pain.

Treatment Implications: Trauma-focused therapy, grounding techniques, treatment of dissociative symptoms.

Self-Punishment

Description: “I deserve it,” “I need to punish myself,” “I’m so bad I should suffer”

Psychological Mechanism: Physical pain expresses self-hatred, guilt, or shame. May provide sense of justice or atonement.

Treatment Implications: Cognitive therapy targeting self-critical beliefs, compassion-focused therapy, trauma processing if self-blame relates to abuse.

Communication and Validation

Description: “It shows people how much I’m hurting,” “Words aren’t enough,” “People take me seriously when they see it”

Psychological Mechanism: Visible wounds communicate internal distress. May elicit care, concern, or validation from others.

Treatment Implications: Communication skills training, assertiveness, identifying and expressing needs verbally, examining relationship patterns.

Sensation-Seeking or Experimentation

Description: “I was curious what it would feel like,” “I like watching myself bleed,” “It’s fascinating”

Psychological Mechanism: Novelty-seeking, fascination with injury, or reduced pain sensitivity.

Treatment Implications: Behavioral interventions, redirection to safer sensation-seeking activities, assessment for conduct disorder or psychopathy traits in severe cases.

Anti-Suicide Function

Description: “When I cut, I don’t feel like I need to kill myself,” “It prevents me from doing something worse”

Psychological Mechanism: Self-harm serves as alternative to suicide, providing relief that prevents escalation to lethal behavior.

Treatment Implications: Complex clinical picture requiring careful risk assessment. Treatment must provide alternative coping without removing the “safety valve” before other skills are in place.

Patterns That Increase Concern

Certain patterns in self-harm history warrant heightened clinical attention:

Multiple Methods – Associated with more severe psychopathology and higher suicide risk

Increasing Frequency – Suggests worsening emotion dysregulation or inadequate coping alternatives

Escalating Severity – Progression from superficial to deeper injuries indicates treatment urgency

Transition to Higher-Lethality Methods – Moving toward methods closer to suicide attempt methods (cutting near major vessels, more dangerous burns)

Impaired Judgment During Episodes – Self-harm while intoxicated or dissociated increases risk of unintended serious injury

Lack of Pain During Self-Harm – Suggests severe dissociation or emotional numbing

Self-Harm in Response to Specific Triggers – Identifies high-risk situations requiring targeted safety planning

Combination of NSSI and Suicide Attempts – Particularly concerning pattern indicating both chronic emotion dysregulation and acute suicide risk

Beyond these risk patterns, several contextual variables further shape assessment and treatment.

Special Considerations

Self-Harm in Adolescents

Self-harm often begins in adolescence, with prevalence peaking in mid-to-late teens:

• May be influenced by peer modeling or social contagion
• Often begins experimentally but can become entrenched coping pattern
• Family response (support vs. punishment) shapes help-seeking and disclosure
• Early intervention can prevent chronic self-harm patterns

Self-Harm in Context of Personality Disorders

Self-harm is particularly associated with borderline personality disorder but occurs across diagnoses:

• In BPD: Often serves multiple functions, linked to identity disturbance and relationship crises
• Pattern may be chronic and treatment-resistant without specialized intervention (DBT, MBT)
• Requires comprehensive treatment approach, not just symptom management

Self-Harm and Trauma History

Strong association between trauma exposure and self-harm:

• May serve to manage trauma-related dissociation, flashbacks, or emotional dysregulation
• Self-punishment function often linked to trauma-related shame or self-blame
• Trauma processing may reduce self-harm urges by addressing root cause

Digital and Social Media Influences

Contemporary considerations in self-harm assessment:

• Online communities may normalize self-harm or provide detailed methods
• Social media posting of injuries may serve communication or validation functions
• “Challenges” or social contagion effects in peer groups
• Can both increase risk (modeling, normalization) and provide support (recovery communities)

What to Document

Your documentation should capture methods, frequency, function, and clinical implications of self-harm.

Why This Information Matters

Self-harm history provides essential information that shapes diagnosis, risk assessment, and treatment planning in ways distinct from other psychiatric history components.

Risk Stratification: While self-harm is typically non-suicidal in intent, it significantly increases future suicide risk. Patients with NSSI history are 5 to 10 times more likely to attempt suicide than those without such history. Understanding self-harm patterns helps identify patients at elevated long-term suicide risk even when current suicidal ideation is absent. Additionally, some self-harm episodes carry unintended lethality – deep cuts near major vessels, severe burns, or self-harm during dissociation may result in death despite non-suicidal intent. Comprehensive risk assessment must account for both the direct risk of self-harm escalation and the statistical elevation in suicide attempt risk.

Diagnostic Clarification: Self-harm patterns inform diagnostic formulation. Chronic self-harm beginning in adolescence with emotion regulation function strongly suggests borderline personality disorder, particularly when combined with relationship instability and identity disturbance. Self-harm linked to dissociation and trauma triggers points toward PTSD or complex trauma presentations. Self-harm occurring exclusively during mood episodes may indicate bipolar disorder. The pattern, function, and context of self-harm provide diagnostic clues that supplement other clinical data.

Understanding Emotion Regulation: The presence and pattern of self-harm reveal critical information about distress tolerance and emotion regulation capacity. A patient who self-harms multiple times daily demonstrates severe emotion dysregulation requiring intensive intervention. One who self-harms only during specific triggers has more targeted skill deficits. The function self-harm serves – affect regulation, managing dissociation, self-punishment, communication – directly guides treatment selection. DBT targets affect regulation and distress tolerance. Trauma therapy addresses dissociation and self-blame. Communication skills training helps those using self-harm to express distress.

Treatment Planning: Self-harm history determines appropriate interventions. Patients with chronic self-harm typically require specialized treatments like DBT, which directly targets self-harm through skills training, behavior chain analysis, and crisis management. Standard supportive therapy often fails with chronic self-harm, while evidence-based interventions show strong efficacy. Understanding what has helped reduce self-harm previously (medications, therapy modalities, environmental changes) guides current treatment recommendations. If self-harm persists despite multiple interventions, this suggests need for intensive treatment like residential DBT or day treatment programs.

Safety Planning: Knowing self-harm methods, triggers, and patterns allows concrete safety planning. A patient who cuts when alone at night needs specific plans for evening hours. One who self-harms in the bathroom may benefit from supervised bathroom use during high-risk periods in inpatient settings. Understanding preferred methods allows means restriction – removing razors, locking up lighters, limiting access to medications. Identifying warning signs (specific emotions, thoughts, situations) enables earlier intervention before self-harm occurs.

Monitoring Treatment Progress: Self-harm frequency and severity serve as measurable treatment outcomes. Reduction from daily to weekly self-harm indicates treatment progress. Transition from deep cuts requiring medical care to superficial scratches shows improved control. Documentation of patterns over time allows objective assessment of whether treatment is working. Persistent high-frequency self-harm despite treatment suggests need for intervention adjustment, medication optimization, or higher level of care.

Understanding self-harm transforms it from a behavior to be eliminated into a communication about suffering, a marker of emotion dysregulation, and a guide for therapeutic intervention. Self-harm assessment reveals not just what patients do, but why they do it – and that understanding becomes the foundation for effective treatment.

Next in this series: Part 10 – Trauma History: Creating Safety for Disclosure

Previous post: Part 8 – Suicide Attempt History: Getting It Right Without Losing the Relationship

Trauma History: How to Ask Without Re-Traumatizing

This is Part 10 in our series on Past Psychiatric History.
Read Part 9: Understanding Self-Harm: Function, Pattern, and Treatment Implications for the previous component.

From physical expressions of pain, we turn to the source: the experiences that fracture sense of safety and forever alter how one moves through the world. Trauma reorganizes both memory and meaning; eliciting it safely helps restore both. Trauma isn’t just what happened – it’s what that experience did to the person’s sense of safety, their ability to trust, their relationship with their own body.

Trauma exposure is central to psychiatric assessment because it carries essential diagnostic implications for PTSD and dissociative disorders, determines treatment selection for trauma-focused therapies, contextualizes many symptoms that make sense only within trauma framework, shapes the therapeutic relationship through understanding trust difficulties and boundaries, and identifies ongoing trauma exposure requiring immediate intervention. The challenge lies in balancing two needs: gathering sufficient information to understand trauma’s impact while avoiding retraumatization by pushing too hard for details or moving too fast.

Learning Objectives

After reading this section, you should be able to:

• Identify key diagnostic and treatment implications of trauma history
• Conduct an initial trauma assessment that avoids retraumatization
• Differentiate childhood, adult, and medical trauma categories
• Recognize dissociative or avoidance responses during trauma assessment
• Document trauma history accurately while maintaining patient safety and dignity

Start With Chart Review

Before discussing trauma directly with the patient, review existing records for prior documentation:

Prior psychiatric evaluations – Look for references to abuse, assault, combat exposure, accidents, or phrases like “trauma history,” “PTSD,” or “childhood adversity.”

Medical records – Emergency department notes may document injuries from assault, domestic violence screenings, or treatment for trauma-related conditions.

Surgical or hospitalization records – May describe circumstances of injuries, accidents, or violence-related admissions.

Prior therapy notes – Often indicate trauma-focused treatment (CPT, PE, EMDR), PTSD diagnosis, or trauma processing work.

Child protective services or legal documentation – May contain reports of abuse, neglect, or witnessed violence if available in records.

Discharge summaries – Psychiatric hospitalizations often document trauma history as part of comprehensive assessment.

Collateral documentation – Family member reports, case manager notes, or school records may reference trauma exposure.

💡 Clinical Pearl: Reviewing existing documentation first helps you pace questioning appropriately and avoid forcing new disclosures about events already recorded elsewhere. If the chart documents “childhood sexual abuse by family member,” you can acknowledge this without requiring the patient to re-disclose painful details. This demonstrates respect for their narrative and reduces retraumatization risk.

Interview the Patient

After chart review, approach trauma assessment with careful attention to pacing, safety, and patient control. The initial evaluation is usually not the time for detailed trauma processing – that’s the work of ongoing therapy. Your job is to identify that trauma occurred, understand its general nature and timing, assess current safety, screen for trauma-related symptoms, and make appropriate referrals.

Creating Safety for Disclosure

Before asking about trauma, establish the frame and give the patient control:

Provide context and control:

• “I’m going to ask about some difficult experiences. You can always say ‘I’d prefer not to answer that right now.’”
• “We don’t need details today – I just want to understand generally what you’ve been through.”
• “You’re in control of what you share and how much detail you provide.”

Normalize trauma responses:

• “Many people who’ve experienced trauma develop nightmares, feeling on edge, or avoiding reminders. These are normal responses to abnormal events.”
• “It’s common for trauma survivors to have difficulty trusting others or feeling safe, even in safe environments.”

Be direct but gentle:

• “Have you experienced something that felt traumatic or life-threatening?”
• “Many of my patients have been through difficult or scary experiences. Has that been true for you?”

💡 Clinical Pearl: You don’t need every detail in the initial evaluation. Simply knowing “childhood sexual abuse occurred” is often sufficient for initial treatment planning. Details can emerge in trauma-focused therapy when safety and trust are established. Pushing for specifics prematurely can retraumatize patients and damage the therapeutic alliance before it’s formed.

Opening Questions

Use general screening questions to establish whether trauma exposure exists:

• “Have you experienced events that felt traumatic or life-threatening?”
• “Have you ever been physically or sexually assaulted?”
• “Have you witnessed violence or death?”
• “Have you been in serious accidents or natural disasters?”
• “Have you experienced combat or war-related trauma?”

Follow-Up Questions for Identified Trauma

If trauma is endorsed, gather essential information without demanding graphic details:

Timing and Duration

• “When did this happen?” or “How old were you?”
• “Was this a single event or did it happen over time?”
• “How long did it continue?”

General Nature

• “Can you tell me generally what type of trauma this was?” (Allow patient to choose level of detail)
• “Was this something that happened to you, or something you witnessed?”

Perpetrator Relationship (if interpersonal trauma)

• “Was this someone you knew?”
• “What was your relationship to this person?”

Current Safety

• “Are you currently safe from this person/situation?”
• “Is there ongoing risk or exposure?”
• “Do you feel safe where you’re living now?”

Impact and Trauma-Related Symptoms

• “How has this affected you?”
• “Do you have nightmares or intrusive memories about it?”
• “Do you avoid things that remind you of what happened?”
• “Do you feel on edge or jumpy?”

Previous Treatment

• “Have you received treatment for trauma before?”
• “What kinds of therapy have you tried?”
• “What was helpful or not helpful?”

What NOT to Ask

Certain types of questions risk retraumatization and should be avoided in initial assessment:

Avoid graphic details: Don’t ask for minute-by-minute accounts or press for sensory details (“What did it feel like?” “Describe exactly what happened”). This level of detail is for trauma processing therapy, not screening.

Avoid “why” questions that imply blame: Never ask “Why didn’t you leave?” “Why didn’t you tell someone?” “Why didn’t you fight back?” These questions suggest the patient is responsible for the trauma or failed to protect themselves adequately.

Avoid multiple repetitions: Don’t make patients recount trauma repeatedly in the same session or across multiple providers if documentation can be shared.

Avoid disbelief or minimization: Never respond with “That doesn’t sound so bad” or “Are you sure that’s what happened?” Trust the patient’s experience.

Types of Trauma to Assess

Trauma exists across multiple categories, each with distinct clinical implications:

Childhood Trauma

Physical abuse – Hitting, beating, burning, or other physical harm inflicted by caregivers

Sexual abuse – Any sexual contact or exploitation by adults or significantly older children

Emotional abuse – Persistent verbal attacks, humiliation, threats, or emotional manipulation

Neglect – Failure to provide basic needs (food, shelter, medical care, supervision, emotional support)

Witnessing domestic violence – Observing violence between parents or caregivers

Sudden loss of caregiver – Death, abandonment, or separation from primary attachment figures

Multiple foster placements – Repeated disruptions in care and attachment

Childhood medical trauma – Painful procedures, life-threatening illness, or frightening hospitalizations

Childhood trauma is particularly impactful because it occurs during critical developmental periods, often involves betrayal by trusted caregivers, and shapes fundamental assumptions about safety, trust, and self-worth.

Adult Trauma

Physical assault – Being attacked, beaten, or physically injured by another person

Sexual assault – Rape, attempted rape, or sexual coercion as an adult

Combat exposure – Military service in war zones, witnessing casualties, killing in combat

Serious accidents – Motor vehicle accidents, workplace injuries, near-drowning

Natural disasters – Hurricanes, earthquakes, floods, fires

Witnessing death or injury – Seeing others die or be seriously harmed, including mass casualty events

Life-threatening illness – Cancer diagnosis, heart attack, stroke, or other medical crises

Intimate partner violence – Ongoing physical, sexual, or psychological abuse by romantic partners

Medical Trauma

Traumatic medical procedures – Painful interventions, especially in childhood or without adequate preparation

Severe illness requiring intensive treatment – Cancer treatment, organ transplants, extended ICU stays

Painful or frightening healthcare experiences – Difficult births, emergency surgeries, medical complications

Medical neglect or abuse – Inadequate pain management, boundary violations, or disrespectful treatment by providers

Medical trauma is often overlooked but can profoundly affect healthcare engagement, treatment adherence, and anxiety in medical settings.

Special Considerations

Multiple and Complex Trauma

Many patients have experienced multiple traumas across their lifespan. Complex trauma – repeated interpersonal trauma, especially beginning in childhood – has distinct clinical presentations including difficulty with affect regulation, relationship instability, dissociation, negative self-concept, and somatization.

You don’t need to catalog every traumatic event in the initial evaluation. Instead, understand:

• Childhood vs. adult trauma – Childhood trauma often has more pervasive developmental impact
• Single incident vs. chronic trauma – Chronic trauma typically causes more complex symptoms
• Interpersonal vs. non-interpersonal – Interpersonal trauma (especially by trusted figures) affects relationships and trust more profoundly
• Whether trauma is ongoing – Current unsafe situations require immediate safety planning

🚩 Red Flag: If a patient is currently in an unsafe environment (ongoing domestic violence, active abuse of children in the home, homelessness in dangerous conditions), safety planning becomes the immediate priority. Documentation should trigger appropriate interventions – safety planning, domestic violence resources, child protective services reporting if mandated, housing assistance.

Dissociation During Assessment

Some trauma survivors dissociate when discussing trauma – they may become emotionally distant, appear “spaced out,” lose track of time, or seem to be staring through you.

If you notice dissociation:

• Slow down the interview pace
• Help ground the patient: “Can you feel your feet on the floor?” “Look around and name five things you can see.”
• Offer to pause: “I notice you seem far away. Would you like to take a break?”
• Provide reassurance: “You’re safe here. We can stop talking about this.”
• Don’t push for more trauma details if the patient is dissociating

🧠 Understanding Dissociation: Dissociation is a protective response to overwhelming experience. During trauma, dissociation allowed survival by separating the person from unbearable physical or emotional pain. In assessment, discussing trauma can trigger this same protective mechanism. Recognizing and responding to dissociation demonstrates trauma-informed care and builds trust.

Cultural Considerations in Trauma Assessment

Cultural factors shape both trauma exposure and willingness to disclose:

• Some cultures emphasize family privacy and loyalty, making disclosure of family violence difficult
• Immigration-related trauma (persecution, dangerous border crossings, family separation) may not be recognized as traumatic by patients who view it as “normal” for their circumstances
• Historical trauma (genocide, slavery, colonization) affects communities across generations
• Some cultures lack vocabulary for concepts like “trauma” or “PTSD”
• Stigma around sexual violence varies widely across cultures

Adapt your assessment to cultural context while maintaining thoroughness in screening for trauma exposure.

What to Document

Your documentation should identify trauma exposure clearly without recording graphic detail. Focus on scope, timing, and clinical implications.

Why This Information Matters

Trauma history is not simply another section of the psychiatric evaluation – it provides essential context that transforms how we understand symptoms, formulate diagnoses, and design treatment. Its significance extends across multiple clinical domains.

Diagnostic Clarity and Symptom Reframing: Many psychiatric symptoms look completely different when understood through a trauma lens. Hypervigilance initially appearing as “paranoia” makes sense as adaptive scanning for danger after assault. Emotional numbness misinterpreted as “depression” may actually be dissociative detachment from overwhelming trauma memories. Relationship instability framed as “personality disorder” often reflects learned mistrust from childhood betrayal. Trauma history doesn’t excuse symptoms, but it explains them – and that explanation fundamentally changes treatment approach. Rather than viewing the patient as “disordered,” we recognize adaptive responses to abnormal circumstances that have outlived their protective function.

Treatment Selection and Prognosis: Trauma history directly determines treatment recommendations. PTSD requires trauma-focused therapies (Prolonged Exposure, Cognitive Processing Therapy, EMDR) as first-line interventions – approaches with strong evidence base but requiring specialized training. Complex trauma may need phase-based treatment: establishing safety and affect regulation before trauma processing. Without trauma history, clinicians may provide generic supportive therapy that doesn’t address core pathology, resulting in persistent symptoms despite treatment. Understanding trauma also sets realistic expectations: therapy for trauma-related conditions often takes months to years, not weeks.

Understanding the Therapeutic Relationship: Trauma survivors often struggle with trust, authority, boundaries, and emotional closeness – all central to therapeutic relationships. A patient with childhood abuse by a parent-aged perpetrator may have difficulty trusting an older therapist. Someone with medical trauma may fear psychiatric treatment. Understanding trauma history allows clinicians to anticipate relationship challenges, normalize them, and work through them rather than pathologizing the patient as “resistant” or “difficult.” When a patient misses appointments after disclosing trauma, this might reflect avoidance (trauma symptom) rather than poor motivation – and that distinction changes the clinical response.

Safety Assessment and Planning: Ongoing trauma exposure requires immediate intervention that supersedes other treatment planning. A patient currently experiencing domestic violence needs safety resources before trauma processing therapy. Child abuse disclosures may trigger mandatory reporting. Unsafe housing situations require addressing before assuming patient can engage in outpatient treatment. Additionally, past trauma increases risk for future trauma – trauma survivors are at higher risk for revictimization, requiring safety planning and psychoeducation about risk reduction.

Connecting Biology and Biography: Trauma doesn’t just create psychological distress – it changes brain structure and function. Chronic trauma affects the developing brain, altering stress response systems, emotion regulation capacity, and memory consolidation. Understanding trauma helps explain why some patients don’t respond to standard treatments, why they might have poor medication adherence (medical mistrust from medical trauma), or why they dissociate in session. This knowledge prevents blaming patients for treatment challenges and instead guides adaptations to meet their needs.

Therapeutic Validation: Simply acknowledging trauma and its impact can be profoundly therapeutic. Many trauma survivors have been told to “get over it,” that “it wasn’t that bad,” or that they should “move on.” A clinician who takes trauma seriously, understands its lasting effects, and validates the patient’s experience provides corrective emotional experience. This validation itself reduces shame, normalizes symptoms, and instills hope that healing is possible.

Gathering trauma history with depth and compassion transforms it from a required screening question into an opportunity for understanding the patient’s entire narrative. Trauma provides context that connects symptoms to survival, reframes pathology as adaptation, and opens pathways to evidence-based healing.

Next in this series: Substance Use History

Previous post: Part 9 – Understanding Self-Harm: Function, Pattern, and Treatment Implications

PPH Documentation Templates & Reference Checklist

Appendix A: Quick-Reference Checklist for PPH Data Points

Use this checklist to ensure comprehensive coverage:

□ Past Psychiatric Diagnosis

• Previous diagnoses and who made them
• Context and timing
• Confirmation status
• Missed or co-occurring disorders

□ Hospitalization History

• Total number of admissions
• Dates of first and most recent
• Hospital names and locations
• Voluntary vs. involuntary status
• Length of stay patterns
• Reasons for admission
• State hospital admissions (if any)
• Discharge dispositions
• Pattern recognition

□ Current Caregivers

• Current psychiatrist/prescriber
• Current therapist
• Case manager or coordinator
• Primary care physician
• Other specialists
• Last appointment dates
• Next appointment dates
• Recent changes in care intensity

□ Psychotherapy History

• Types tried (CBT, DBT, psychodynamic, etc.)
• Duration of each
• What was/wasn’t helpful
• How therapies ended
• Patterns across relationships
• Current therapy status

□ Medication History

• All psychiatric medications tried
• Doses and durations
• Response to each
• Side effects and tolerability
• Reasons for discontinuation
• Adequacy of trials
• Current medications
• ECT history (if applicable)

□ Suicide Attempt History

• Number of attempts
• Timing of each
• Methods used
• Intent and planning
• Medical treatment required
• Triggers and context
• Aborted/interrupted attempts
• Current suicidal ideation status

□ Self-Harm History

• History of NSSI
• Methods used
• Age at onset
• Current frequency
• Function of self-harm
• Severity of injuries
• Current status

□ Trauma History

• Types experienced
• Timing and duration
• Current safety status
• Trauma-related symptoms
• Previous trauma-focused treatment

Appendix B: Sample Documentation Templates

Template 1: Comprehensive PPH Note

PAST PSYCHIATRIC HISTORY:

Diagnoses: Patient reports diagnoses of [list]. [Diagnosis 1] was made by [provider type] in [year/timeframe]. [Diagnosis 2] diagnosed by [provider] after [context]. No history of [relevant ruled-out conditions].

Hospitalizations: [Number] lifetime psychiatric hospitalizations. First admission [year] at [location] for [reason]. Most recent admission [date] at [hospital] for [reason], length of stay [X days], discharged to [disposition]. [State hospital admissions if applicable]. Pattern suggests [revolving door/escalating severity/treatment resistance].

Current Treatment Team:

• Psychiatry: Dr. [Name], seen [frequency], last appointment [date], next scheduled [date]
• Therapy: [Name, credentials], seen [frequency], last [date]
• PCP: Dr. [Name] at [practice]

Psychotherapy: Previous therapy includes [modalities/durations]. Patient reports [what was helpful]. Currently [in therapy/not in therapy].

Medication Trials:

• Antidepressants: [List with doses, durations, responses]
• Mood Stabilizers: [Same format]
• Antipsychotics: [Same format]

Note: [Number] adequate trials without significant response, suggesting treatment-resistant depression.

Suicide Attempts: [Number] lifetime attempts. Most recent [date] via [method], requiring [medical treatment]. [Intent, planning, triggers]. [Current SI status].

Self-Harm: [History with methods, frequency, function, current status OR “Denies history of NSSI”]

Trauma: Reports [trauma type] at age [X]. [Current safety]. Endorses [trauma symptoms]. [Previous trauma treatment status].

Template 2: Brief PPH for Established Patient

PPH: [X] prior hospitalizations, most recent [month/year]. Diagnoses include [list]. Currently followed by Dr. [Name] (psychiatry) and [Name] (therapy). Current medications: [list with doses]. [X] lifetime suicide attempts, most recent [year]. History of [trauma type]. See full PPH in [date] for details.

Template 3: EMR-Friendly Problem List Format

Past Psychiatric History:

• Diagnoses: MDD (recurrent, severe), GAD, PTSD
• Hospitalizations: 4 lifetime (2015, 2018, 2022, 2024-current)
• Providers: Dr. Smith (psychiatry, monthly), Jane Doe LCSW (weekly therapy)
• Medications: Multiple SSRI/SNRI trials, partial response to venlafaxine
• Safety: 2 prior SAs (2015, 2022), currently denies SI
• Trauma: Childhood sexual abuse, EMDR in progress

Template 4: Quick Charting Summary Table

Template 5: Resident vs. Attending Documentation Comparison

Resident-Level Documentation (Learning):

PPH: Patient has depression and anxiety. Has been hospitalized before. 

Currently sees a therapist and takes medications. Has had suicidal 

thoughts in the past. History of trauma.

Attending-Level Documentation (Comprehensive):

PPH: Patient carries diagnoses of MDD (recurrent, severe) and GAD, both 

established by outpatient psychiatrist Dr. Jones after 2-year longitudinal 

assessment (2018-2020). Four lifetime psychiatric hospitalizations: first 

at age 28 (2018) for suicidal ideation, most recent discharge yesterday 

(3-week admission for SI with plan, involuntary status, discharged improved 

on medication changes). Currently followed by Dr. Jones (psychiatry, monthly) 

and Sarah Smith LCSW (weekly CBT for 3 years). Medication trials include 

4 adequate SSRI trials without response, currently on venlafaxine 225mg 

with partial benefit. One prior suicide attempt (2022, overdose requiring 

ICU admission, high intent). History of childhood physical abuse age 5-12, 

currently safe, endorses hypervigilance and nightmares, engaged in trauma-

focused therapy.

Key Differences:

• Attending version specifies WHO made diagnoses and WHEN
• Details hospitalization pattern and legal status
• Names providers with frequency and duration
• Documents medication trial adequacy
• Describes suicide attempt lethality and intent
• Contextualizes trauma with current safety

Appendix C: Collateral Information Workflow

When to Seek Collateral Information

Particularly valuable when:

• Patient has limited recall or insight
• Diagnostic uncertainty exists
• Treatment resistance is present
• Safety concerns are elevated
• Significant gaps exist in history
• Patient gives permission or it’s clinically necessary

Sources of Collateral Information

Clinical sources:

• Previous treatment providers
• Hospital discharge summaries
• Outpatient clinic notes
• Emergency department records
• Primary care records

Personal sources:

• Family members
• Close friends
• Legal guardians
• Case managers
• Residential program staff

How to Request Records

For recent hospitalizations:

1. Obtain patient consent (or document clinical necessity)
2. Get specific hospital name, location, approximate dates
3. Contact medical records immediately

• Fax: Most reliable for urgent requests
• Phone: For clarification and follow-up
• Portal: For some integrated systems

1. Request: “Discharge summary for [Patient Name, DOB] admitted approximately [dates]”
2. Follow up in 3-5 business days if not received
3. Document in chart: “Records requested from [hospital] on [date]”

For outpatient records:

1. Obtain patient consent with specific provider names
2. Contact provider’s office with written request
3. Specify: “Treatment notes for [Patient Name, DOB] covering dates [range]”
4. May need to pay copying fees
5. Allow 30 days for fulfillment
6. Document request and follow-up attempts

How to Speak with Current Providers

Before calling:

• Obtain patient consent
• Have specific questions prepared
• Review what you already know

During the call:

• Introduce yourself and your role
• Confirm they’re able to discuss the patient
• Ask focused questions:
• “What’s been your understanding of their diagnosis?”
• “What treatments have been most/least helpful?”
• “Have you had concerns about safety?”
• “What’s been their pattern of engagement?”
• Thank them and offer reciprocal information sharing

After the call:

• Document conversation in medical record
• Include: Date, who you spoke with, key information
• Note any discrepancies with patient’s report
• Plan how to integrate into formulation

Integrating Collateral Information

Reconcile discrepancies:

• Patient report vs. collateral information
• Different providers’ perspectives
• Documentation vs. verbal reports

Consider context:

• Who is providing information and their relationship
• When the information was gathered
• What the informant’s motivations might be

Use to enhance, not replace:

• Collateral supplements your assessment
• Direct patient interview remains primary
• Multiple perspectives create fuller picture

Template Documentation

Collateral Information Obtained:

Spoke with Dr. [Name], patient’s outpatient psychiatrist of [duration], on [date]. Dr. [Name] reports patient followed since [year] for [diagnoses]. Medication trials have included [list]. Patient has shown [pattern]. Provider expressed concern about [specific issues]. This information is consistent with/differs from patient’s self-report in the following ways: [describe].

Reviewed discharge summary from [Hospital] dated [date]. Summary indicates admission for [reason], length of stay [duration], treatment included [interventions], discharged on [medications], disposition [where]. Documented diagnosis: [diagnoses].

Discrepancies between sources noted and will be clarified. Collateral information suggests [clinical significance].

References

Core Textbooks

1. Carlat DJ. The Psychiatric Interview. 5th ed. Philadelphia, PA: Wolters Kluwer; 2023.
2. Shea SC. Psychiatric Interviewing: The Art of Understanding. 3rd ed. Philadelphia, PA: Elsevier; 2017.
3. MacKinnon RA, Michels R, Buckley PJ. The Psychiatric Interview in Clinical Practice. 3rd ed. Washington, DC: American Psychiatric Publishing; 2015.
4. Robinson DJ. Three Spheres: A Psychiatric Interviewing Primer. Rapid Psychler Press; 2000.
5. Sims A. Symptoms in the Mind: An Introduction to Descriptive Psychopathology. 4th ed. Saunders Elsevier; 2003.
6. Fish FJ, Hamilton M. Fish’s Clinical Psychopathology: Signs and Symptoms in Psychiatry. 3rd ed. Bristol, UK: Wright; 1985.

Practice Guidelines & Foundational Frameworks

1. Silverman JJ, Galanter M, Jackson-Triche M, et al. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults. Am J Psychiatry. 2015;172(8):798–802. doi:10.1176/appi.ajp.2015.1720501.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text revision (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022.
3. Bland DA, Lambert K, Raney L. Resource Document on Risk Management and Liability Issues in Integrated Care Models. Washington, DC: American Psychiatric Association; 2013.
4. Hamdi NR, Cutler MJ, Hollon SD, et al. APA guidelines on evidence-based psychological practice in health care. Am Psychol Assoc. 2021.
5. Arias-Reynoso M, Bell JL, Blueford P, et al. _Management of First-Episode Psychosis and Schizophrenia (SCZ)._Washington, DC: Department of Veterans Affairs; 2023.
6. Bahraini N, Bodie C, Brenner LA, et al. _Assessment and Management of Patients at Risk for Suicide._Washington, DC: Department of Veterans Affairs; 2024.
7. American Academy of Addiction Psychiatry. Core Competencies for Use of Collaborative Care in the Treatment of Substance Use Disorders (Guidance). American Academy of Addiction Psychiatry; 2024.
8. Battles J, Azam I, Grady M, Reback K. Advances in Patient Safety and Medical Liability. Rockville, MD: Agency for Healthcare Research and Quality; 2017.
9. Brasel KJ, deRoon-Cassini TA, Bernard A, et al. Best Practices Guidelines: Screening and Intervention for Mental Health Disorders and Substance Use and Misuse in the Acute Trauma Patient. Chicago, IL: American College of Surgeons; 2022.
10. Brookman RR, Committee on Adolescent Health Care. Mental Health Disorders in Adolescents. Washington, DC: American College of Obstetricians and Gynecologists; 2017.

Interviewing, History-Taking, and Communication

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3. Smith PC, Araya-Guerra R, Bublitz C, et al. Missing clinical information during primary care visits. _JAMA._2005;293(5):565–571. doi:10.1001/jama.293.5.565.
4. Barsky AJ. Forgetting, fabricating, and telescoping: The instability of the medical history. _Arch Intern Med._2002;162(9):981–984. doi:10.1001/archinte.162.9.981.
5. Levy AG, Scherer AM, Zikmund-Fisher BJ, et al. Prevalence of and factors associated with patient nondisclosure of medically relevant information to clinicians. JAMA Netw Open. 2018;1(7):e185293. doi:10.1001/jamanetworkopen.2018.5293.
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7. Haidet P, Paterniti DA. “Building” a history rather than “taking” one: A perspective on information sharing during the medical interview. Arch Intern Med. 2003;163(10):1134–1140. doi:10.1001/archinte.163.10.1134.
8. Savander ÉE, Voutilainen L, Hintikka J, Peräkylä A. What to take up from the patient’s talk? The clinician’s responses to the patient’s self-disclosure of their subjective experience in the psychiatric intake interview. Front Psychiatry. 2024;15:1352601. doi:10.3389/fpsyt.2024.1352601.
9. Laws MB, Lee Y, Taubin T, Rogers WH, Wilson IB. Factors associated with patient recall of key information in ambulatory specialty care visits: Results of an innovative methodology. PLoS One. 2018;13(2):e0191940. doi:10.1371/journal.pone.0191940.
10. Dreicer JJ, Parsons AS, Rencic J. The diagnostic medical interview. Med Clin North Am. 2022;106(4):601–614. doi:10.1016/j.mcna.2022.01.005.

Readmission and Continuity of Care

Smith TE, Haselden M, Corbeil T, et al. Relationship between continuity of care and discharge planning after hospital psychiatric admission. Psychiatr Serv. 2020;71(1):75–78. doi:10.1176/appi.ps.201900233.

Berardelli I, Sarubbi S, Rogante E, et al. Exploring risk factors for re-hospitalization in a psychiatric inpatient setting: A retrospective naturalistic study. BMC Psychiatry. 2022;22(1):821. doi:10.1186/s12888-022-04472-3.

Donisi V, Tedeschi F, Wahlbeck K, Haaramo P, Amaddeo F. Pre-discharge factors predicting readmissions of psychiatric patients: A systematic review of the literature. BMC Psychiatry. 2016;16(1):449. doi:10.1186/s12888-016-1114-0.

Baeza FLC, da Rocha NS, Fleck MPA. Readmission in psychiatry inpatients within a year of discharge: The role of symptoms at discharge and post-discharge care in a Brazilian sample. Gen Hosp Psychiatry. 2018;51:63–70. doi:10.1016/j.genhosppsych.2017.11.008.

Virtanen M, Peutere L, Härmä M, Ropponen A. Factors associated with readmissions in psychiatric inpatient care: A prospective cohort study based on hospital registers. BMC Psychiatry. 2024;24(1):734. doi:10.1186/s12888-024-06193-1.

Fonseca Barbosa J, Gama Marques J. The revolving door phenomenon in severe psychiatric disorders: A systematic review. Int J Soc Psychiatry. 2023;69(5):1075–1089. doi:10.1177/00207640221143282.

Leppänen J, Kieseppä V, Eskelinen S, et al. Clinical predictors of readmission to psychiatric inpatient care: A 20-year follow-up study of former adolescent inpatients. Psychiatry Res. 2025;351:116606. doi:10.1016/j.psychres.2025.116606.

Sfetcu R, Musat S, Haaramo P, et al. Overview of post-discharge predictors for psychiatric re-hospitalisations: A systematic review. BMC Psychiatry. 2017;17(1):227. doi:10.1186/s12888-017-1386-z.

Del Favero E, Montemagni C, Villari V, Rocca P. Factors associated with 30-day and 180-day psychiatric readmissions: A snapshot of a metropolitan area. Psychiatry Res. 2020;292:113309. doi:10.1016/j.psychres.2020.113309.

Silva M, Antunes A, Loureiro A, et al. Factors associated with length of stay and readmission in acute psychiatric inpatient services in Portugal. Psychiatry Res. 2020;293:113420. doi:10.1016/j.psychres.2020.113420.

Mascayano F, Haselden M, Corbeil T, et al. Patient-, hospital-, and system-level factors associated with 30-day readmission after psychiatric hospitalization. J Nerv Ment Dis. 2022;210(10):741–746. doi:10.1097/NMD.0000000000001529.

Biringer E, Hartveit M, Sundfør B, Ruud T, Borg M. Continuity of care as experienced by mental health service users: A qualitative study. BMC Health Serv Res. 2017;17(1):763. doi:10.1186/s12913-017-2719-9.

Petkari E, Kaselionyte J, Altun S, Giacco D. Involvement of informal carers in discharge planning and transition between hospital and community mental health care: A systematic review. _J Psychiatr Ment Health Nurs._2021;28(4):521–530. doi:10.1111/jpm.12701.

Haselden M, Corbeil T, Tang F, et al. Family involvement in psychiatric hospitalizations: Associations with discharge planning and prompt follow-up care. Psychiatr Serv. 2019;70(10):860–866. doi:10.1176/appi.ps.201900028.

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Caffeine

1. van Dam RM, Hu FB, Willett WC. Coffee, caffeine, and health. N Engl J Med. 2020;383(4):369-378. doi:10.1056/NEJMra1816604.
2. Liu C, Wang L, Zhang C, et al. Caffeine intake and anxiety: a meta-analysis. Front Psychol. 2024;15:1270246. doi:10.3389/fpsyg.2024.1270246.
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Tobacco

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Cannabis

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10. Rittiphairoj T, Leslie L, Oberste JP, et al. High-concentration delta-9-tetrahydrocannabinol cannabis products and mental health outcomes: a systematic review. Ann Intern Med. 2025. doi:10.7326/ANNALS-24-03819.
11. Hines LA, Freeman TP, Gage SH, et al. Association of high-potency cannabis use with mental health and substance use in adolescence. JAMA Psychiatry. 2020;77(10):1044-1051. doi:10.1001/jamapsychiatry.2020.1035.
12. Kapler S, Adery L, Hoftman GD, et al. Assessing evidence supporting cannabis harm reduction practices for adolescents at clinical high-risk for psychosis: a review and clinical implementation tool. Psychol Med. 2023:1-11. doi:10.1017/S0033291723002994.
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14. Sagar KA, Gruber SA. The complex relationship between cannabis use and mental health: considering the influence of cannabis use patterns and individual factors. CNS Drugs. 2025;39(2):113-125. doi:10.1007/s40263-024-01148-2.
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17. Hill KP, Gold MS, Nemeroff CB, et al. Risks and benefits of cannabis and cannabinoids in psychiatry. Am J Psychiatry. 2022;179(2):98-109. doi:10.1176/appi.ajp.2021.21030320.
18. de Bode N, Kroon E, Sznitman SR, Cousijn J. The differential effects of medicinal cannabis on mental health: a systematic review. Clin Psychol Rev. 2025;118:102581. doi:10.1016/j.cpr.2025.102581.

Vaping

1. Overbeek DL, Kass AP, Chiel LE, Boyer EW, Casey AMH. A review of toxic effects of electronic cigarettes/vaping in adolescents and young adults. Crit Rev Toxicol. 2020;50(6):531-538. doi:10.1080/10408444.2020.1794443.
2. Wold LE, Tarran R, Crotty Alexander LE, et al. Cardiopulmonary consequences of vaping in adolescents: a scientific statement from the American Heart Association. Circ Res. 2022;131(3):e70-e82. doi:10.1161/RES.0000000000000544.
3. Park JA, Crotty Alexander LE, Christiani DC. Vaping and lung inflammation and injury. Annu Rev Physiol. 2022;84:611-629. doi:10.1146/annurev-physiol-061121-040014.
4. Stefaniak AB, LeBouf RF, Ranpara AC, Leonard SS. Toxicology of flavoring- and cannabis-containing e-liquids used in electronic delivery systems. Pharmacol Ther. 2021;224:107838. doi:10.1016/j.pharmthera.2021.107838.
5. Rose JJ, Krishnan-Sarin S, Exil VJ, et al. Cardiopulmonary impact of electronic cigarettes and vaping products: a scientific statement from the American Heart Association. Circulation. 2023;148(8):703-728. doi:10.1161/CIR.0000000000001160.
6. Traboulsi H, Cherian M, Abou Rjeili M, et al. Inhalation toxicology of vaping products and implications for pulmonary health. Int J Mol Sci. 2020;21(10):3495. doi:10.3390/ijms21103495.
7. Jonas A. Impact of vaping on respiratory health. BMJ. 2022;378:e065997. doi:10.1136/bmj-2021-065997.
8. Braymiller JL, Barrington-Trimis JL, Leventhal AM, et al. Assessment of nicotine and cannabis vaping and respiratory symptoms in young adults. JAMA Netw Open. 2020;3(12):e2030189. doi:10.1001/jamanetworkopen.2020.30189.
9. Hernandez ML, Burbank AJ, Alexis NE, et al. Electronic cigarettes and their impact on allergic respiratory diseases: a work group report of the AAAAI Environmental Exposures and Respiratory Health Committee. J Allergy Clin Immunol Pract. 2021;9(3):1142-1151. doi:10.1016/j.jaip.2020.12.065.
10. Clendennen SL, Smith J, Sumbe A, et al. Symptoms of depression and anxiety and subsequent use of nicotine and THC in electronic cigarettes. Subst Use Misuse. 2023;58(5):591-600. doi:10.1080/10826084.2023.2177110.
11. Chung J, Stjepanović D, Cheng B, et al. Cannabis vaping and mental health: the association of Δ-9-tetrahydrocannabinol and cannabidiol with anxiety and depressive symptoms—findings from the United States National Youth Tobacco Survey (2021-2023). Addiction. 2025. doi:10.1111/add.70218.
12. Watson CV, Alexander DS, Oliver BE, Trivers KF. Substance use among adult marijuana and nicotine e-cigarette or vaping product users, 2020. Addict Behav. 2022;132:107349. doi:10.1016/j.addbeh.2022.107349.
13. McClure EA, Piper ME, Crotty Alexander LE, et al. Effects of inhaled tobacco and cannabis co-use on respiratory health and tobacco cessation: an official American Thoracic Society research statement. Am J Respir Crit Care Med. 2025;211(11):2021-2042. doi:10.1164/rccm.202507-1792ST.
14. Boakye E, Obisesan OH, Uddin SMI, et al. Cannabis vaping among adults in the United States: prevalence, trends, and association with high-risk behaviors and adverse respiratory conditions. Prev Med. 2021;153:106800. doi:10.1016/j.ypmed.2021.106800.

Sedative Hypnotic

1. Brunner E, Chen CYA, Klein T, et al. The joint clinical practice guideline on benzodiazepine tapering: considerations when benzodiazepine risks outweigh benefits. American College of Medical Toxicology; 2024. Practice Guideline.
2. Brunner E, Chen CYA, Klein T, et al. The joint clinical practice guideline on benzodiazepine tapering: considerations when benzodiazepine risks outweigh benefits. American Society of Addiction Medicine; 2025. Practice Guideline.
3. Alvarez J, Angelino AF, Aviles O, et al. Guidelines for managing substance withdrawal in jails. American Society of Addiction Medicine; 2023. Practice Guideline.
4. Department of Veterans Affairs. Management of Substance Use Disorder (SUD). Department of Veterans Affairs; 2021. Practice Guideline.
5. Soyka M. Treatment of benzodiazepine dependence. N Engl J Med. 2017;376(12):1147-1157. doi:10.1056/NEJMra1611832.
6. Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med. 2003;348(18):1786-1795. doi:10.1056/NEJMra020617.
7. Robertson S, Peacock EE, Scott R. Benzodiazepine use disorder: common questions and answers. Am Fam Physician. 2023;108(3):260-266.
8. Soong C, Burry L, Cho HJ, et al. An implementation guide to promote sleep and reduce sedative-hypnotic initiation for noncritically ill inpatients. JAMA Intern Med. 2019;179(7):965-972. doi:10.1001/jamainternmed.2019.1196.
9. Steinman MA. Alternative treatments to selected medications in the 2023 American Geriatrics Society Beers Criteria®. J Am Geriatr Soc. 2025;73(9):2657-2677. doi:10.1111/jgs.19500.
10. Lorvick J, Hemberg JL, Browne EN, et al. Ecological momentary assessment study of same-hour polysubstance use among people who use opioids and additional substances. Drug Alcohol Depend. 2025;269:112582. doi:10.1016/j.drugalcdep.2025.112582.
11. Tori ME, Larochelle MR, Naimi TS. Alcohol or benzodiazepine co-involvement with opioid overdose deaths in the United States, 1999-2017. JAMA Netw Open. 2020;3(4):e202361. doi:10.1001/jamanetworkopen.2020.2361.
12. Haber PS. Identification and treatment of alcohol use disorder. N Engl J Med. 2025;392(3):258-266. doi:10.1056/NEJMra2306511.
13. Alvanzo A, Kleinschmidt K, Kmiec JA, et al. Clinical practice guideline on alcohol withdrawal management. American Society of Addiction Medicine; 2020. Practice Guideline.

Hallucinogens

1. Barber GS, Dike CC. Resource Document on Ethical and Practical Implications of Psychedelics in Psychiatry. American Psychiatric Association; 2022. Practice Guideline.
2. Hutchison KE, Hooper JF, Karoly HC. Psilocybin outside the clinic. JAMA Psychiatry. 2025. doi:10.1001/jamapsychiatry.2025.3038.
3. Ford H, Fraser CL, Solly E, et al. Hallucinogenic persisting perception disorder: a case series and review of the literature. Front Neurol. 2022;13:878609. doi:10.3389/fneur.2022.878609.
4. Doyle MA, Ling S, Lui LMW, et al. Hallucinogen persisting perceptual disorder: a scoping review covering frequency, risk factors, prevention, and treatment. Expert Opin Drug Saf. 2022;21(6):733-743. doi:10.1080/14740338.2022.2063273.
5. Simonsson O, Goldberg SB, Chambers R, et al. Psychedelic use and psychiatric risks. Psychopharmacology (Berl). 2025;242(7):1577-1583. doi:10.1007/s00213-023-06478-5.
6. Ricci V, Ciavarella MC, Marrangone C, et al. Modern perspectives on psychoses: dissociation, automatism, and temporality across exogenous and endogenous dimensions. Front Psychiatry. 2025;16:1543673. doi:10.3389/fpsyt.2025.1543673.
7. Myran DT, Pugliese M, Xiao J, et al. Emergency department visits involving hallucinogen use and risk of schizophrenia spectrum disorder. JAMA Psychiatry. 2025;82(2):142-150. doi:10.1001/jamapsychiatry.2024.3532.
8. Griswold KS, Del Regno PA, Berger RC. Recognition and differential diagnosis of psychosis in primary care. Am Fam Physician. 2015;91(12):856-863.
9. McIntyre RS, Kwan ATH, Mansur RB, et al. Psychedelics for the treatment of psychiatric disorders: interpreting and translating available evidence and guidance for future research. Am J Psychiatry. 2025;182(1):21-32. doi:10.1176/appi.ajp.20230902.
10. Tabaac BJ, Shinozuka K, Arenas A, et al. Psychedelic therapy: a primer for primary care clinicians—historical perspective and overview. Am J Ther. 2024;31(2):e97-e103. doi:10.1097/MJT.0000000000001727.
11. Yao Y, Guo D, Lu TS, et al. Efficacy and safety of psychedelics for the treatment of mental disorders: a systematic review and meta-analysis. Psychiatry Res. 2024;335:115886. doi:10.1016/j.psychres.2024.115886.
12. Wang E, Mathai DS, Gukasyan N, Nayak S, Garcia-Romeu A. Knowledge, attitudes, and concerns about psilocybin and MDMA as novel therapies among U.S. healthcare professionals. Sci Rep. 2024;14(1):28022. doi:10.1038/s41598-024-78736-1.
13. U.S. Food and Drug Administration. Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book). U.S. Food and Drug Administration.
14. Hinkle JT, Graziosi M, Nayak SM, Yaden DB. Adverse events in studies of classic psychedelics: a systematic review and meta-analysis. JAMA Psychiatry. 2024;81(12):1225-1235. doi:10.1001/jamapsychiatry.2024.2546.
15. Hosein MM, Reid MJ, Walser S, et al. Considerations and cautions for the integration of psilocybin into routine clinical care: a consensus statement from the US National Network of Depression Centers’ Task Group on Psychedelics and Related Compounds. EClinicalMed. 2025;89:103517. doi:10.1016/j.eclinm.2025.103517.
16. De Gregorio D, Aguilar-Valles A, Preller KH, et al. Hallucinogens in mental health: preclinical and clinical studies on LSD, psilocybin, MDMA, and ketamine. J Neurosci. 2021;41(5):891-900. doi:10.1523/JNEUROSCI.1659-20.2020.
17. Barnett BS, Greer GR. Psychedelic psychiatry and the consult-liaison psychiatrist: a primer. J Acad Consult Liaison Psychiatry. 2021;62(4):460-471. doi:10.1016/j.jaclp.2020.12.011.
18. Carroll KM. The profound heterogeneity of substance use disorders: implications for treatment development. Curr Dir Psychol Sci. 2021;30(4):358-364. doi:10.1177/09637214211026984.
19. Strang J, Babor T, Caulkins J, et al. Drug policy and the public good: evidence for effective interventions. Lancet. 2012;379(9810):71-83. doi:10.1016/S0140-6736(11)61674-7.
20. Dike C, Briz L, Fadus M, et al. Resource Document on Ethics at the Interface of Religion, Spirituality, and Psychiatric Practice. American Psychiatric Association; 2021. Practice Guideline.
21. Chwyl C, Wilson-Poe AR, Hoffman KA, et al. Building standards of psychedelic care: qualitative examination of expert perspectives on safety, inclusion, and accountability. Int J Drug Policy. 2025:104938. doi:10.1016/j.drugpo.2025.104938.

Inhalant

1. Berling I, Isbister GK. Rare but relevant: hydrocarbons and sudden sniffing syndrome. Addiction. 2025. doi:10.1111/add.70082.
2. Sandau KE, Funk M, Auerbach A, et al. Update to practice standards for electrocardiographic monitoring in hospital settings: a scientific statement from the American Heart Association. Circulation. 2017;136(19):e273-e344. doi:10.1161/CIR.0000000000000527.
3. Cao D, Arens AM, Chow SL, et al. Part 10: adult and pediatric special circumstances of resuscitation: 2025 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2025;152(16_suppl_2):S578-S672. doi:10.1161/CIR.0000000000001380.
4. Ford JB, Sutter ME, Owen KP, Albertson TE. Volatile substance misuse: an updated review of toxicity and treatment. Clin Rev Allergy Immunol. 2014;46(1):19-33. doi:10.1007/s12016-013-8371-1.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text revision (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022.
6. Jupina M, Weleff J, Harp J, Anand A. Cognitive, imaging, and psychiatric changes associated with chronic toluene use: case report and literature review. J Addict Dis. 2024;42(4):556-566. doi:10.1080/10550887.2023.2229735.
7. Kerester S, Bloom J, Schwartz L, et al. Alkyl nitrite (“poppers”) exposures in the US. JAMA Netw Open. 2025;8(7):e2523408. doi:10.1001/jamanetworkopen.2025.23408.
8. Tardelli VS, Martins SS, Fidalgo TM. Differences in use of inhalants among sexual minorities in the USA in 2015-2018. Addict Behav. 2021;115:106789. doi:10.1016/j.addbeh.2020.106789.
9. Cruz SL, Bowen SE. The last two decades on preclinical and clinical research on inhalant effects. Neurotoxicol Teratol. 2021;87:106999. doi:10.1016/j.ntt.2021.106999.
10. Berling I, Chiew A, Brown J. Poisonings from hydrocarbon inhalant misuse in Australia. Addiction. 2023;118(7):1370-1375. doi:10.1111/add.16166.
11. Anderson CE, Loomis GA. Recognition and prevention of inhalant abuse. Am Fam Physician. 2003;68(5):869-874.
12. Lubman DI, Yücel M, Lawrence AJ. Inhalant abuse among adolescents: neurobiological considerations. Br J Pharmacol. 2008;154(2):316-326. doi:10.1038/bjp.2008.76.
13. Nguyen J, O’Brien C, Schapp S. Adolescent inhalant use prevention, assessment, and treatment: a literature synthesis. Int J Drug Policy. 2016;31:15-24. doi:10.1016/j.drugpo.2016.02.001.
14. Karaca G, Hatipsoylu E, Ekmekci A, et al. Toluene inhalant addiction and cardiac functions in young adults: a comparison of electrocardiographic and echocardiographic parameters. Clin Cardiol. 2024;47(11):e70037. doi:10.1002/clc.70037.
15. Yücel M, Takagi M, Walterfang M, Lubman DI. Toluene misuse and long-term harms: a systematic review of the neuropsychological and neuroimaging literature. Neurosci Biobehav Rev. 2008;32(5):910-926. doi:10.1016/j.neubiorev.2008.01.006.

OTC abuse

1. Here are the new citations from this list, excluding anything you already had:
2. Chadi N, Walker-Harding L. Nonmedical use of controlled medications by adolescents and young adults: clinical report. Pediatrics. 2024;154(6):e2024069298. doi:10.1542/peds.2024-069298.
3. Windhab LG, Gastberger S, Hulka LM, et al. Dextromethorphan abuse among opioid-dependent patients. Clin Neuropharmacol. 2020;43(5):127-133. doi:10.1097/WNF.0000000000000403.
4. Schifano F, Chiappini S, Miuli A, et al. Focus on over-the-counter drugs’ misuse: a systematic review on antihistamines, cough medicines, and decongestants. Front Psychiatry. 2021;12:657397. doi:10.3389/fpsyt.2021.657397.
5. Benotsch EG, Koester S, Martin AM, et al. Intentional misuse of over-the-counter medications, mental health, and polysubstance use in young adults. J Community Health. 2014;39(4):688-695. doi:10.1007/s10900-013-9811-9.
6. Seelen-de Lang B, Jong C, Hutschemaekers G, Didden R, Noorthoorn E. TAPS-tool reveals severe under detection of substance use problems in patients with severe mental illness. PLoS One. 2024;19(7):e0305142. doi:10.1371/journal.pone.0305142.
7. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352(11):1112-1120. doi:10.1056/NEJMra041867.
8. Tong ST, Polak KM, Weaver MF, et al. Screening for psychotherapeutic medication misuse in primary care patients: comparing two instruments. J Am Board Fam Med. 2019;32(2):272-278. doi:10.3122/jabfm.2019.02.180172.
9. Shekho D, Mishra R, Kamal R, et al. Polypharmacy in psychiatry: an in-depth examination of drug-drug interactions and treatment challenges. Curr Pharm Des. 2024;30(21):1641-1649. doi:10.2174/0113816128297170240513105418.
10. Lessenger JE, Feinberg SD. Abuse of prescription and over-the-counter medications. J Am Board Fam Med. 2008;21(1):45-54. doi:10.3122/jabfm.2008.01.070071.
11. Dutta S, Buciuc AG, Barry P, Padilla V. A narrative review on toxidromes in the psychiatric population: implications for overdose prevention. J Clin Med. 2025;14(17):6160. doi:10.3390/jcm14176160.
12. Mosca A, Chiappini S, Mancusi G, et al. Over-the-counter psychosis: a systematic review of the misuse of antihistamines, cough medicines, and decongestants and the risk of developing psychosis. Curr Neuropharmacol. 2025;23(8):956-973. doi:10.2174/011570159X344365250114064248.
13. Patnode CD, Perdue LA, Rushkin M, et al. Screening for unhealthy drug use: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2020;323(22):2310-2328. doi:10.1001/jama.2019.21381.
14. Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, Mitchell AA. Recent patterns of medication use in the ambulatory adult population of the United States: the Slone Survey. JAMA. 2002;287(3):337-344. doi:10.1001/jama.287.3.337.
15. Stanojević-Ristić Z, Mrkić I, Ćorac A, et al. Healthcare professionals’ knowledge and behaviors regarding drug–dietary supplement and drug–herbal product interactions. Int J Environ Res Public Health. 2022;19(7):4290. doi:10.3390/ijerph19074290.
16. Ben-Arye E, Halabi I, Attias S, Goldstein L, Schiff E. Asking patients the right questions about herbal and dietary supplements: cross cultural perspectives. Complement Ther Med. 2014;22(2):304-310. doi:10.1016/j.ctim.2014.01.005.
17. Steinman MA, Hanlon JT. Managing medications in clinically complex elders: “there’s got to be a happy medium”. JAMA. 2010;304(14):1592-1601. doi:10.1001/jama.2010.1482.
18. Volkow ND, McLellan AT. Opioid abuse in chronic pain—misconceptions and mitigation strategies. N Engl J Med. 2016;374(13):1253-1263. doi:10.1056/NEJMra1507771.
19. Kowalchuk A, Gonzalez SJ, Zoorob RJ. Substance misuse in adults: a primary care approach. Am Fam Physician. 2024;109(5):430-440.
20. Goodman CW, Brett AS. A clinical overview of off-label use of gabapentinoid drugs. JAMA Intern Med. 2019;179(5):695-701. doi:10.1001/jamainternmed.2019.0086.
21. McNeilage AG, Browne E, Nielsen S, Ashton-James CE, Murnion B. Healthcare practitioner and other professionals’ perspectives on gabapentinoid misuse and dependence: a systematic review of qualitative studies. Eur J Pain. 2025;29(9):e70116. doi:10.1002/ejp.70116.
22. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624-1645. doi:10.1001/jama.2016.1464.
23. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain—United States, 2022. MMWR Recomm Rep. 2022;71(3):1-95. doi:10.15585/mmwr.rr7103a1.
24. Blanco C, Volkow ND. Management of opioid use disorder in the USA: present status and future directions. Lancet. 2019;393(10182):1760-1772. doi:10.1016/S0140-6736(18)33078-2.
25. Ellis MS, Xu KY, Tardelli VS, et al. Gabapentin use among individuals initiating buprenorphine treatment for opioid use disorder. JAMA Psychiatry. 2023;80(12):1269-1276. doi:10.1001/jamapsychiatry.2023.3145.
26. Batki S, Ciccarone D, Hadland SE, et al. Management of Stimulant Use Disorder. American Academy of Addiction Psychiatry; 2023. Practice Guideline.

Designer Drugs

1. Ricci V, Chiappini S, Martinotti G, Maina G. Novel psychoactive substances and psychosis: a comprehensive systematic review of epidemiology, clinical features, neurobiology, and treatment. Neurosci Biobehav Rev. 2025:106384. doi:10.1016/j.neubiorev.2025.106384.
2. Prete MM, Feitosa GTB, Ribeiro MAT, Fidalgo TM, Sanchez ZM. Adverse clinical effects associated with the use of synthetic cannabinoids: a systematic review. Drug Alcohol Depend. 2025;272:112698. doi:10.1016/j.drugalcdep.2025.112698.
3. Baumann MH, Solis E, Watterson LR, et al. “Bath salts,” “Spice,” and related designer drugs: the science behind the headlines. J Neurosci. 2014;34(46):15150-15158. doi:10.1523/JNEUROSCI.3223-14.2014.
4. Daziani G, Lo Faro AF, Montana V, et al. Synthetic cathinones and neurotoxicity risks: a systematic review. Int J Mol Sci. 2023;24(7):6230. doi:10.3390/ijms24076230.
5. Graddy R, Buresh ME, Rastegar DA. New and emerging illicit psychoactive substances. Med Clin North Am. 2018;102(4):697-714. doi:10.1016/j.mcna.2018.02.010.
6. Kourouni I, Mourad B, Khouli H, Shapiro JM, Mathew JP. Critical illness secondary to synthetic cannabinoid ingestion. JAMA Netw Open. 2020;3(7):e208516. doi:10.1001/jamanetworkopen.2020.8516.
7. Khullar V, Jain A, Sattari M. Emergence of new classes of recreational drugs—synthetic cannabinoids and cathinones. J Gen Intern Med. 2014;29(8):1200-1204. doi:10.1007/s11606-014-2802-4.
8. Luethi D, Liechti ME. Designer drugs: mechanism of action and adverse effects. Arch Toxicol. 2020;94(4):1085-1133. doi:10.1007/s00204-020-02693-7.
9. Grafinger KE, Liechti ME, Liakoni E. Clinical value of analytical testing in patients presenting with new psychoactive substances intoxication. Br J Clin Pharmacol. 2020;86(3):429-436. doi:10.1111/bcp.14115.
10. Peacock A, Bruno R, Gisev N, et al. New psychoactive substances: challenges for drug surveillance, control, and public health responses. Lancet. 2019;394(10209):1668-1684. doi:10.1016/S0140-6736(19)32231-7.
11. Riederer AM, Campleman SL, Carlson RG, et al. Acute poisonings from synthetic cannabinoids—50 U.S. Toxicology Investigators Consortium Registry sites, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(27):692-695. doi:10.15585/mmwr.mm6527a2.

Alcohol

1. Wood E, Albarqouni L, Tkachuk S, et al. Will this hospitalized patient develop severe alcohol withdrawal syndrome? The Rational Clinical Examination systematic review. JAMA. 2018;320(8):825-833. doi:10.1001/jama.2018.10574.
2. Kranzler HR, Soyka M. Diagnosis and pharmacotherapy of alcohol use disorder: a review. JAMA. 2018;320(8):815-824. doi:10.1001/jama.2018.11406.
3. Wood E, Pan J, Cui Z, et al. Does this patient have alcohol use disorder? The Rational Clinical Examination systematic review. JAMA. 2024;331(14):1215-1224. doi:10.1001/jama.2024.3101.
4. Ngui HHL, Kow ASF, Lai S, et al. Alcohol withdrawal and the associated mood disorders—a review. Int J Mol Sci. 2022;23(23):14912. doi:10.3390/ijms232314912.
5. Mauermann ML, Staff NP. Peripheral neuropathy. JAMA. 2025. doi:10.1001/jama.2025.19400.