Using Family History for Formulation, Risk, and Medication Choice
This is Part 2 in our series on Family History.
Read Part 1: Family Psychiatric History: Risk, Heritability, and How to Ask for the prior component.
Family history data becomes clinically powerful only when you interpret it accurately and apply it to formulation, risk assessment, and treatment planning. This section addresses common diagnostic pitfalls, high-risk family patterns, and how to document family history effectively.
Learning Objectives
After reading this section, you should be able to:
- Differentiate true bipolar family history from borderline personality patterns
- Recognize the clinical implications of familial substance use and suicide
- Identify chart sources that clarify ambiguous family history labels
- Apply family history to medication selection and treatment planning
- Document family psychiatric history systematically using a structured format
Start With Chart Review
Before interpreting family history, review prior documentation for clarification and context:
- Prior psychiatric evaluations: Look for previously documented family “bipolar” versus “mood swings” or “borderline” labels that may need reinterpretation
- Old risk assessments: Past suicide risk assessments often document family history of suicide or attempts with more detail than routine notes
- Previous genetic consults: If available, these provide structured pedigree information
- Patterns across encounters: Compare family history documented at different timepoints; evolving disclosure (e.g., new revelation of family suicide) has clinical meaning
- Collateral documentation: Social work notes or family meeting summaries may contain family history information not captured elsewhere
💡 Clinical Pearl: When prior notes label a relative as “bipolar” but describe chronic instability and self-harm rather than discrete episodes, flag this for clarification during interview. The genetic implications differ substantially.
Interview the Patient
For Part B, focus on follow-up questions that clarify ambiguous family history and assess high-risk patterns.
Clarifying “Bipolar” Labels
- “When you say your mother was bipolar, what did you actually see her do?”
- “Were there times she was clearly ‘normal’ between episodes, or was she always unstable?”
- “Did her mood changes last days to weeks, or did they shift within hours?”
- “Was she ever hospitalized during a high or manic period?”
Clarifying Family Suicide History
- “Has anyone in your family died by suicide?”
- “How old were you when that happened?”
- “How did your family talk about it, or did they avoid discussing it?”
- “Do you ever worry you might end up the same way?”
Clarifying Family Substance Use Patterns
- “When did your relative’s drinking or drug use start to cause problems?”
- “Did multiple people on that side of the family have similar problems?”
- “What was it like growing up in that household?”
- “Do you see any patterns between their use and your own?”
💡 Clinical Pearl: When patients disclose family suicide, ask about identification with the deceased: “Do you ever worry you might end up the same way?” This question feels direct but opens critical risk assessment territory.
Not All “Bipolar” in the Family Is Bipolar: Recognizing Borderline Family Patterns
Many patients describe a family member as “bipolar” when the clinical picture actually suggests borderline personality disorder (BPD). These are vastly different disorders with different genetic implications.
Bipolar Mania: Episodic and Sustained
Bipolar mania is characterized by episodic, sustained mood changes (days to weeks) with distinct changes from baseline:
“For weeks she’d be on top of the world, talking nonstop, not sleeping, starting five new businesses, spending money we didn’t have. Then she’d crash or go back to normal.”
Patients describe decreased need for sleep, grandiosity, pressured speech, increased goal-directed activity, and often hospitalization. There are clear periods of normal functioning between episodes.
Borderline Personality Disorder: Chronic and Reactive
BPD is marked by chronic, pervasive instability that is reactive to interpersonal stress:
“She’s been like this my whole life. Her mood changes in minutes when she feels rejected; she cuts when overwhelmed, threatens suicide when people try to leave; every relationship ends badly.”
Mood shifts are rapid (hours), triggered by perceived abandonment or conflict, accompanied by self-harm and suicidal gestures, with intense, unstable relationships and chronic emptiness. There’s no episodic pattern with return to baseline: it’s constant chaos with fluctuating intensity.
Why This Distinction Matters
If a patient reports a family history of “bipolar disorder” but describes chronic interpersonal chaos and self-harm, that is not genetic risk for bipolar disorder. BPD is not strongly heritable in the same way.
True family history of bipolar disorder, especially if multiple relatives, early onset, psychotic features, or repeated hospitalizations, substantially increases genetic risk and should lower your threshold for diagnosing bipolar disorder.
🚩 Red Flag: Family “bipolar” label with no clear episodes, but chronic self-harm and relationship chaos, should prompt rethinking genetic risk assumptions. This is not the same heritability signal.
💡 Clinical Pearl: Always ask: “Can you describe what you mean when you say they were bipolar? What did you actually observe?” The behavioral description matters more than the label.
When Family History Signals Risk: Substance Use and Suicide
Family History of Substance Use
Family history of substance-use disorders has both genetic and environmental implications. Patients with first-degree relatives who have alcohol use disorder have about a seven-fold increased risk of developing it themselves. Growing up in a household with parental substance use is also an adverse childhood experience (ACE) that increases lifetime risk for psychiatric disorders, relationship difficulties, and later substance use in the patient.
What you’re assessing:
- Genetic risk: Multiple affected relatives, early onset, and severe course suggest high genetic loading
- Environmental impact: Did the patient grow up in chaos, neglect, or unpredictability due to parental substance use?
- Intergenerational patterns: Is there a family tendency to self-medicate psychiatric symptoms with substances?
🚩 Red Flag: Dense family history of substance use combined with early onset in the patient suggests both high genetic vulnerability and environmental reinforcement. These patients need aggressive intervention and close monitoring.
Family History of Suicide
Family history of suicide significantly increases a patient’s own suicide risk. This is due to both genetic factors (impulsivity, mood disorders, aggression) and environmental factors (modeling, trauma, loss of protective figures). Knowing a patient has lost a family member to suicide, especially a parent or sibling, should heighten vigilance for suicide risk throughout treatment.
What you’re assessing:
- Suicide risk in patient: Family history of suicide is a well-established risk factor
- Unresolved grief or trauma: Loss of a parent to suicide in childhood has profound developmental effects
- Identification with deceased relative: Does the patient fear or expect a similar outcome?
- Anniversary reactions: Does symptom intensity spike near the anniversary of the death?
💡 Clinical Pearl: Ask directly: “Has anyone in your family died by suicide?” Patients often don’t volunteer this information but will disclose when asked with compassion and without judgment.
How to Use Family History in Formulation and Medication Choice
Family history isn’t just a list of diagnoses: you’re looking for patterns that inform diagnosis and treatment.
Strong genetic loading: Multiple first-degree relatives with the same disorder (e.g., mother, sister, and maternal aunt all with bipolar disorder) indicates high genetic risk and informs diagnosis.
Treatment response: “My mother had severe depression and only responded to Effexor.” If your patient has similar symptoms and family history, venlafaxine is a reasonable first choice.
Age of onset: “My brother developed schizophrenia at 19.” Early onset in relatives predicts more severe course.
Substance-use patterns: “Everyone on my dad’s side drinks heavily.” Suggests both genetic vulnerability and modeled behavior.
Suicide risk: “My father and uncle both died by suicide.” Elevates patient’s risk and requires ongoing monitoring.
Environmental context: “My mother was hospitalized for psychosis throughout my childhood.” Signals early trauma and attachment disruption, regardless of genetic risk.
What to Document
Your documentation should make family history usable for future clinicians by summarizing the key diagnoses, patterns, and implications for risk and treatment. Select the level of detail based on how much family history alters your diagnostic thinking and management plan.
| Documentation Level | What to Include | Example | When to Use This Level |
|---|---|---|---|
| Minimal | Disorders present or absent, relationship, suicide history | “Family history positive for depression (mother), alcohol use disorder (father). Negative for bipolar disorder, schizophrenia. No family history of suicide.” | Routine cases with unremarkable family history |
| Standard | Minimal + treatment response, severity, age of onset, and clarification of ambiguous labels | “Mother: MDD, good response to sertraline, no hospitalizations. Father: AUD, multiple DUIs, deceased age 58 (liver failure). Sister: reported ‘bipolar’ but description consistent with BPD (chronic instability, self-harm, no discrete episodes).” | Standard psychiatric evaluations requiring formulation |
| Detailed | Standard + second-degree relatives, clustering patterns, environmental context, suicide details, and explicit treatment implications | “First-degree: Mother (MDD, sertraline responder), Father (AUD, deceased), Sister (BPD per behavioral description). Second-degree: Maternal grandmother (possible MDD, ECT in 1960s), Paternal uncle (suicide by gunshot, age 35, history of depression). Patterns: Mood disorders on maternal side, substance use and early death on paternal side.” | Complex presentations, dense family pathology, family suicide, or when family history significantly alters treatment planning |
Example of Detailed Documentation
First-degree relatives (parents, siblings, children):
- Mother: Major depressive disorder, treated with sertraline with good response, no hospitalizations, alive
- Father: Alcohol use disorder, multiple DUIs, deceased (liver failure at 58)
- Sister: Bipolar I disorder, multiple manic episodes requiring hospitalization, stable on lithium
Second-degree relatives (grandparents, aunts, uncles):
- Maternal grandmother: “Nervous breakdown” in her 40s, treated with ECT (records unavailable), reportedly responded well
- Paternal uncle: Died by suicide at 35 (gunshot), history of depression
Patterns identified:
- Multiple relatives with mood disorders on maternal side
- Substance use and early death on paternal side
- Family history of completed suicide
Clinical implications:
- High genetic loading for affective illness; monitor for bipolar emergence if presenting with depression
- Family suicide history elevates patient’s own risk; ongoing monitoring indicated
- Mother’s sertraline response informs medication selection if antidepressant indicated
Why This Information Matters
The goal of family psychiatric history is to understand both the genetic vulnerabilities your patient carries and the environmental context in which they developed, because both shape current presentation, prognosis, and treatment needs.
A patient with dense family history of bipolar disorder presenting with their first depressive episode warrants different monitoring than one with no psychiatric family history. A patient whose father and uncle died by suicide requires ongoing risk assessment regardless of current symptom severity. A patient whose mother responded to a specific medication has a rational starting point for pharmacotherapy.
Family history transforms your assessment from symptom cataloging to risk-informed clinical reasoning. Document it systematically, interpret it carefully, and use it to guide every phase of treatment planning.
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