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:
| Component | Focus of Inquiry |
| Past Psychiatric Diagnoses | What diagnostic labels has the patient received, from whom, and when? |
| Psychiatric Hospitalizations | When, where, how long, and what precipitated each admission? |
| Current and Previous Treatment Providers | Who is actively involved in their care, and who has been in the past? |
| Support Systems | Who helps the patient at home? |
| Psychotherapy History | What types of therapy, with what frequency, over what duration, and with what benefit? |
| Medication and ECT Trials | Which treatments have been attempted, at what doses, for how long, and with what response? |
| Suicide Attempt History | Methods used, medical severity, circumstances, and frequency over time. |
| Non-Suicidal Self-Injury | Patterns, methods, functions, and timeline of self-harm behaviors. |
| Trauma Exposure | Significant traumatic events across the lifespan that inform current presentation. |
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
