For this assignment, you will appraise a clinical practice guideline (CPG).? The purpose of this assignment is to acquaint you with a clinical practice g

THE AMERICAN PSYCHIATRIC ASSOCIATION

PRACTICE GUIDELINES FOR THE Psychiatric Evaluation of Adults THIRD EDITION

APA Work Group on Psychiatric Evaluation Joel J. Silverman, M.D., Chair Marc Galanter, M.D. Maga Jackson-Triche, M.D., M.S.H.S. Douglas G. Jacobs, M.D. James W. Lomax II, M.D. Michelle B. Riba, M.D. Lowell D. Tong, M.D. Katherine E. Watkins, M.D., M.S.H.S.

Systematic Review Group Laura J. Fochtmann, M.D., M.B.I. Richard S. Rhoads, M.D. Joel Yager, M.D.

APA Steering Committee on Practice Guidelines Michael J. Vergare, M.D., Chair James E. Nininger, M.D., Vice-Chair Thomas J. Craig, M.D. Deborah Cowley, M.D. Nassir Ghaemi, M.D., M.P.H. David A. Kahn, M.D. John M. Oldham, M.D. Carlos N. Pato, M.D., Ph.D. Mary S. Sciutto, M.D.

Assembly Area Liaisons Daniel J. Anzia, M.D., Chair of Area Liaisons (and Area IV) John M. de Figueiredo, M.D. (Area I) Marvin Koss, M.D. (Area II) William M. Greenberg, M.D. (Area III) John P.D. Shemo, M.D. (Area V) Robert M. McCarron, D.O. (Area VI) Jason W. Hunziker, M.D. (Area VII)

APA wishes to acknowledge the contributions of former APA staff to these guidelines: Robert Kunkle, M.A., Robert Plovnick, M.D., Sara Reid, M.A., Seung-Hee Hong, and William E. Narrow, M.D., M.P.H.

APA and the Work Group on Psychiatric Evaluation especially thank Laura J. Fochtmann, M.D., M.B.I, and Robert Kunkle, M.A., for their outstanding work and effort on developing these guidelines.

The executive summary for this practice guideline was published by The American Journal of Psychiatry in 2015 (doi: 10.1176/appi.ajp.2015.1720501).

Copyright 2016, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of

U.S. Copyright Act. For permission for reuse, visit APAP Permissions & Licensing Center at http://www.appi.org/customer-service/permissions.

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Library of Congress Cataloging-in-Publication Data APA Work Group on Psychiatric Evaluation, author.

The American Psychiatric Association practice guidelines for the psychiatric evaluation of adults / APA Work Group on Psychiatric Evaluation, Joel J. Silverman, chair, [and eleven others]. — Third edition.

p. ; cm. Practice guidelines for the psychiatric evaluation of adults. Includes bibliographical references. ISBN 978-0-89042-465-0 (pbk. : alk. paper) I. Silverman, Joel J., contributor. II. American Psychiatric Association, publisher. III. Title. IV. Title: Practice

guidelines for the psychiatric evaluation of adults. [DNLM: 1. Adult. 2. Mental Disorders—diagnosis—Practice Guideline. 3. Interview, Psychological—meth-

ods—Practice Guideline. WT 150] RC469 616.89075—dc23

2015022857

British Library Cataloguing in Publication Data A CIP record is available from the British Library.

Copyright 2016, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of

U.S. Copyright Act. For permission for reuse, visit APAP Permissions & Licensing Center at http://www.appi.org/customer-service/permissions.

Contents Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Background and Development Process . . . . . . . . . . . . . . . . . . . . . . 1

Rating the Strength of Research Evidence and Recommendations . . 1

Goals and Scope of Guidelines for the Psychiatric Evaluation of Adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Time Required to Complete a Psychiatric Evaluation . . . . . . . . . . . . 2

Proper Use of Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Organization of the Practice Guidelines for the Psychiatric Evaluation of Adults . . . . . . . . . . . . . . . . . . . . . . . . 3

Guideline Statements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

History of Present Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Psychiatric History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Substance Use History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Medical History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Review of Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Family History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Personal and Social History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Examination, Including Mental Status Examination . . . . . . . . . . . . . . .6

Impression and Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Copyright 2016, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of

U.S. Copyright Act. For permission for reuse, visit APAP Permissions & Licensing Center at http://www.appi.org/customer-service/permissions.

Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Guidelines and Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Guideline I. Review of Psychiatric Symptoms, Trauma History, and Psychiatric Treatment History . . . . . . . . . . . . . . 9

Guideline II. Substance Use Assessment . . . . . . . . . . . . . . . . . . . . . 15

Guideline III. Assessment of Suicide Risk . . . . . . . . . . . . . . . . . . . . . 18

Guideline IV. Assessment of Risk for Aggressive Behaviors. . . . . . . 23

Guideline V. Assessment of Cultural Factors . . . . . . . . . . . . . . . . . . 27

Guideline VI. Assessment of Medical Health . . . . . . . . . . . . . . . . . . 30

Guideline VII. Quantitative Assessment . . . . . . . . . . . . . . . . . . . . . . 35

Guideline VIII. Involvement of the Patient in Treatment Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Guideline IX. Documentation of the Psychiatric Evaluation . . . . . . . 44

Review of Available Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Guideline I. Review of Psychiatric Symptoms, Trauma History, and Psychiatric Treatment History . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Guideline II. Substance Use Assessment . . . . . . . . . . . . . . . . . . . . . 48

Guideline III. Assessment of Suicide Risk . . . . . . . . . . . . . . . . . . . . . 57

Guideline IV. Assessment of Risk for Aggressive Behaviors. . . . . . . 65

Guideline V. Assessment of Cultural Factors . . . . . . . . . . . . . . . . . . 74

Guideline VI. Assessment of Medical Health . . . . . . . . . . . . . . . . . . 79

Guideline VII. Quantitative Assessment . . . . . . . . . . . . . . . . . . . . . . 95

Guideline VIII. Involvement of the Patient in Treatment Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Guideline IX. Documentation of the Psychiatric Evaluation . . . . . . 134

Quality Measurement Considerations . . . . . . . . . . . . . . . . . . . . . . 137

Guideline I. Review of Psychiatric Symptoms, Trauma History, and Psychiatric Treatment History . . . . . . . . . . . . . . . . . . . . . . . . . 137

Guideline II. Substance Use Assessment . . . . . . . . . . . . . . . . . . . . 138

Guideline III. Assessment of Suicide Risk . . . . . . . . . . . . . . . . . . . . 139

Guideline IV. Assessment of Risk for Aggressive Behaviors. . . . . . 140

Copyright 2016, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of

U.S. Copyright Act. For permission for reuse, visit APAP Permissions & Licensing Center at http://www.appi.org/customer-service/permissions.

Guideline V. Assessment of Cultural Factors . . . . . . . . . . . . . . . . . .141

Guideline VI. Assessment of Medical Health . . . . . . . . . . . . . . . . . .142

Guideline VII. Quantitative Assessment . . . . . . . . . . . . . . . . . . . . . .144

Guideline VIII. Involvement of the Patient in Treatment Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .144

Guideline IX. Documentation of the Psychiatric Evaluation . . . . . . .145

Guideline Development Process . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Management of Potential Conflicts of Interest . . . . . . . . . . . . . . . . .145

Work Group Composition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145

Expert Opinion Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . .145

Systematic Review Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . .146

Rating the Strength of Supporting Research Evidence . . . . . . . . . .147

Rating the Strength of Recommendations . . . . . . . . . . . . . . . . . . . .147

External Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148

Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148

Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

Disclosures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Advisor to the Work Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Individuals and Organizations That Submitted Comments . . . . . . 164

Copyright 2016, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of

U.S. Copyright Act. For permission for reuse, visit APAP Permissions & Licensing Center at http://www.appi.org/customer-service/permissions.

Copyright 2016, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of

U.S. Copyright Act. For permission for reuse, visit APAP Permissions & Licensing Center at http://www.appi.org/customer-service/permissions.

1

Executive Summary

Background and Development Process These Practice Guidelines for the Psychiatric Evaluation of Adults mark a transition in the Ameri- can Psychiatric Association’s Practice Guidelines. Since the publication of the Institute of Medicine (2011) report, “Clinical Practice Guidelines We Can Trust,” there has been an increasing focus on us- ing clearly defined, transparent processes for rating the quality of evidence and the strength of the overall body of evidence in systematic reviews of the scientific literature. These guidelines were de- veloped using a process intended to be consistent with the recommendations of the Institute of Med- icine (2011), the Principles for the Development of Specialty Society Clinical Guidelines of the Council of Medical Specialty Societies (2012), and the requirements of the Agency for Healthcare Research and Quality (AHRQ) for inclusion of a guideline in the National Guideline Clearinghouse. Parameters used for the guidelines’ systematic review are included with the full text of the guide- lines; the development process is fully described in a document available on the APA Web site: http:/ /www.psychiatry.org/File%20Library/Practice/APA-Guideline-Development-Process–updated- 2011-.pdf. To supplement the expertise of members of the guideline work group, we used a “snowball” survey methodology to identify experts on psychiatric evaluation and solicit their input on aspects of the psychiatric evaluation that they saw as likely to improve specific patient outcomes (Yager et al. 2014). Results of this expert survey are included with the full text of the practice guideline.

Rating the Strength of Research Evidence and Recommendations

The new guideline recommendations are rated using GRADE (Grading of Recommendations As- sessment, Development and Evaluation), an approach adopted by multiple professional organiza- tions around the world to develop practice guideline recommendations (Guyatt et al. 2008, 2013). With the GRADE approach, the strength of a guideline statement reflects the level of confidence that potential benefits of an intervention outweigh the potential harms (Andrews et al. 2013). This level of confidence is informed by available evidence, which includes evidence from clinical trials as well as expert opinion and patient values and preferences. Evidence for the benefit of a particular intervention within a specific clinical context is identified through systematic review and is then balanced against the evidence for harms. In this regard, harms are broadly defined and might in- clude direct and indirect costs of the intervention (including opportunity costs) as well as potential for adverse effects from the intervention. Whenever possible, we have followed the admonition to current guideline development groups to avoid using words such as “might” or “consider” in drafting these recommendations because they can be difficult for clinicians to interpret (Shiffman et al. 2005).

As described under “Guideline Development Process,” each final rating is a consensus judgment of the authors of the guidelines and is endorsed by the APA Board of Trustees. A “recommendation” (denoted by the numeral 1 after the guideline statement) indicates confidence that the benefits of the intervention clearly outweigh harms. A “suggestion” (denoted by the numeral 2 after the guideline statement) indicates uncertainty (i.e., the balance of benefits and harms is difficult to judge, or ei-

Copyright 2016, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of

U.S. Copyright Act. For permission for reuse, visit APAP Permissions & Licensing Center at http://www.appi.org/customer-service/permissions.

2 APA Practice Guidelines

ther the benefits or the harms are unclear). Each guideline statement also has an associated rating for the “strength of supporting research evidence.” Three ratings are used: high, moderate, or low (denoted by the letters A, B and C, respectively) and reflect the level of confidence that the evidence reflects a true effect based on consistency of findings across studies, directness of the effect on a spe- cific health outcome, and precision of the estimate of effect and risk of bias in available studies (AHRQ 2014; Balshem et al. 2011; Guyatt et al. 2006).

It is well recognized that there are guideline topics and clinical circumstances for which high-quality evidence from clinical trials is not possible or is unethical to obtain (Council of Medical Specialty Soci- eties 2012). For example, it would not be ethical to randomly assign only half of patients with depres- sion to be asked about suicidal ideas. Many questions need to be asked as part of the assessment, and inquiring about a particular symptom or element of the history cannot be separated out for study as a discrete intervention. It would also be impossible to separate changes in outcome due to assessment from changes in outcomes due to ensuing treatment. Research on psychiatric assessment is also compli- cated by multiple confounding factors, such as the interaction between the clinician and the patient or the patient’s unique circumstances and experiences. For these and other reasons, the vast majority of topics covered in these guidelines on psychiatric evaluation have relied on forms of evidence such as consensus opinions of experienced clinicians or indirect findings from observational studies rather than being based on research from randomized trials. The GRADE working group and guidelines developed by other professional organizations have noted that a strong recommendation may be appropriate even in the absence of research evidence when sensible alternatives do not exist (Andrews et al. 2013; Brito et al. 2013; Djulbegovic et al. 2009; Hazlehurst et al. 2013).

Goals and Scope of Guidelines for the Psychiatric Evaluation of Adults

Despite the difficulties in obtaining quantitative evidence from randomized trials for practice guidelines such as psychiatric evaluation, guidance to clinicians can still be beneficial in enhancing care to patients. Thus, in the context of an initial psychiatric evaluation, a major goal of these guide- lines is to improve the identification of psychiatric signs and symptoms, psychiatric disorders (including substance use disorders), other medical conditions (that could affect the accuracy of a psychiatric diagnosis), and patients who are at increased risk for suicidal or aggressive behaviors. Additional goals relate to identifying factors that could influence the therapeutic alliance, enhance clinical decision making, enable safe and appropriate treatment planning, and promote better treat- ment outcomes. Finally, the psychiatric evaluation is the start of a dialog with patients about many factors, including diagnosis and treatment options. Further goals of these guidelines are to improve collaborative decision making between patients and clinicians about treatment-related decisions as well as to increase coordination of psychiatric treatment with other clinicians who may be involved in the patient’s care.

Time Required to Complete a Psychiatric Evaluation It is essential to note that these guidelines are not intended to be comprehensive in scope. Many crit- ical aspects of the psychiatric evaluation are not addressed by these guidelines. For example, it is assumed that initial psychiatric or other medical assessments will need to identify the reason that the patient is presenting for evaluation. It is similarly important to understand the patient’s back- ground, relationships, life circumstances, strengths, and vulnerabilities.

Furthermore, depending on the context, recommended areas of inquiry may need to be post- poned until later visits, and recommended questions will not always be indicated for a specific pa-

Copyright 2016, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of

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The APA Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition 3

tient. The findings of the expert survey reiterate that experts vary in the extent to which particular elements of the initial psychiatric evaluation are assessed. This also highlights the importance of clinical judgment in tailoring the psychiatric evaluation to the unique circumstances of the patient and in determining which questions are most important to ask as part of an initial assessment.

Proper Use of Guidelines The APA Practice Guidelines are not intended to serve or be construed as a “standard of medical care.” Judgments concerning clinical care depend on the clinical circumstances and data available for an individual patient and are subject to change as scientific knowledge and technology advance and practice patterns evolve. These guideline statements were determined on the basis of the relative bal- ance of potential benefits and harms of a specific assessment, intervention, or other approach to care. As such, it is not possible to draw conclusions about the effects of omitting a particular recommen- dation, either in general or for a specific patient. Furthermore, adherence to these guidelines will not ensure a successful outcome for every individual, nor should these guidelines be interpreted as including all proper methods of evaluation and care or excluding other acceptable methods of eval- uation and care aimed at the same results. The ultimate recommendation regarding a particular as- sessment, clinical procedure, or treatment plan must be made by the psychiatrist in light of the psy- chiatric evaluation, other clinical data, and the diagnostic and treatment options available. Such recommendations should be made in collaboration with the patient and family, whenever possible, and incorporate the patient’s personal and sociocultural preferences and values in order to enhance the therapeutic alliance, adherence to treatment, and treatment outcomes.

Organization of the Practice Guidelines for the Psychiatric Evaluation of Adults

As part of aligning the practice guidelines’ development process with national standards, we have transitioned to a new guideline format. Each set of Practice Guidelines will consist of multiple dis- crete topics of relevance to an overall subject area. In the Practice Guidelines for the Psychiatric Evaluation of Adults, these topics consist of Review of Psychiatric Symptoms, Trauma History, and Psychiatric Treatment History; Substance Use Assessment; Assessment of Suicide Risk; Assessment of Risk for Aggressive Behaviors; Assessment of Cultural Factors; Assessment of Medical Health; Quantitative Assessment; Involvement of the Patient in Treatment Decision Making; and Docu- mentation of the Psychiatric Evaluation. For each topic, guideline statements will be followed by a discussion of the rationale, potential benefits and harms, and approaches to implementing the guideline statements. This portion of the Practice Guidelines is expected have the greatest utility for clinicians. A second section of the Practice Guidelines provides a detailed review of the evidence for guideline statements in accord with national guideline development standards. This review of research evidence and data from the expert survey is followed by a discussion of quality measure- ment considerations, including their appropriateness for each topic.

Guideline Statements The following represents a summary of the recommendations and suggestions compiled from all Practice Guidelines for the Psychiatric Evaluation of Adults, with some statements being a part of more than one of these guidelines. In the context of these guideline statements, it is important to note that assessment is not limited to direct examination of the patient. Rather, it is defined as “[t]he

Copyright 2016, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of

U.S. Copyright Act. For permission for reuse, visit APAP Permissions & Licensing Center at http://www.appi.org/customer-service/permissions.

4 APA Practice Guidelines

process of obtaining information about a patient through any of a variety of methods, including face-to-face interview, review of medical records, physical examination (by the psychiatrist, an- other physician, or a medically trained clinician), diagnostic testing, or history-taking from collat- eral sources.” The evaluation may also require several meetings, with the patient, family, or others, before it can be completed. The amount of time spent depends on the complexity of the problem, the clinical setting, and the patient’s ability and willingness to cooperate with the assessment.

This summary is organized according to common headings of an evaluation note. As noted above, the guidelines are not intended to be comprehensive, and many aspects of the psychiatric evalua- tion are not addressed by these recommendations and suggestions. Recommendations for the initial psychiatric evaluation of a patient appear in bold font, whereas suggestions appear in italic font. The strength of supporting research evidence for these recommendations and suggestions is given rating C (low) because of the difficulties in studying psychiatric assessment approaches in con- trolled studies as described above. References to the specific guideline in which the recommenda- tion or suggestion is found are denoted by the following footnotes:

1Guideline I. Review of Psychiatric Symptoms, Trauma History, and Psychiatric Treatment History 2Guideline II. Substance Use Assessment 3Guideline III. Assessment of Suicide Risk 4Guideline IV. Assessment of Risk for Aggressive Behaviors 5Guideline V. Assessment of Cultural Factors 6Guideline VI. Assessment of Medical Health 7Guideline VII. Quantitative Assessment 8Guideline VIII. Involvement of the Patient in Treatment Decision Making 9Guideline IX. Documentation of the Psychiatric Evaluation

History of Present Illness

• Reason that the patient is presenting for evaluation:

• Psychiatric review of systems,1 including anxiety symptoms and panic attacks3

• Past or current sleep abnormalities, including sleep apnea6

• Impulsivity3,4

Psychiatric History

• Past and current psychiatric diagnoses1,3

• Prior psychotic or aggressive ideas, including thoughts of physical or sexual aggression or homicide4

• Prior aggressive behaviors (e.g., homicide, domestic or workplace violence, other physically or sexually aggressive threats or acts)4

• Prior suicidal ideas, suicide plans, and suicide attempts, including attempts that were aborted or interrupted as well as the details of each attempt (e.g., context, method, damage, potential lethality, intent)3

• Prior intentional self-injury in which there was no suicide intent3

• History of psychiatric hospitalization and emergency department visits for psychiatric issues1,3,4

• Past psychiatric treatments (type, duration, and, where applicable, doses)1

• Response to past psychiatric treatments1

Copyright 2016, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of

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The APA Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition 5

• Adherence to past and current pharmacological and nonpharmacological psychiatric treatmen

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