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For general principles and components of a psychiatric evaluation, refer to the American Psychiatric Association's Practice Guideline for the Psychiatric Evaluation of Adults. A complete diagnosis of depression should address the following:

  • History of the present illness and current symptoms

  • Psychiatric history, including symptoms of mania, current and past treatments (including duration and dosages), and responses to treatment

  • General medical history

  • Medications, including prescribed and over-the-counter agents and supplements

  • History of substance use and treatment for substance use disorders

  • Personal history (e.g., psychological development, response to life transitions, major life events)

  • Social, occupational, and family histories

  • Review of the patient's prescribed and over-the-counter medications

  • Review of systems

  • Mental status examination

  • Physical examination (by psychiatrist or by other health care professional)

  • Diagnostic tests as indicated to rule out general medical causes of depressive symptoms

References

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