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1. Elderly patients and patients with medical conditions

While advanced chronological age alone does not necessitate a change in the approach to the psychiatric evaluation, the strong association of old age with chronic disease and related impairments may increase the need for emphasis on certain aspects of the evaluation. The general medical history and evaluation, cognitive mental status examination, and functional assessment may need to be especially detailed because of the high prevalence of disease-related disability, use of multiple medications, cognitive impairment, and functional impairment in older people. The psychiatrist should attempt to identify all of the general medical and personal care clinicians involved with the patient and to obtain relevant information from them if the patient consents. It is also helpful to obtain information from the family.

The personal and social history includes coverage of common late-life issues, including the loss of a spouse or partner, the loss of friends or close relatives, residential moves, the new onset of disabilities, financial concerns related to illness or disability, and intergenerational issues, such as informal caregiving or financial transfers between members of different generations. It is important to evaluate intergenerational strains such as midlife couples with young children who cannot care for elderly relatives or, increasingly, patients in their 90s whose children are now in their 70s and ill themselves.

The psychiatrist may need to accommodate the evaluation to patients who cannot hear adequately. Use of sign language interpreters, amplification, a quieter interview room, and enabling lip reading are possible means to do this. When an elderly patient is brought for psychiatric evaluation by a family member, special effort may be necessary to ensure that both patient and family member have an opportunity to talk to the psychiatrist alone.

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2. Incarcerated persons

Increasing numbers of individuals with mental illness are incarcerated in jails, prisons, and other correctional facilities and require psychiatric evaluation (205–208). In addition, suicide is one of the leading causes of death in correctional settings, and urgent suicide assessments may be needed for individuals at risk (11, 209, 210).

The psychiatric evaluation of incarcerated individuals will include the general elements common to any psychiatric evaluation (211–213) but will place additional emphasis on aspects of the individual's alcohol and substance use history and legal history, including previous episodes of incarceration and associated behavioral changes. Psychosocial stressors, including new legal complications (e.g., denial of parole), receiving bad news about loved ones at home, and experiencing sexual assault or other trauma, are also important to assess, as these may increase the likelihood of suicidal behaviors (214). Similarly, the recentness of the incarceration (210, 214, 215) or placement in isolation (216–219) may be relevant to determination of suicide risk. Depending on the likely duration of incarceration, options for care following transfer between correctional institutions or for aftercare following release may also need to be explored as part of the evaluation.

Access to space that allows for auditory privacy and physical safety is necessary to adequately perform psychiatric evaluations in correctional settings (212).

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3. Homeless persons

Evaluations of persons who are homeless may require both modifications of the evaluation process and unique interviewing skills. The disengaged lifestyle and mistrust often encountered in homeless persons may make a classically direct approach difficult if not impossible (220). As a result, the first step toward psychiatric evaluation is engagement. This process can take from days to years in nonclinical settings (e.g., on the street, under bridges, in shelters). Evaluation becomes possible when the homeless person believes that engaging with the psychiatrist will not recapitulate previous negative experiences, lost opportunities within the health care system, and encounters in jail and prison that heighten a fear of consequences from talking honestly. By necessity, then, the full psychiatric evaluation of homeless persons typically unfolds over numerous, often brief, and seemingly casual interactions.

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4. Persons with mental retardation

The evaluation of individuals with mental retardation presents a number of clinical challenges. Although psychiatric illnesses occur at increased rates in those with mental retardation (221, 222), it is not always possible to establish a definitive axis I diagnosis as a cause for behavioral symptoms (223). Depending on the extent of the patient's intellectual limitations, the diagnosis of mental retardation may have been unrecognized before the behavioral symptoms began.

In interviewing individuals with mental retardation, particular attention needs to be given to the phrasing of questions so that they will be understandable to the patient. The use of general psychiatric self-report scales or other structured interview formats may be problematic in this regard (221, 224). Behavioral observations or functional measures will often carry a greater weight in the assessment process, and patients with more severe mental retardation may be unable to report on their own mental experiences (225, 226). Thus, obtaining a comprehensive description of symptoms, signs, and aspects of history from family members, caretakers, and other professionals is often crucial. This is particularly true when persons with mental retardation present for evaluation in the context of a behavioral crisis, because otherwise minor events (e.g., changes in routine, upsetting interpersonal interactions) may be quite distressing and result in catastrophic reactions. Similar issues with evaluation may be observed in individuals with other developmental disabilities.

Evaluation for co-occurring general medical conditions is particularly important in adults with mental retardation, given higher rates of undetected medical illnesses (222, 227) as well as the tendency for atypical clinical presentations of medical illnesses (140, 227).

References

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