E3.2

Past Psychiatric History

Prior episodes, hospitalizations, medication trials, therapy, suicide attempts. Predicts course and treatment response better than almost anything else.

Encounter card

Setting

First encounter (comprehensive); updated when new history emerges or treatment trajectory changes.

Opening move

Ask about prior episodes, treatments, hospitalizations, and suicide attempts systematically. Use a year-by-year scaffolding when complex.

Sample language

"Walk me through your psychiatric history — when did you first see a mental health provider?"
"What medications have you tried over the years? What worked, what didn't, what side effects?"
"Have you ever been hospitalized for mental health reasons?"
"Have you ever attempted suicide or seriously thought about it?"

Listen for

Age of onset (early vs late). Episode pattern (single vs recurrent, episodic vs chronic). Prior diagnoses and how they were reached. Medication trials with response and tolerability. Therapy types and engagement. Hospitalization history. Suicide attempts (lethality, intent, precipitants).

Common pitfalls

Accepting "I've tried everything" without details — ask about specific drugs, doses, durations. Missing the time gap between first symptoms and first treatment. Not distinguishing inadequate trials from true non-response.

Red flags / escalate: Multiple prior suicide attempts (highest predictor of future attempt). Recent psychiatric hospitalization. Pattern of incomplete treatment trials suggesting access or adherence barriers. History suggesting bipolar diagnosis missed in past.

Documentation

Year-by-year or episode-by-episode summary. Medication trials with drug, dose, duration, response, AEs. Hospitalizations with year, indication, length. Suicide attempts with method, year, context.

Real-world reality: Full biopsychosocial formulation in clinical practice is often abbreviated due to time pressure; documenting it explicitly in initial evaluations and at major decision points produces better continuity than the casual mental formulation.

Past psychiatric history predicts response and course more reliably than current presentation alone.

Warm grey-tinted clinical notebook page, sienna accent. A patient's episode timeline across years — episodes, treatments, hospitalizations, attempts. Margin clusters on what each tells us.

Past psychiatric history is one of the most predictive parts of the psychiatric evaluation. The patient's history of prior episodes, treatments, hospitalizations, and suicide attempts predicts current course and treatment response more reliably than current presentation alone.

Prior episodes — when, what type, severity, duration, what helped, recurrence pattern. The patient with three prior depressive episodes is in different clinical territory than the patient with a first episode. The patient whose episodes follow a regular seasonal pattern needs a different approach than the patient whose episodes are unpredictable.

Medication trial history deserves specific detail. Drug, dose, duration, response, adverse effects. "I've tried everything for depression" often turns out, on careful questioning, to be a series of inadequate trials — 50 milligrams of sertraline for two weeks, then switched because of nausea. Adequate trial means therapeutic dose for adequate duration; many "treatment-resistant" patients have failed inadequate trials. Identify what hasn't truly been tried adequately.

Hospitalizations — year, indication, length, what led to discharge. Multiple hospitalizations indicate chronicity and severity. Hospitalizations following specific precipitants give you the trigger pattern.

Suicide attempts — when, method, intent, lethality, what stopped or rescued them, what followed. Multiple prior attempts are the strongest predictor of future attempts. The patient with prior attempts needs particular attention to suicide risk assessment in the current encounter. Document each prior attempt specifically.

Hidden bipolar is the diagnostic question that comes up frequently. The patient with recurrent depression that hasn't responded well to SSRIs may have bipolar disorder that's been missed. Take a careful hypomania history: brief periods of feeling unusually high, energized, decreased need for sleep, increased goal-directed activity, sometimes irritability rather than euphoria. Antidepressant-induced activation or rapid response that didn't last suggests bipolar. Family history of bipolar I or completed suicide adds weight to the hypothesis.

Past psychiatric history is where the longitudinal pattern lives. The current visit is one moment in a longer arc; the history places the moment in context.

Documenting prior medication trials — drug, dose, duration, response, AEs. Distinguishing adequate vs inadequate trials. Margin notes on definitions.

The anchor

Past psychiatric history — prior episodes, treatments, hospitalizations, attempts — predicts course and response more reliably than current presentation alone.

Common pattern: bipolar diagnosis missed in past, treated as recurrent depression. Margin clusters on history clues — antidepressant-induced switches, family history, mood instability, early age of onset.

Prove it

A patient says "I've tried everything for my depression — nothing works." How do you respond?

This connects to

E3.1

HPI

Current episode vs longitudinal pattern.

E7.3

Med Trials & Response

What inadequate trials look like.

Locked concepts unlock as you reach them on the path.