Stage 3: History Elements
Concept 4 of 8
E3.4

Medical History & Medications

Medical conditions and medications shape psychiatric symptoms, treatment options, and outcomes. The med list is part of the psychiatric assessment.

Encounter card
Setting
Every psychiatric encounter — medical history and full medication reconciliation including OTC, supplements, and "as needed" medications.
Opening move
Ask about active medical conditions, recent diagnoses, surgeries, and pregnancy. Reconcile all medications — prescription, OTC, supplements, herbals, illicit. Ask about medications that have been started, stopped, or changed in the last 3-6 months.
Sample language
  • "What medical conditions are you currently being treated for?"
  • "Can you list all the medications you take, including over-the-counter and supplements?"
  • "Have any medications been started, stopped, or changed recently?"
  • "Any allergies or reactions to medications?"
Listen for
Conditions that cause/mimic psychiatric symptoms (thyroid, B12, lupus, MS, epilepsy, OSA, cancer, pain). Medications causing psychiatric AEs (steroids, interferon, beta-blockers, anticholinergics, levetiracetam, isotretinoin). Drug interactions with planned psychiatric medications. Pregnancy/breastfeeding status.
Common pitfalls
Trusting the chart's med list without reconciliation. Missing OTC anticholinergics in elderly. Missing recent prednisone burst as precipitant of mood symptoms. Not asking about pregnancy/contraception in women of childbearing potential.

Red flags / escalate: New psychiatric symptoms in the context of medical change (new mass, new neurologic symptom, new medication). Anticholinergic burden in elderly. Severe drug interactions in planned regimen. Active pregnancy with high-risk psychotropic.

Documentation
Active conditions list. Full medication reconciliation with doses. Allergies with reaction type.

Real-world reality: Med reconciliation through EMR is famously unreliable. Patient-brought medication bottles (or photos of bottles) is the gold standard. Plan time for this at first visits and after hospitalizations.

A psychiatric assessment without medical reconciliation is incomplete. Medications and conditions are co-determinants of psychiatric presentation.

Warm grey-tinted clinical notebook page, sienna accent. Medical conditions and medications shaping psychiatric presentation — thyroid → mood, steroids → mania, anticholinergics → cognition. Margin clusters on common bridges.

Medical history and medication reconciliation are essential parts of the psychiatric evaluation, not optional context. Medical conditions cause and mimic psychiatric symptoms; medications produce psychiatric side effects; drug interactions complicate any psychiatric prescribing. The psychiatric assessment without medical reconciliation is incomplete.

Medical conditions that affect psychiatry: Thyroid disease (hyper- and hypothyroidism both produce mood and cognitive symptoms — check TSH). B12 deficiency (depression, cognitive impairment — check level). Lupus and other autoimmune disease (CNS involvement). Multiple sclerosis (mood symptoms, fatigue, cognitive). Epilepsy (interictal psychiatric symptoms, postictal states). Obstructive sleep apnea (depression, anxiety, fatigue — undertreated commonly). Cancer (depression rates substantial; cytokines may contribute). Chronic pain. Diabetes. Heart disease.

Medications that produce psychiatric side effects: Steroids — psychiatric effects range from mild mood changes to mania to psychosis, especially at higher doses. Interferons — depression. Beta-blockers — depression in some patients. Anticholinergics — cognitive impairment. Levetiracetam — depression and irritability ("Keppra rage"). Isotretinoin — depression and suicidality. Many cardiac medications. Some chemotherapy. Hormonal contraceptives in vulnerable patients. The new psychiatric symptom in a medically complex patient may be the medication.

Reconcile the full medication list. Prescription, OTC, supplements, herbals, illicit. Recent changes in the last 3-6 months are particularly relevant — the new SSRI plus over-the-counter dextromethorphan is a serotonin syndrome setup. Don't trust the chart list; ask the patient and family. The patient on five medications according to the chart often is actually on eight or twelve, with the chart missing the supplements, the borrowed medications, and the OTCs that became routine.

Drug interactions matter. Screen psychiatric medications against the full medical regimen. CYP interactions are common — fluoxetine plus tamoxifen, fluvoxamine plus clozapine, carbamazepine inducing many co-medications. Pharmacodynamic interactions matter — additive QTc, additive CNS depression, serotonin syndrome combinations.

Pregnancy and reproductive status in women of childbearing potential. Ask. Document contraception. The psychiatric medication chosen often depends on the answer.

Full medication reconciliation — prescription, OTC, supplements, herbals, recent changes. Margin notes on why each category matters.
The anchor

Medical conditions and medications shape psychiatric presentation and treatment. Reconcile every medication, including OTC and supplements. Document medical conditions affecting psychiatric care.

Pregnancy and reproductive status as part of medical history — affects medication choice, formulation, and counseling. Margin clusters on what to ask.
Prove it

A 65-year-old woman presents with new-onset depression. She has hypertension on lisinopril and atenolol, hypothyroidism on levothyroxine, and was started on prednisone 40mg 2 weeks ago for polymyalgia rheumatica. How does this medical history change your approach?

This connects to
E3.5
Social History
Where context expands.
E5.1
Biopsychosocial Formulation
Where medical and psychiatric integrate.

Locked concepts unlock as you reach them on the path.

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