The intoxicated patient presents specific challenges to psychiatric assessment. Intoxication impairs the assessment itself, mimics or masks underlying psychiatric symptoms, and produces acute risks that may be more urgent than any psychiatric question. The framework: stabilize medically first, identify substance and intent, defer detailed psychiatric assessment until clearer.
Medical stabilization first. ABCs (airway, breathing, circulation). Vital signs. Glucose. Mental status trajectory. Risk of withdrawal anticipated. Severe opioid intoxication threatens respiratory drive — naloxone if indicated. Severe alcohol withdrawal threatens with seizures and DTs over days — anticipate and treat. Acute stimulant intoxication may produce cardiac or hyperthermia emergencies. The psychiatric assessment is incomplete until medical stability is achieved.
Identify the substance and amount. What was taken? How much? When? Route? Co-ingestants? Urine drug screen and serum alcohol level standard in any altered patient. Ask explicitly: "Help me understand what you took. I'm not asking to get you in trouble — I'm asking because what you took changes how I take care of you." Patients often disclose more under that framing than under interrogation.
Ask about intent. Was this recreational or was the intoxication itself an attempt to harm? The patient who took 30 acetaminophen with alcohol is a suicide attempt regardless of stated framing. Even apparent recreational overdoses sometimes have suicidal ideation underneath; ask specifically.
Defer detailed psychiatric assessment until the patient is clearer. The intoxicated patient can't engage in a meaningful interview about their depression history or their relationship struggles. The acute psychiatric questions — am I safe to discharge? does this person need hospitalization? — sometimes can be answered with limited data, but the detailed assessment waits.
Reassess after intoxication resolves. Often the picture changes substantially. The patient who looked acutely suicidal during intoxication may have full restoration of mood and future orientation in sobriety. The patient who was minimally interactive during intoxication may engage fully in assessment after clearing. Plan for the sober assessment, not for disposition during acute intoxication.