Biopsychosocial Assessment
A biopsychosocial assessment is a collaborative process that aims to identify the important factors that are relevant to creating a plan of psychopharmacological and psychotherapeutic treatment. Since every person is unique, every assessment is unique. As the assessment process unfolds it may become clear that more attention needs to be paid to one area (for instance, medical illnesses, or cognitive functioning) and this may lead to consultation with other experts. Nevertheless, there are some key elements of a biopsychosocial assessment that are appropriate for almost everyone, these include –
A history of mood symptoms - factors that lead to worsened symptoms, and those that alleviate symptoms; a history of treatment and response to treatment; the relationship of mood symptoms to other symptoms (such as anxiety, physical symptoms, etc.).
- A general medical history
- A developmental, social and cultural history – particularly paying attention to patterns and recurring experiences in relationships.
- A history of school and work
- A review of psychiatric and medical symptoms
- An assessment of cognitive functioning
- Identification of strengths and problems
For many people it will also be useful to do a detailed history of mood episodes over time, what is called a retrospective mood chart. This not only clearly identifies the person’s unique pattern of mood variation, but it is also a very effective way of summarizing past treatment and response. Often a very detailed retrospective mood chart makes it clear what combination of treatment is most likely to be useful.
Assessment of the most appropriate treatment options will include an assessment for specialized treatment and treatment setting. If treatment is needed that is not provided by the assessor, then appropriate referrals will be provided.
When there is a need for more information we will use other sources including –
- Past psychiatric, psychotherapy or medical records
- Pharmacy records
- Information from diaries, other records
- Collateral history
When specialized assessments are indicated we will arrange for –
- Substance abuse assessment
- Psychological assessment
- Nutritional assessment
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