Peer Perspectives

Taking a Family History in Mental Health and SUD Intake Evaluations — It Can Make a Difference

By Jerrold Pollak, PhD, ABPP, ABN

Most mental health and substance use disorder (SUD) intake evaluations are completed by nonmedically trained clinicians: social workers, mental health counselors, and psychologists. The standard of care across all of the mental health disciplines, including psychiatric nursing and psychiatry, continues to evolve regarding what should be included in these assessments.

For many years, it has been a given that an intake evaluation should involve an overview of complaints/symptoms, a psychosocial and mental health/SUD history, a mental status, a case formulation, one or more working DSM-5 criteria-based diagnoses, and a recommended plan of intervention/treatment.

In contrast, insufficient attention continues to be paid by all of the behavioral health disciplines to the completion of a detailed family history of neurodevelopmental, medical/neurologic, and neuropsychiatric disorder as well as SUD. At best, many intake evaluations include, in passing, basic information germane to this aspect of a client’s history, e.g., “the client’s father had depression.”

Barriers to Completing a Family History
There are a number of obstacles to the routine inclusion of a detailed family history in intake evaluations, including the following:

• Reluctance to purse an aspect of history taking that is not a well-established part of the standard of care.

• The perception that family history taking often results in incomplete and unreliable information and that the information obtained is probably not worth the additional time amid the many intake evaluations that clinicians routinely have to complete.

• The inclination to underestimate the potential clinical utility of a family history for differential diagnosis and treatment planning. The latter includes risk reduction strategies for clients who have an increased vulnerability to the development of certain mental health and/or substance abuse disorders based on their family history.

• Clinicians’ lack of confidence regarding how to best obtain, interpret, and utilize the information gleaned from a family history, especially data about medical/neurologic conditions.

• An understandable inclination on the part of nonmedically trained clinicians to obtain information relevant to psychodynamic, psychosocial, and socio-cultural factors such as the effects of neglect, mistreatment, and other forms of trauma, as opposed to biomedical influences (notably heredity/familial factors) on the development of mental health and SUDs (Pollak & Miller, 2019).

• The lack of a “gold standard” family history inventory/questionnaire or brief semistructured interview to facilitate information gathering and clinical decision making (Milne et al., 2009).

• Concerns about impinging on the client’s privacy and provoking unnecessary distress regarding what can sometimes be a sensitive subject.

Indeed, there are drawbacks to the routine completion of a family history. Perhaps the biggest encumbrance is being left with an abundance of information that is difficult to sort through and interpret. In some instances, this may result in clinical paralysis, which interferes with the timely development of working diagnoses and an initial treatment plan.

Reasons to Consider Taking a Formal Family History
Family history is a significant risk factor for many mental health disorders (Milne et al., 2009). The apple does not fall far from the tree, as it is relatively common for clients with neurodevelopmental, neuropsychiatric, medical/neurologic, and/or substance use disorders to have one or more relatives with histories of similar if not identical difficulties. This is certainly the case for DSM-5 neurodevelopmental conditions such as intellectual disability, autism spectrum disorder, ADHD, specific learning disorders, and communication disorders.

This adage also applies reasonably well to clients with neuropsychiatric conditions such as anxiety, mood, psychotic, and personality disorders. Moreover, clients struggling with SUDs frequently have relatives with identical or kindred conditions.

Of particular clinical relevance are cases of family medical/neurologic illness, which can sometimes be a contributory influence if not a sufficient explanation for a client’s recent history and presenting complaints/symptoms. This includes later onset mental status change (after the age of 40) which is not well explained by psychosocial/psychodynamic factors and can sometimes reflect an early onset neurodegenerative condition or other medical/neurologic condition, especially among clients with a compatible family history (Pollak & Miller, 2011).

A family history can also help to elucidate what conditions a client may be vulnerable to developing given certain lifestyle factors. For instance, a family history of one or more relatives with prodromal or full-blown psychosis with onset in the adolescent and young adult years is a risk factor for the development of psychotic symptoms in other family members. However, this history becomes a stronger risk factor for this outcome for clients with early-onset heavy and persistent cannabis use and/or recurrent consumption of other substances that can trigger psychotic symptoms (Pollak, 2016).

Similarly, a strong family history of neurodegenerative disease is an important risk factor for the development of a comparable illness trajectory beginning in middle age, but it becomes a somewhat better predictor for clients with conditions such as multiple concussions, which can accelerate neurodegenerative change.

Aspects of the family history can also suggest the need for referral for specialty consultations, notably neurology, psychopharmacology, and psychological/neuropsychological testing.

Even when a family history is not found to be helpful for differential diagnosis and/or treatment planning, the information gleaned can result in a better appreciation of the pressures/stresses that clients may have experienced as a consequence of family-based neurodevelopmental, medical/neurologic, neuropsychiatric, and/or substance abuse disorders. This understanding may facilitate alliance building and prove to be a productive issue to address during the intake process and/or in psychotherapy.

Enhancing Reliability When Taking a Family History
The client and preferably another informant (usually another family member, in-law, or close family friend) should complete a family history questionnaire in the office prior to the intake interview. Clinicians can create their own forms. However, useful inventories/questionnaires (with sections devoted to family history) can be downloaded from the internet at no cost using search phrases such as “neuropsychological testing history form” and “family history mental health form.” These documents can be modified based on clinician need and preferences.

The form should be limited to biological relatives and also indicate the family member(s) with the reported condition. Preferably coverage ought to encompass a broad range of relatively common neurodevelopmental, medical/neurologic, neuropsychiatric, and substance-related issues as well as histories pertaining to suicide, homicide, disruptive/rule breaking behavior, and eccentric/peculiar thinking and behavior.

The section pertaining to substance use should contain multiple categories of substance misuse. The DSM-5 chapter “Substance-Related and Addictive Disorders” provides a useful typology.

In addition to first-degree relatives (parents and siblings), informant(s) should be encouraged to provide information about second-degree relatives (grandparents, uncles, aunts, and cousins) and even third-degree family members when available.

The completed form can be a springboard to clarify and refine this documentation. This approach reduces the probability of misinformation based on a client’s lack of familiarity with medical and psychiatric conditions and other factors that sometimes adversely reflect the accuracy of the report.

The estimated age of onset of the reported conditions ought to be clarified. In each instance, informants should also be asked about the basis for the information. For instance, the informant may report firsthand knowledge as well as information gleaned from multiple sources over many years that a great aunt ended her life. Conversely, the report may be based on nothing more than a rumor that circulated over many years within the family. For all reports informants should also be asked how credible they feel the information is, regarding the family member in question.

In some instances, to increase the probability of an accurate appraisal, the intake clinician may need to provide examples of typical signs/symptoms of a condition that has been reported. A client may state, for example, that their mother was depressed most of her life but, upon inquiry, some of the signs/symptoms reported suggest a possible bipolar spectrum depression as opposed to a unipolar depressive disorder. The intake clinician can then review some common presentations of bipolar spectrum disorder, including bipolar depression, which the client may be able to confirm or deny once they have been described (Miller & Noel, 2019).

When reviewing family history, it is relatively common for clients to report conditions with which the intake clinician may have little, if any, familiarity. This knowledge gap can be addressed via an internet search and/or by consulting with a medically trained mental health clinician—an advanced practice registered nurse with specialization in psychiatry or another medical specialty and/or a psychiatrist who might be available in the intake clinician’s workplace or an affiliated clinical setting. The intake clinician can also consider consulting with the client’s primary care provider regarding this issue.

— Jerrold Pollak, PhD, ABPP, ABN, is a clinical and neuropsychologist at Seacoast Mental Health Center in Portsmouth, NH, and an independent allied health professional for the Department of Medical Services in the Section of Psychiatry at Exeter Hospital in Exeter, NH.

References
Miller, G.E., & Noel. R.L. (2019). Unipolar vs. bipolar depression: A clinician’s perspective. Current Psychiatry, 18, 10-14, 16-18.

Milne, B. J., Caspi, A., Crump, R., Poulton, R., Rutter, M., Sears, M.R., & Moffitt, T.E. (2009). The validity of the family history screen for assessing family history of mental disorders. American Journal of Genetics, Part B, Neuropsychiatric Genetics, 150, 41-49.

Pollak, J. (2016). Cannabis use-neuropsychiatric effects of early onset (adolescent use). Paradigm, 20, 12-13, 22.

Pollak, J., & Miller, J. J. (2011). Mental disorder or medical disorder? Clues for differential diagnosis and treatment planning. Journal of Clinical Psychology Practice, 2, 33-40.

Pollak, J., & Miller, J. J. (2019). Advancing the medical literacy of non-medically trained mental health providers. Newsletter- Academy of Medical Psychology, September, 8, 5, 10-11, 13.