Psychiatric Case Formulation Assistant
Structure psychiatric assessments with evidence-based biopsychosocial case formulations
What You Can Do
This skill guides you through structured psychiatric case formulation using a biopsychosocial framework. You input patient presentation, assessment data, and clinical history, then receive a comprehensive formulation that integrates symptom synthesis, differential diagnosis reasoning, predisposing/precipitating/perpetuating factors, protective factors, and evidence-based treatment recommendations. The output is suitable for clinical documentation, insurance authorizations, case conferences, and supervision.
Features
organizes clinical data across biological, psychological, and social domains for comprehensive case conceptualization
systematically explores diagnostic possibilities with clinical reasoning for each consideration
identifies vulnerability factors, triggering events, and maintaining mechanisms
highlights resilience and strengths that inform treatment approach
justifies medication selection, psychotherapy modalities, and ancillary interventions with clinical reasoning
generates medical necessity documentation suitable for payer review and approval
incorporates suicide/homicide risk formulation within the broader case context
structures cases for teaching and consultation with clear reasoning pathways
Example Output
Example 1: Complex Mood/Anxiety Presentation
Biopsychosocial Formulation:
- Biological: Family history of bipolar disorder; recent thyroid dysfunction; poor sleep hygiene; inconsistent medication adherence
- Psychological: Perfectionism, rumination patterns; history of emotional invalidation in childhood
- Social: Recent job loss; strained marital relationship; limited social support network
Differential Diagnosis Reasoning: GAD vs. MDD with anxiety vs. Bipolar II with mixed features (elevated goal-directed activity despite depressed mood argues against pure MDD; cycling pattern supports bipolar consideration)
Treatment Recommendation: Initiate mood stabilizer (lamotrigal) with SSRI tapering; cognitive behavioral therapy targeting perfectionism; sleep hygiene intervention; marital therapy.
Example 2: Treatment-Resistant Schizophrenia
Perpetuating Factors: Antipsychotic non-adherence due to sexual dysfunction side effects; ongoing cannabis use; family expressed emotion; limited vocational engagement.
Protective Factors: Intact cognitive functioning; strong maternal relationship; interest in music therapy.
Clinical Formulation: Poor response to risperidone likely attributable to adherence and ongoing substance use rather than true pharmacologic resistance. Recommend: clozapine trial with sexual dysfunction monitoring; substance abuse counseling; family psychoeducation; supported employment referral.
What's Included
- SKILL.md instruction file with detailed case formulation methodology:
- Biopsychosocial Assessment Template: structured form for organizing presenting complaint, history of present illness, and relevant background
- Differential Diagnosis Worksheet: framework for systematically evaluating each diagnostic consideration
- Case Formulation Document Template: clinical record-ready format for comprehensive formulation
- Treatment Planning Checklist: evidence-based interventions matched to formulation elements
- Insurance Authorization Template: medical necessity language for payer submissions
Who It's For
- Practicing Psychiatrists — comprehensive case documentation for complex diagnostic presentations
- Psychiatric Residents and Fellows — structured learning model for case conceptualization and clinical reasoning
- Forensic Evaluators — systematic approach to complex cases involving legal/risk considerations
- Consultation-Liaison Psychiatrists — thorough formulations for medical-psychiatric comorbidity cases
- Medical Students in Psychiatry Rotation — educational framework demonstrating expert clinical thinking
Best For
- Complex diagnostic presentations with differential diagnosis uncertainty
- Treatment-resistant cases requiring documented clinical rationale
- Insurance authorization requests demanding medical necessity justification
- Supervision and case conferences with trainees or peers
- Documentation of systematic clinical reasoning for medicolegal protection
- Integrated treatment planning across medication and psychotherapy modalities
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