Psychiatry STACER Preparation Guide

The Standardized Assessment of a Clinical Encounter Report (STACER) is a semi-structured examination of Canadian psychiatry resident’s interviewing and consultancy skills. An STACER examination is usually a 50 minute diagnostic interview of a volunteer patient that both the resident and examiners do not know. The purpose of the STACER is to demonstrate your psychiatric interview skills, present a mental status examination, generate a comprehensive DSM-5 diagnosis (and differential diagnosis), a biopsychosocial formulation of the patient, and finally, a comprehensive treatment and management plan.

Think of the STACER as interviewing a patient for the purpose of taking over their care. This means you must gather as much information as possible during the 50 minute diagnostic assessment. The challenge with the interviews and questions on STACER examinations is that it is not the same as what you do in real life when you see patients. In the real clinical setting, we try to know our patients over multiple visits, we have old charts and collateral, and we don't have the pressure of examiners in the room!

One of the most challenging parts of a STACER is you are given a random, real patient to do a 50 minute assessment on. Since patient's symptoms may range from being in remission (i.e. - an outpatient) to being very symptomatic (i.e. - an inpatient), this can each present as a challenge in their own way. Here are some common patient “prototypes” that you may encounter.

A STACER with an inpatient can sometimes be easier because there is a clear precipitating factor leading to a hospital admission. This means you can usually formulate the current presentation or reason for admission, and this makes your formulation at the end cleaner.

A STACER with an outpatient can be more challenging because their psychiatric disorder may be in remission, or they may have minimal symptoms. In this case, you may end up formulating the patient's overall course of illness and diagnosis, or their last episode of illness. Pick one thing to formulate, and stick with it. Thus, you will want to get the past psychiatric history up front, as there is no “real HPI.” The easiest way to approach the outpatient is to ask them “when were you last unwell?”

A STACER with a patient who is vague, tangential, or circumstantial can be very challenging!

• If you become confused by a patient's psychiatric history, ask them:
  • When were you last well, or when did the functional decline begin?
  • When you were really well, what did you do? What was your premorbid function?
  • How many times have you been admitted to hospital for a psychiatric problem?
  • What was the admission for?
  • What was the admission like for you?
• If the patient isn't able to give you a medication history, really try to nail it down by asking specific questions such as:
  • Is it an antidepressant? Antipsychotic?
  • Is it [name of medication?]
  • Did you take the medication reliably all the time?
• Get a rough timeline by asking:
  • Days, weeks, months, or years?

A STACER with a patient who becomes affectively dysregulated and tearful during the interview can be difficult to manage as well.

• Be empathetic and don’t forget to attend to the patient in front of you (give them tissues if they're crying!!!)
• Acknowledge when the interview is difficult and patient is having trouble, try to contain the interview as much as possible by asking less affectively laden questions, return back to thse questions when the patient settles

The STACER lasts usually between 90 minutes to 120 minutes, with the following breakdown of times:

• Interview (60 minutes)
  • 50 minutes for interview with patient
  • 10 minutes for presentation preparation (patient is gone)
• Case Presentation (20-25 minutes)
• Examiner Questions (20 minutes)

• Explain the purpose of the STACER, and that this is an examination for you and for your own learning
• Explain limits of confidentiality

• Ask patient are they an inpatient or outpatient?
• Are they voluntary or certified/formed?
• What is the working diagnosis they have been given?
  • You might want to quickly check their insight by asking:
    • What do you think about the diagnosis? The treatment they're on?
    • What are the goals of treatment? Are they eventually going to outpatient or inpatient care?
    • What's the plan for the future?
• What treatment are they on?
  • Medications
    • Is it working for them?
    • What is the dose?
    • History of medication non-adherence?
  • Therapy
    • Is it working for them? Why or why not?

• Get a chronological timeline
  • When was your first contact with psychiatrist or mental health?
  • # of hospitalizations, or # of episodes of psychiatric symptoms
  • Are there periods of wellness between hospitalization or episodes?
  • What treatments or therapy have they had?
  • Ask specific timeline questions
    • Was that [weeks, months, years] ago?
  • Who are their mental health providers?
    • Family doctor, psychiatrist, psychologist, counsellor, social worker (this helps you identify protective factors)

• If you don't get a good personal history, you won't get a good formulation!
  • “Are there any other major life events that have contributed to who you are today?”

• Establish the index psychiatric event:
  • First when you felt you were becoming unwell
  • First when you were in contact with the mental health system
  • These two may not always occur at the same time! For some people, they may never remember a time where they were feeling well (hint: might want to think about persistent depressive disorder, traumas, and personality disorders)
• For example, if you're not sure whether mood symptoms or psychotic symptoms started first, ask yourself:
  • Is it schizoaffective disorder? (i.e. - are there clear psychotic symptoms in the absence of mood symptoms for > 2 weeks?)
  • Is it schizophrenia? Are there prodromal symptoms (i.e. - was there a significant functional decline during high school/university? Did they become more withdrawn? Other prodromal symptoms?)

• If substance use is a primary concern, then address:
  • Substance use disorder criteria
  • Impact of substance use on the individual and to others
  • Motivation to change

• Getting the patient to self-formulate can be helpful!
• Discuss the impact of family on relationships
• Understand issues from a cultural and family perspective if possible

Key things to ask on a geriatric STACER include:

• Functional Review
  • ADLs, IADLs
  • Hearing/Vision
  • Geriatric Giants, including: Falls (fears of falling), incontinence, polypharmacy, and cognition
  • Supports: home care, day programs, private/public care, family supports
• Safety
  • Driving
  • Wandering, getting lost
  • Leaving food on stove
  • Forgetting to turn off taps
  • Are there grandchildren in the home who might be at risk?
• Medications
  • Are medications blister packed? What is the medication adherence?
  • Use of any OTC/Supplements/Herbals!
• Family history
  • Needs to include history of neurodegenerative disorders
• Cognitive screening
  • At a minimum get orientation questions (date, time, place location)
  • Do a Mini-Cog if there is any suspicion about cognitive impairment
  • If neurological exam is indicated, do it!
• Mood disorders
  • If depressed, ask about somatic delusions and delusions of poverty (common in the elderly)
• Common diagnoses to consider:
  • Late-life depression
  • Mild cognitive impairment
  • Neurodegenerative disorders

• Comment on patient reliability at the outset
• Save yourself by mention what you missed on history (but mention it once and then move on, don’t apologize too much!), and also what else you would have liked to collect if you had more time
• If you intentionally skipped certain things on history - also justify it (e.g. - “I did not screen for OCD symptoms because it was low on my differential”)
• Summarize and synthesize, do not present everything you got from the patient all over again! The examiners were there in the room too!
• Don't forget to bring up major safety issues identified on the history

• Describe a fulsome mental status
  • Comment on patient's reliability, accessibility
  • Comment on abnormal motor movements, frailty, hearing impairment, gait aids, tremors
  • Comment on cognition, even if you didn't do formal testing!
  • Is their mood-congruent, consistent with subject matter
  • Mention any aphasia
  • Explain cognition (i.e. - no language deficits, no word finding difficulties, etc.)
  • Are there somatic delusions, nihilistic, delusions of poverty (common in the elderly)

Present your main diagnosis and differential diagnoses. Explain why you believe the patient meets criteria for the main diagnosis and why the other diagnoses are less likely.

• State exactly what you are formulating (“I am formulating …”)
  • Outpatient: you might formulate their history of recurrent depression, their most recent episode of depression, their chronic depression, their anxiety symptoms, their personality (e.g. - sensitivity to invalidation), or distress
  • Inpatient: current presentation or admission
• Formulation themes for the “psycho” part of biopsychosocial include:
  • Low self-esteem
  • Identity issues
  • Safety/security
  • Control
  • Autonomy vs. dependency
  • Intimacy/sexuality
  • Trust
  • Attachment
  • Loss
• Stick with a theme or framework that makes sense to you:
  • Attachment theory: secure, dismissive, preoccupied, fearful/disorganized attachment
  • Psychodynamic: unconscious conflicts and defenses
  • Cognitive behavioural: core beliefs and automatic thoughts
  • Dialectical behavioural: emotional dysregulation and invalidation
  • Interpersonal: interpersonal themes (grief, dysfunctional relationships, interpersonal conflicts, and role transitions)

Outline your management plan very clearly:

1. Save yourself: Identify any missing information that you did not get in the interview that you would like to obtain now (shows self-awareness of your limitations)
2. Safety: Identify any safety concerns (SI/HI, AH/VH, driving risks, risks to children)
3. Status: Inpatient or outpatient, voluntary or involuntary; what is their capacity to consent to treatment?
4. Collateral: Talking to patient's family, friends, doctors, social workers for safety assessment or diagnostic clarification
5. Biological:
   • Short-term:
     • Investigations: Blood work (CBC, TSH, B12, electrolytes, extended electrolytes), neuroimaging, urine testing, urine dipstick (if woman of childbearing age), baseline ECG if > 40 years old
     • Medications:
       • Start a new medication
       • Stop a current medication
       • Switch to a new medication
       • Titrate medication to therapeutic dose
       • Continue current medication if it's going well
   • Intermediate:
     • Rating Scales: Use scales to assess symptoms and response to treatment
     • Medication monitoring:
       • Extrapyramidal symptoms, tardive dyskinesia, AIMS
       • Drug plasma levels (e.g. - lithium)
       • Antidepressants: electrolytes
       • Antipsychotics: prolactin, metabolic monitoring (fasting glucose, lipids, cholesterol, weight, waist circumference)
       • Lithium: parathyroid, TSH, calcium
     • Referral to another specialist if needed
   • Long-term
     • What is the overall adherence with medications? If there is non-adherence, might the patient benefit from a depot or a Community Treatment Order (CTO)?
   • Substance Use
     • Anti-craving medications and replacement therapies
6. Psychological
   • Short-term:
     • Psychoeducation about their illness (e.g. - bipolar disorder requires psychoeducation around seasonality, medication discontinuation, substance use)
   • Intermediate/long-term:
     • Self-help, bibliotherapy
     • Psychotherapies:
       • Pick a psychotherapy is relevant for not just the illness, but also the patient
       • CBT, DBT, dynamic, supportive, group therapy, family therapy, couples counselling, mindfulness, AA, etc.
     • Family support and interventions
     • Bipolar disorder: Interpersonal Rhythm Therapy
     • Depression: CBT, IPT (if there are psychosocial precipitants like losses, role transition, role dispute, bereavement)
     • Psychosis: CBT for psychosis, social skills training, cognitive remediation
     • Borderline personality: DBT (to build interpersonal skills)
     • Behavioural activation
   • Substance Use
     • What stage of change are they at and could they benefit from motivational interviewing? Could they use addictions support and rehabilitation services?
7. Social
   • Employment Assistance Programs
   • Job interventions
   • Finances
   • Volunteer Organization (pets, animals)
   • Intensive Case Management
   • Clubs
   • Art Therapy
   • Income assistance
   • Engaging them to do more meaningful work
   • Family Doctor, Psychiatrist, Social Work involvement, Counsellor Involvement
   • Think creatively!

Jane Doe is a 17 year old female, single, in Grade 12, who reports symptoms of inattention, low mood, and chronic suicidal ideation for the past 1 year. There are no symptoms of grandiosity, reckless behaviours, or impulsivity. She does not have any symptoms of psychosis such as hallucinations, delusions or

On medical history, she has a hypothyroidism and a traumatic brain injury at age 7 from playing hockey. There is a 1 year history of alcohol use, with withdrawal seizures, blackouts, and overuse. On personal history, she has some questions about her sexual identity and relationships with others. She has thoughts of suicide, but no plan or intent. Home environment is safe and there is no abuse from adults or others in the home.

1. Save yourself: “I would like to ask more around the patient's relationships and issues around gender identity.”
2. Safety: Patient has a history of chronic suicidal ideation, but no plan or intent. There are no safety concerns at home, and no concerns about child abuse.
3. Status: There is no role for involuntary hospital admission and she is suitable for ongoing outpatient care.
4. Collateral: Talk to the patient's family, friends, doctors, social workers for diagnostic clarification
5. Biological:
   • Short-term:
     • Investigations: Blood work (CBC, TSH, B12, electrolytes, extended electrolytes), baseline ECG, baseline weight/height/BMI
     • Medications: Start a stimulant medication for ADHD (pick a medication and describe the titration schedule and dosage). Consider anti-craving medications and replacement therapies for alcohol use (pick a medication and describe the titration schedule and dosage).
   • Intermediate:
     • Medication monitoring:
       • Weight, height, and blood pressure measurement from stimulant use
6. Psychological
   • Short-term:
     • Psychoeducation about ADHD and alcohol use
     • Behavioural management at school
   • Intermediate/long-term:
     • Motivational interviewing for alcohol use
     • Family support and interventions
     • Family systems therapy
     • Parenting support
   • Substance Use
     • What stage of change are they at and could they benefit from motivational interviewing? Could they use addictions support and rehabilitation services?
7. Social
   • Short-term
     • Liaise with patient's GP, psychiatrist, and school counsellor
   • Long-term
     • Develop an individualized education plan, work with teachers to identify psychoeducational challenges

• Transition to Psychiatric Residency: Unique Stresses; Unique Rewards
• Awdish, R. L. (2017). A View from the Edge—Creating a Culture of Caring. New England Journal of Medicine, 376(1), 7-9.
• De Leon, J. (2013). Is psychiatry scientific? A letter to a 21st century psychiatry resident. Psychiatry investigation, 10(3), 205-217.