What Entails a Psychiatric Evaluation?

As you may imagine, psychiatric problems are difficult to diagnose due to their complexity and infinitely different presentations.  Often, an absolute diagnosis is not made even in the first few visits.

The first visit, however, is very important in clarifying the path that assessment and treatment will take.

Every psychiatrist has his or her own system for the initial evaluation, but we all generally cover the same information.

My initial visits with patients under the age of 18 vary.  Depending on the situation, I may meet with the patient and his or her parents together for 75 minutes, or meet the parents first and later the child.  It generally depends on the age of the child and/or the nature of the problem and the relationships between the child and parents.  I can usually give a clinical formulation and give recommendations within the first 1-2 visits.

I meet with adults for 75 minutes for the first session, summarize with a clinical formulation and give recommendations.

As you will see, there is a lot to cover in the first session and the assessment and collection of information is an ongoing process.

The following outlines the basic structure of the initial evaluation:

The History: This is the most important part of the evaluation.  This is the chance to describe the problem(s) that led up to the visit and any precipitating stressors.  A review of the symptoms the person experiences is included here.

The Past Psychiatric History: This covers any past episodes similar to the recent one, past treatment including medications used and responses (it is very helpful to know doses and amount of time on the medications), past dangerous behavior, self-harm behavior or suicide attempts, and any past hospitalizations.

Family History: Medical and mental health problems with parents and siblings are reviewed as well as problems that extended family members have had.  Genetics play a strong role in mental health problems.

Substance Use: A review of alcohol and street drug use, along with history of over-the-counter medication abuse is conducted.  This is followed with a review of tobacco and caffeine use.

Developmental History: Birth history is reviewed including pre-natal substance exposure, complications during and after the pregnancy with the client and the mother, regulatory problems during infancey, birth weight, term of pregnancy, parent(s)’ depression or other problems post-natal, developmental delays, stressors in the home during infancy, and history of sexual, emotional or physical abuse.

Medical History: Contact information for the client’s primary care physician taken, review of any current or past medical problems and medical complaints is conducted.  A history of vision or hearing problems is assessed.  Next, there is a review of any history of head injury, especially an injury with loss of consciousness, memory loss, or behavior change.  Any surgeries are assessed and history of seizure disorder.

For women, history of menses and any problems physically or psychologically are assessed as well as pregnancy history.  For the appropriate age groups, sexual history is assessed as well, including history of sexually transmitted disease.

Any other relevant medical history is obtained as well.

Social History: This history evaluates functioning in many areas of life including-

-Issues with parents, kids, siblings, and overall home life are assessed.

-Issues with significant others.

-School issues, including history of learning problems or special needs.

-Legal problems and behavior problems.

-Peers, social supports.

-Ongoing stressors a person may have.

-Work/career issues.

-For teens, driving and transportation problems.

-Individual and family strengths and interests.

-Cultural and religious issues.

Mental Status: Appearance, interaction and speech, behavior, mood and affect, thoughts and cognitive abilities are assessed.  These are informal cognitive assessments and more thorough ones are conducted by psychological testing as needed.

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