“A first psychiatric evaluation provides a chance to talk with a psychiatrist in a private, nurturing environment about your mental health concerns. Your provider will enquire about your symptoms, personal and medical history, treatment history and daily activities. This information can provide you with a better understanding of your needs and direct the next steps you should take.”
For some people, seeking psychiatric care for the first time can feel daunting, it can be a bit daunting, particularly if they aren’t sure what they will be asked or what the session will involve. A preliminary psychiatric evaluation will allow the clinician to gain a sense of your problem(s), background psychiatric history, medical history, current lifestyle and treatment objectives. By understanding psychiatric evaluation what to expect, you will feel more prepared and able to have an open, productive discussion with your healthcare provider.
The initial assessment is not a pass or fail exam. It’s a long clinical discussion that will help your psychiatrist understand your unique situation and what further steps to take.
What Is an Initial Psychiatric Assessment?
The initial psychiatric assessment is the initial comprehensive assessment by a psychiatric provider. It is to learn why you are seeking treatment and to determine symptomology and concerns, review health history and formulate a treatment plan.
The assessment might examine your current symptoms, past mental health care, medical history, medications, family history, relationships, work or school experiences and other possibly relevant circumstances for your emotional health.
There are several key elements that are part of psychiatric evaluation that are specified by the American Psychiatric Association: the indication for treatment, psychiatric symptoms and treatment history, physical health, psychosocial factors, mental status examination, and safety issues.
It is possible that the process may differ for each individual. Some exams can be highly symptom oriented and others may require much more on prior treatment, medical or life history.
What Happens During the First Psychiatric Appointment?
1. You Will Discuss Why You Are Seeking Care
The appointment will usually begin by discussing what brought you to psychiatric care. Your provider may ask about the concerns that are affecting you and when you first noticed them.
You may be asked questions such as:
- What are you worried about now?
- When did you initially observe these changes?
- How often do you get your symptoms?
- Have they become more severe or frequent?
- How are they affecting your daily life?
- What would you like to change or improve?
You might want to talk about changes in your mood, anxiety, sleep, focus, energy, motivation, behavior or capacity to cope with day to day tasks.
You do not have to figure out the right way to talk about what you are going through. It may be helpful information for the provider just to state in your own words what you have noticed.
2. Your Mental Health History Will Be Reviewed
Your provider might want to know if you’ve had psychiatric treatment or counseling before. This may include past diagnosis, therapy, psychiatric evaluations, hospitalization and medications.
You can also share what treatments you’ve used and if they helped, caused side effects, or if they didn’t give you what you wanted.
The information regarding treatment in the past is relevant as it will give the provider a better idea of the history and can help to inform the future. The assessment does not just have to take place in the present. Knowing what happened in the past can be useful for understanding the clinical context.
3. Your Medical History and Medications May Be Discussed
Mental health can affect physical health, and physical health can impact mental health. Your provider may inquire about your entire medical history. Any present health problems, prior illnesses, surgery, allergies, sleeping problems etc.
You will also be asked to go over any prescription, over the counter, vitamins or supplements you are taking.
This information may be relevant in the psychiatric context and for treatment. Because some medical conditions can manifest symptoms that resemble mental health issues, a thorough assessment might take into account both physical and mental health.
Previous healthcare providers’ records may be helpful in giving a history if you have them.
4. Your Family and Personal History May Be Explored
Your provider may ask about your family mental health history and important aspects of your personal and social background.
Questions may cover:
- Family history of mental health conditions
- Important relationships
- Current sources of support
- Work or school
- Major life changes
- Significant stressors
- Living situation
- Previous experiences that may affect your mental health
These questions help you position your symptoms within the framework of your life. Two people can have similar symptoms for completely different reasons, so knowing the individual’s circumstances can assist a clinician make a more tailored assessment.
5. Your Current Symptoms Will Be Explored in More Detail
You may be asked more details about your symptoms by your doctor. When discussing anxiety, they may ask when it’s worse, how bad it is and how it affects your life.
Your provider might also ask about sleep or mood changes, how long they have been present, how intense they are and how they impact your function.
May involve mood, anxiety, sleep, hunger, attention, energy, thoughts, behavior and feelings.
6. You May Be Asked About Substance Use and Safety
Initial assessments may include alcohol, tobacco, recreational drug and medication use questions. These questions help providers identify factors that may affect symptoms, health or treatment.
When clinically appropriate, a doctor may ask about self harm, suicide or injuring others. These are common questions that are part of responsible psychiatric evaluation and are designed to assist in determining safety issues.
Elements of psychiatric evaluation include assessment of suicide, self injury, and aggressive behavior, according to the American Psychiatric Association.
It is crucial to be truthful about safety issues. In case of a mental health crisis, or if you think you or someone else may hurt yourselves, don’t wait for a regular appointment, call for emergency help.
What Is a Mental Status Examination?
A mental status examination is another part of many psychiatric assessments. It does not necessarily involve a complicated physical test. Instead, the provider observes and evaluates aspects of your current mental and emotional functioning during the appointment.
Depending on the situation, the provider may consider:
- Appearance and general behavior
- Speech
- Mood and emotional expression
- Thought patterns
- Attention and concentration
- Memory and cognition
- Perception
- Insight and judgment
The mental status examination helps the provider understand your current presentation and identify symptoms or concerns that may not be fully captured through questions alone. The American Psychiatric Association describes it as a systematic collection of information based largely on clinical observation during the interview.
You may also complete questionnaires or symptom screening tools. These can be used to help give more details regarding the severity or pattern of some symptoms. It is important to remember, however, that the assessment measures are not used to diagnose the condition but should be used in conjunction with clinical judgement.
Will You Receive a Diagnosis During the Assessment?
Sometimes, an evaluation can provide enough information to make a diagnosis. Other times, more information or follow-up appointments may be required to come to a definitive decision.
Psychiatric diagnosis is not a diagnosis based on just one symptom or one questionnaire. The provider should take into account the length and intensity of symptoms, how they affect daily functioning, medical issues, past history, and other factors that could account for the symptoms.
DSM criteria are used by educated healthcare professionals to diagnose mental disorders.
Your doctor may not diagnose you immediately away. If symptoms overlap and many causes are considered, it may take time to assess.
What Happens After the Psychiatric Assessment?
The doctor may discuss their initial thoughts and next steps at the end of the session. Treatment recommendations depend on symptoms, history, preferences, goals and situation.
After this, you might:
- Managing medication
- Counseling or psychotherapy
- Additional assessment
- Medical evaluation
- Referrals to another healthcare professional
- Follow up psychiatric appointments
- Monitoring symptoms over time
Not everyone’s treatment is the same. Your provider might talk about other options, possible benefits, and possible risks, and what might work for you.
How Can You Prepare for an Initial Psychiatric Assessment?
You do not have to know all the answers prior to the appointment. But it’s possible to be more effective when you need to share information.
Before your assessment, consider:
- Writing down your main concerns and symptoms
- Noting when your symptoms started
- Listing your current medications and supplements
- Gathering relevant medical or psychiatric records
- Thinking about previous treatments and your response to them
- Identifying your main treatment goals
- Writing down questions you want to ask
You can also consider how your concerns impact your life, such as sleep, work, school, and relationships, as well as routine activities.
Most importantly, try to be honest and open in the appointment. There is no need to use medical or technical terms or to describe your experiences in a specific manner. If more information is needed, your provider can ask additional questions.
This is a list of some of the most frequently asked questions about psychiatric evaluation.
Psychiatric Evaluation What to Expect: Common Questions
How long does an initial psychiatric assessment take?
The duration may vary based on your concerns, history, and how much information the provider has to look at. More complex situations may require additional time or follow up appointments.
Should I bring anything to my appointment?
A current medication list, pertinent medical charts, past psychiatric charts and a list of questions may be beneficial. Notes of symptoms that you wish to discuss can also be brought.
Is an assessment only for people who already have a diagnosis?
No, you can make a psychiatric appointment to see if you have symptoms or changes that you are concerned about, even if you have never received a mental health diagnosis.
Take the First Step Toward Understanding Your Mental Health
The first psychiatric evaluation is a chance to talk about what you are feeling and to get a professional’s understanding of your concerns. Usually, it includes examining the symptoms, mental and medical history, and personal life, as well as medication and safety issues and treatment objectives.
There is no need to know the exact diagnosis you have or the treatment you require, prior to your appointment. That is part of what the assessment is designed to help determine.
If you are looking for personalized psychiatric care, Mind Matters Psychiatry provides initial psychiatric assessments designed to understand each person’s individual needs and concerns. Learn more about the Initial Psychiatric Assessment at Mind Matters Psychiatry and the next steps toward receiving appropriate psychiatric care.
