As you may imagine, psychiatric problems can be difficult to diagnose due to their complexity and infinitely different presentations.
At times, an absolute diagnosis is not made even in the first few visits. The initial visit, however, is very important in clarifying the path that assessment and treatment will take. Every provider has his or her own system for the initial evaluation, but we all generally cover the same information.
We meet with patients for up to 60 minutes for the first session, which includes a clinical formulation and treatment 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 a psychiatric diagnostic evaluation:
History
This is the chance to describe the problem(s) that led up to the visit and any precipitating stressors.
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
We will review any medical and mental health problems of parents and siblings.
Substance Use
We will discuss alcohol and illicit drug use, along with any history of over-the-counter medication abuse.
Medical History
During this review, we will gather contact information for the primary care physician and discuss any current or past medical problems or concerns. We will also discuss any history of head injury, especially an injury with loss of consciousness, memory loss, seizures, or surgeries.
Social History
This history evaluates functioning in many areas of life. Topics covered include issues with significant others as well as school-related concerns, such as a history of learning problems or special needs. We also discuss any legal issues, work/career concerns, behavioral problems, individual and family dynamics, as well as cultural and religious issues.
What to Bring
If Applicable and Able To:
Current medication bottles
Prior mental health records
Current medical records
Work history
Academic records
