The most important part of a psychiatric evaluation is the interview with the patient. An adult patient can expect to spend approximately 45 to 90 minutes with the psychiatrist during the initial evaluation. Usually the patient fills out paperwork before the meeting. This generally includes a questionnaire of basic information such as name, address, phone number, insurance information, and an emergency contact. Some questionnaires ask for the presenting problem (the problem that is bringing the patient to see the psychiatrist). There may be a list of potential symptoms that the patient can check off as applicable, such as “I feel down or blue,” “my appetite is not what it used to be,” “I have trouble sleeping at night.” Sometimes, people feel more comfortable expressing painful feelings in writing, and these types of questionnaires can be a helpful source of information.
The adult patient will be interviewed individually unless s/he wishes to include a spouse, family member, or friend who can provide helpful information. Adults must give consent, or permission for their psychiatrists to speak to others about them. This is to protect the patient’s privacy and confidentiality. The exception to this would be in an emergency, if the patient was at risk of harming himself/herself or others. For example, if a patient told a psychiatrist that he planned to kill himself that evening, the psychiatrist could not keep this confidential and would be obligated to arrange hospitalization. A judge can also subpoena patient records.
During an initial interview, a psychiatrist will typically ask of a series of questions to help determine the underlying problem and how best to treat it. Some of the interview is open-ended, during which the patient says whatever is on his or her mind. However, the psychiatrist must also ask certain specific questions to gather the necessary information to finish the interview in the time provided. Psychiatrists like to start appointments on time and end them on time so that the patients know what to expect, and so that others are not kept waiting.
During the interview, the psychiatrist will look for signs and symptoms of psychiatric conditions. Symptoms are subjective evidence-the feelings experienced by the patient. Signs are objective evidence-that which can be observed by other people. For example, a depressed person may have the symptom of sadness and the sign of tearfulness. An anxious patient may have the symptom of nervousness and the sign of restlessness. If you had strep throat, you would have the symptom of soreness after swallowing and the sign of a bright red throat. (Sometimes, the word “symptoms” is used to signify “signs and symptoms.”
A standard evaluation includes the chief complaint, history of present illness, and past psychiatric, developmental, medical, family and social history, including use of alcohol or recreational drugs. The chief complaint is the presenting problem, generally the answer the patient gives when asked by the psychiatrist, “What brings you in here today?” The history of present illness is a description of the symptoms and problems leading up to the chief complaint. The past psychiatric history includes past psychiatric diagnoses, medications, psychotherapy, and hospitalizations. Medical history includes current and past medical problems, surgeries, medications, and allergies. It is important for a psychiatrist to know about all medications that a patient takes, even over-the-counter and herbal remedies or vitamins, to ensure that they don’t interact with a psychiatric medication that might be prescribed. Social history includes such issues as family life, school, jobs, hobbies, friendships, alcohol and/ or drug use, and any history of trauma or abuse.
There are certain standard questions that psychiatrists must ask during a psychiatric evaluation, whether or not they think that a patient will answer “yes.” Some of my patients, particularly teenagers, have told me that they felt insulted when past health providers asked them these questions. The most frequent offenders are “have you had thoughts of hurting yourself?” “Have you had thoughts of hurting others?” “Have you used alcohol or recreational drugs?” “Have you ever used laxatives or made yourself vomit to lose weight?” “Are you sexually active?” “Have you ever been physically or sexually abused?” “Have you ever heard voices when no one was in the room?” The teenagers feel insulted that the psychiatrist is “assuming” that they must be using drugs or be ill enough to be hallucinate. I explain that psychiatrists ask all new patients these questions because it is important not to miss a “yes” response. People are sometimes reluctant to volunteer information unless they are asked. It would be very harmful not to realize that a patient was feeling suicidal or was at risk for a sexually-transmitted disease.
An evaluation of a child can be conducted in a few different ways. Ideally, the parent(s), guardian(s), and child can be interviewed separately at least once and together at least once. It is preferable that all parents and guardians be interviewed. A telephone interview can be arranged if one parent is out-of-state. The advantage of interviewing the caregivers separately from the child is that it allows them to share information privately. However, a group session is also useful to provide information on how family members communicate with each other. A psychiatrist will try to respect a child’s privacy and give parents feedback in general terms, such as a summary of the assessment and recommendations.
A psychiatrist is legally obligated to obtain written consent from the parents or guardians to talk to other people about the patient. The child does not need to give consent, but the psychiatrist will try to work with the child and explain why talking to others is important. A psychiatrist might wish to talk to a child’s therapist, pediatrician, teacher and/or former clinicians.
The exception to the confidentiality rule is if a clinician suspects that the child is being abused. Clinicians are legally required to report suspected abuse to the Department of Social Services whether or not the guardian gives consent.
Sometimes psychiatrists use semi-structured interviews to diagnose patients. These consist of a series of standardized questions about different possible symptoms. The psychiatrist can hone in on the diagnosis based on the answers given. It is semi-structured (not completely structured) because psychiatrists can ask their own questions in addition to the standard questions. These types of interviews are carefully tested to ensure that they yield accurate diagnoses. A popular interview for children is the K-SADS (Kiddie-Schedule for Affective Disorders and Schizophrenia).
A psychiatrist may order blood tests since certain medical problems can mimic psychiatric conditions. Low thyroid function can cause poor mood, energy, concentration and motivation, which may be mistaken for depression. Overly high thyroid function can cause restlessness, insomnia, excessive energy, racing heart, and even psychotic thinking. This could look like mania, anxiety or ADHD.