What Happens in a Psychiatric Evaluation?
When you hear the words psychiatric evaluation, you may experience anxiety and fear as you wonder what exactly that is and whether it means you’re crazy. In this article, I will address the following questions:
What is a psychiatrist?
There are so many psy- professions out there – Psychiatrist, psychologist, psy-D, for example – that it can be confusing to even understand the difference.
The prefix psycho- derives from Greek. It denotes “mind, mental; spirit, unconscious.”
A psychiatrist is a medical doctor. Like all doctors, psychiatrists must complete college and medical school. Psychiatry is a medical specialty, just like cardiology or surgery. In other words, a psychiatrist is a medical doctor specialized in the treatment of mental illness.
All medical doctors share the following educational and clinical experiences:
Completion of undergraduate educational requirements to enter medical school including coursework in basic sciences such as biology and chemistry.
Completion of medical school educational requirements including anatomy, physiology, and pathology.
Clinical experience in hospitals and outpatient clinics in the specialties of primary care, internal medicine, surgery, pediatrics, psychiatry, obstetrics and gynecology, neurology, and emergency medicine.
Additional clinical experience in specialties of interest.
Upon graduating medical school, students officially become doctors, denoted by MD (for Doctor of Medicine) or DO (for Doctor of Osteopathy). However, new doctors cannot practice medicine until they complete further training called residency.
Depending on the specialty, residency lasts for at least 3 years. During residency, doctors work in various branches of their chosen specialty, while also completing requirements in other relevant specialties.
Psychiatry residency lasts 4 years. In addition to working in the field of psychiatry, residents must also work in internal medicine, neurology, and emergency medicine. Within the field of psychiatry, residents must work in the hospital as well as in outpatient clinics in various sub-specialties of psychiatry including child and adolescent, addiction, consult-liaison, geriatrics, and community psychiatry. Simultaneously, residents must complete coursework throughout their training. Upon completion of residency, psychiatrists may enter practice, or they may choose to pursue further training called fellowship if they wish to sub-specialize.
Why would I see a psychiatrist rather than another mental healthcare professional?
Psychiatrists are the only mental healthcare professionals who are medical doctors.
As such, psychiatrists are uniquely positioned to evaluate mental health symptoms in a medical context. Many symptoms of mental illness may relate to underlying diseases such as anemia, hypothyroidism, nutritional deficiencies, and dementia. Psychiatrists can screen, evaluate, and treat these underlying diseases, and they have received the most training to do so.
Psychiatrists can prescribe medications.
Medications are often an important part of a treatment plan. Psychiatrists, psychiatric physician’s assistants and psychiatric nurse practitioners are the only mental health care professionals who are allowed to prescribe medication, except for some states which allow psychologists to prescribe medication. Of all mental health care professionals who can prescribe medication, psychiatrists have received the most training to do so.
If you need both therapy and medications, you can receive both services from one psychiatrist.
This is not just practically convenient. There are major therapeutic implications to having one provider for both therapy and medication. When a psychiatrist is also a skilled therapist, he or she can understand whether your symptoms need to be addressed with a medication intervention, a therapeutic intervention, or both. As such, a psychiatrist who also acts as your therapist has the greatest insight into what is happening in the global picture of your mental health and can tailor interventions holistically.
Another important advantage to having one provider for therapy and medication is to avoid what’s known as splitting. Splitting refers to an unconscious process in which things are seen as good-or-bad, black-or-white. Clinically, this means that one provider may be seen as good and another provider as bad. Splitting can lead to poor patient outcomes if, for example, the therapist is seen as good and the psychiatrist is seen as bad, and as a result, the patient selectively shares information among providers.
Some styles of therapy are dedicated to helping patients work through this split and to see things as good-and-bad, black-and-white. It is often easier to work through this split if the patient only has one provider and therefore does not have the option of avoiding conflicting feelings.
Psychiatrists have the most extensive educational and training requirements of any mental healthcare professional.
As described above, the training to become a psychiatrist is long and arduous. At a minimum, it consists of 4 years of college; 4 years of medical school; and 4 years of residency. That is 12 years at a minimum, which may be even longer if a psychiatrist pursues a sub-specialty. Psychiatrists receive training in all aspects of mental health – biological, social, psychological. This global knowledge comes at the expense of less time dedicated to specific aspects of mental health relative to other mental healthcare professionals. However, the fact remains that psychiatrists are required to spend the most time in education and training before being able to practice.
What happens during a psychiatric evaluation?
A psychiatric evaluation consists of two parts: history taking and mental status examination.
History Taking
Taking a history is what all doctors do when they ask questions. Doctors need to know information about your health in the past and present to try to understand the cause of your current symptoms. In psychiatry, a complete history includes the following components:
History of Present Illness - what brings you in to seek treatment today?
Past Psychiatric History - what kind of mental health symptoms and treatment have you had in the past?
Past Medical History - what other medical conditions do you have?
Medication - what medications and supplements are you taking currently?
Allergies - what drug allergies do you have?
Family History - what mental health conditions run in your family?
Developmental and Social History - how was childhood, school, career, relationships? How is your current living situation?
Psychiatric Review of Systems - what other psychiatric symptoms might you be having, which haven't been covered by the prior questions?
A psychiatrist may not address all of these components in the first visit, but he or she should address enough components in order to make a targeted treatment plan.
Mental Status Examination
Photo Credit: Ani Kolleshi
The second part of the evaluation, the mental status exam, is the mental health equivalent of a doctor's physical exam. For example, when you see a primary care doctor, he or she will take your blood pressure and pulse, and listen to your heart and lungs with a stethoscope. That is a physical exam. In mental health, rather than evaluating your body by physically touching and measuring things, a psychiatrist evaluates your mental status by watching and by listening. A psychiatrist pays attention to your body language, your facial expressions, the tone of your voice, and the themes that you bring up, among other things. This is extremely important in mental healthcare because the topics that come up are often emotionally charged and difficult to discuss. It is incumbent upon a skilled psychiatrist to pick up on the subtleties and nuances of what you are feeling both for the purpose of making an accurate diagnosis and, even more importantly, for the purpose of building a solid relationship in which you feel heard, seen, understood and safe.
Why are psychiatric evaluations important?
Mental health can be a very confusing field. A common symptom such as anxiety can have many different causes. For example, you could have a medical issue such as hyperthyroidism which causes you anxiety. You could be experiencing a major stressor like a conflict at work or at home. You could have had anxiety all of your life and wondered if it's in the normal spectrum of day-to-day anxiety or if it's actually an anxiety disorder. You could have an anxiety disorder, or you could have anxiety that is actually a symptom of another disorder such as depression or trauma.
A thorough psychiatric evaluation is the best way to assess all possible causes of a current mental health symptom. An accurate assessment is the foundation of effective treatment. In other words, you have to know what you're treating in order to treat it correctly.
One important note to this entire article: Sometimes it can be scary to find out what's going on. In this article, I've described what actually goes into a psychiatric evaluation in terms of all the training that is required for it and then the actual evaluation itself. In some ways, this is the behind-the-scenes, psychiatrist's perspective. However, what matters the most is that the psychiatric evaluation is the first contact in establishing a patient-doctor relationship. And every good doctor knows that the patient-doctor relationship is the foundation for the entire course of treatment, without which no treatment can occur.
Personally, in my evaluations, I always like to ask my patients what they notice, what they worry about and what they feel that they need. I find that sometimes, people really want to take a deep dive and try to understand what they're experiencing; other times, people are just worried and/or confused, and they want a space to talk about that and feel safe. Medicine, especially psychiatry, is an art. It is the art of creating a relationship with someone who may feel scared, vulnerable, upset and ashamed; and giving that person the space to face whatever makes them feel scared, vulnerable, upset and ashamed. This is perhaps the most important part of the psychiatric evaluation, and it is not written in any book. In my book, though, the psychiatric evaluation is about understanding the person in front of me, and understanding how to create a relationship which allows that person to do what they need to do to feel better.
