What to Expect in a Psychiatric Evaluation
- Chris Masuda
- May 15
- 4 min read
I wanted to write about what to expect during a psychiatric evaluation after I saw someone this month who let me know how much anxiety they had before coming to see me. This feeling is one that I have heard countless times, which is ironic considering I'm a short soft spoken asian woman who used to cringe at the word ''conflict''. Of course, it's not about my appearance. It's about the fact someone is in my office getting ready to talk about deeply personal things with a complete stranger. It's enough to make anyone nervous, from kids to the elderly, from the quiet to the outspoken, from a teacher to a combat veteran. I hope that knowing what to expect may help alleviate just a teaspoon of that fear.
There are all kinds of psychiatric evaluations and I'd like to outline how I structure most of mine. The evaluations I do tend to be an hour long and focused on diagnosis and treatment in an urgent care outpatient setting. I have folks sit in the waiting room, then I walk out to get the patient. I introduce myself, we sit down, and I ask what brings them in. I typically just listen for the first 15 minutes to anything the patient wants to tell me about what they're struggling with.
After the patient has gotten the most pressing things off their chest, I ask questions about symptoms and their history. I'll ask about things like how mood, anxiety, sleeping and eating have been lately. I'll contrast that with how those were in the past. I screen for certain disorders with brief clusters of questions such as ''have you ever had nightmares or re-experiencing bad things during the day?'' If someone says yes to something, I might ask follow up questions. I also like to understand the current stressful things in the person's life.
I then ask questions in order to get certain parts of medical and psychiatric history to aid me in diagnosis and treatment. Buckets of information I need to get include things like medical conditions (ie diabetes, high blood pressure), allergies to medications, family history of mental illness, social circumstances (is the patient married or what kind of job do they have).
Certain buckets of information are important but somewhat sensitive, such as any history of trauma, history of substance use, or if there's any thoughts of self harm. The patient has control over what information to give or not give. The best diagnosis and treatment recommendations usually come from as much information as possible, but it's the patient's choice throughout the entire process. Sometimes trust develops over several sessions, and my diagnosis and recommendations can get updated and adjusted. Certain things like trauma I actually encourage the patient to avoid giving me details during the first session, because I don't want to root up too much disturbance without knowing someone enough to help them contain it.
Usually by the time we've covered the above topics, we are almost running out of time. A lot of people fear not knowing what to say during these evaluations. In my experience we usually have the opposite problem. There is too much information to capture in a single hour. We do our best, and in the last 15 minutes I will share my working diagnosis or what I suspect is happening, and my recommendations for treatment. Treatment can include medication or therapy suggestions or both. I make referrals if needed. I'll discuss safety planning if needed. I'll always ask if the patient has any questions. We weigh risks and benefits of each option together.
As the psychiatrist, I lead us during the hour in the flow of questions and discussion. If there's a lapse or awkward silence, that's on me. Using another metaphor, I'm your guide during a hike. I know the route and can lead us, but I'll be very responsive to how slow or fast you want to go, to any detours you'd like to take, etc. And as a hiker, you can choose to stop at any time.
Sometimes after a single hour I'm unsure of the diagnosis, especially with trickier ones that can be easily mistaken for other things. In those cases, I might ask the patient to sign releases of information allowing me to get more information from their therapist, a family member, a friend, or other doctors. Just knowing patients across time can also aid in diagnosis and adjusting my understanding of what's going on and how to help.
Keep in mind the above description is simply my typical flow for an hour evaluation. If the patient has a specific goal for the hour, it might look different. For example if the patient only wants therapy and has a lot to get off their chest, I might save a lot of the information bucket questioning for later. If the patient is a minor and has a parent in the room, we might play musical chairs a bit by having part of the interview be with the teenager alone, and part of it being with the parent. This is a collaborative process and the patient's needs direct my decisions and actions.
Most of my patients look lighter when they leave the hour long evaluation. I like to check in with them at the end and they often say they were surprised at how it wasn't as bad as they had feared. I often hear they feel pretty good after sharing their story.
I'll also let you in on a little secret: I feel a little nervous before each evaluation too. I take a few deep breaths, I stretch, I treat myself with kindness, and then I start to wonder what the person in the waiting room might be thinking and feeling. Within seconds I forget about my anxiety and I'm left in a neutral, curious state of mind, ready to connect to another human being in all of our beauty and imperfections.
