As you may imagine, psychiatric problems are difficult to diagnose due to their complexity and infinitely different presentations. Often, an absolute diagnosis is not made even in the first few visits. The first 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. I meet with adults for 75 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: Medical and mental health problems with parents and siblings are reviewed.
- Substance Use: A review of alcohol and illicit drug use, along with history of over-the-counter medication abuse.
- Medical History: Contact information for the client’s primary care physician taken, review of any current or past medical problems and medical complaints is conducted. Next, there is a review of 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 including-Issues with significant others. School issues, including history of learning problems or special needs. Legal problems and behavior problems. Work/career issues.Individual and family strengths and interests. Cultural and religious issues
What to Bring
If applicable: Current medication bottles, prior mental health records, current medical records, work history, academic records.