So you’re going to see a psychiatrist.

Maybe your primary care doctor or gynecologist has sent you for a consultation. Perhaps family members or significant others have coerced strongly urged you to see one. Maybe the police have diverted you from jail to the psychiatric emergency room for evaluation. Maybe the psychiatrist is coming to you, if you’re in the hospital due to a severe medical or surgical problem, as a result of a request from your primary team. Or perhaps you yourself are independently seeking mental health care.

What exactly happens during a psychiatric visit? Does it involve a couch? Intrusive and aloof questions? Immediate medicating?

Maybe.

A visit to the psychiatrist is usually similar to a visit to any other physician, except without the physical exam. (In fact, the psychiatrist may even decline to shake your hand.) Ideally, the interview will comfortably unfold into a relaxed dialogue. Although there are various schools of psychiatric practice (some only prescribe medications; some engage psychoanalysis; some practice cognitive approaches; etc.), the initial psychiatric interview—which may last anywhere between 50 to 90 minutes—involves the following:

Chief complaint. Most psychiatrists usually open with some variant of the question, “What brings you in today?” The response to this initial question can significantly affect the remainder of the interview. For example, if the answer is, “I want you to take out the chip that Dick Cheney has planted in my brain,” that will likely require a different approach as compared to a response of, “Ever since my wife asked for a divorce, I’ve felt terrible.”

History of present illness. Expect to provide a narrative as to what events culminated in this visit. What happened? When did it start? What are the details? Why are you seeking treatment now, versus a month ago or next week?

Furthermore, the psychiatrist will likely ask questions to learn more about the following areas:

Depression. This will include, amongst other things, inquiries into mood, sleep, energy, daily activities, and suicidality. Most psychiatrists will also tack on a question about homicidality.

Mania. In addition to asking about energy level, reckless activities, impulsivity, and other criteria, s/he will hopefully inquire into duration, intensity, and how these symptoms may or may not interfere with daily function.

Psychosis. Do not feel offended when she asks about hallucinations, paranoia, and other seemingly non-reality-based items. She’s just doing her job.

Anxiety. Under this umbrella falls panic attacks, obsessions, compulsions, past trauma, and other symptoms of consuming worry.

A skilled psychiatrist will subtly weave these questions into the conversation. I’d like to think that most of us strive to create and maintain rapport for an interview that is both diagnostic and therapeutic, but this isn’t always the case. Sometimes we’re preoccupied. Sometimes we’re just having a bad day. Some of us just aren’t warm and, uh, interpersonally skilled.

Past psychiatric history. Here will fall inquiries into past psychiatric hospitalizations and outpatient mental health care. It will also include inquiries into past suicide attempts (how, when, why), acts of self-harm, and any experiences with past psychiatric medications. (It is supremely helpful if you know what you were prescribed, the ostensible reasons as to why you were prescribed the medication, how long you took it for, and if it was at all helpful. This can help guide current pharmacological treatment, if deemed necessary.) The psychiatrist may ask you if you had received any psychiatric diagnoses in the past, based on your previous answers.

Substance use. Most psychiatrists ask about tobacco use and, if you do smoke, will inquire into your desire to stop. This is called health maintenance. They will also ask about alcohol use (how much, how often, what type). There may also be inquiries into DUIs and other legal and social ramifications of alcohol consumption. Although alcoholism is considered a mental health diagnosis, this information also clarifies the answers you provide in other parts of the interview. For example, if you reported that you have felt depressed since you graduated from high school, but later report that you started drinking heavily on a daily basis after high school graduation, this casts doubt on a primary diagnosis of depression. Alcohol is a depressant (in every sense of the word).

Also expect inquiries into illicit substance use (cocaine and other street drugs; prescription drugs, such as Oxycontin; etc.) If, for example, you report that you must cover all the windows and mirrors in your house with linen to prevent ghosts from entering your residence and then report that you’ve smoked methamphetamine for the past ten years, it is more likely that your brain is damaged from the methamphetamine, rather than schizophrenia.

Past medical (and surgical) history. Certain medical problems seem to cluster with psychiatric diagnoses (like multiple sclerosis, fibromyalgia, lupus, etc.). Some medical conditions can be linked to psychiatric presentations (like hypothyroidism and depression—oft discussed, but uncommonly seen; a brain tumor can result in cognitive and personality changes). Some medical conditions psychologically contribute to mental discomfort (like a recent diagnosis of cancer). The psychiatrist should also inquire into any past seizures (as some medications can lower the seizure threshold), head trauma with losses of consciousness (which suggests potential brain injury, even if not seen on a head scan), and HIV risk factors (as HIV/AIDS can absolutely adversely affect mental status).

Allergies to medications. We don’t like to prescribe medications that may result in harm or death. I’m just saying.

Current medications. This can help clarify medical conditions (as a surprising number of people often do not know what medical problems they have). This list can also induce grief in the psychiatrist, particularly if it goes on… and on… and on… with numerous psychotropic medications. This may also include inquiries into over-the-counter medications and herbal preparations.

Social history. Unlike our medical and surgical colleagues, we inquire into more life history: Where were you born and raised? siblings? family life? abuse? education? employment history? relationships? marriage? kids? current financial situation? social support? goals? This area not only helps us understand patients more as people (rather than diagnoses), but also gives some insight as to how you cope with stress, what you identify as your strengths, how you may relate to other people (including the psychiatrist!), personality style and function, and how you view yourself in the world. (This provides the grist for the psychotherapeutic mill.)

Family history. Expect questions about who else in the family has mental health issues (”Aunt Joanne was really, really weird—she had problems” can make it into the chart), including suicides, hospitalizations, and substance misuse problems.

In addition to gathering all of this history, the psychiatrist will also conduct a “mental status exam” (a separate topic for another post) during the course of the interview. At the conclusion of the session, the psychiatrist will hopefully offer a tentative working assessment and plan for care.

It is in the psychiatrist’s best interest to build rapport with the patient. In fact, one tenet that is often repeated during our training is, “The purpose of the first visit is to ensure that the patient comes back for the second.” Much of the first visit is spent developing rapport because

1. We cannot offer interventions if we do not have data. And we have very limited data if the patient does not talk. Or if the patient isn’t even present.
2. Unlike our medical and surgical colleagues, we cannot affect change in one day or in one week (although we all wish that was not the case!). Changes in mental health and behavior take time.

One of my favorite supervisors offered this to me: “We’re in the business of helping people reach their hopes, dreams, goals, and desires.” And the first interview helps build the database to reach that end.