What Happens During a Psychiatric Evaluation? Full Walkthrough
Scheduling your first psychiatrist’s appointment is an important step in making the right decision in order to improve your health. However, you may be nervous about going, especially if you have never been to a psychiatrist or psychiatrist nurse practitioner before. If you are like many people, you probably have several questions, including the types of questions you can expect to answer, whether you will be asked about your childhood, or if you will be given a diagnosis or a prescription.
We understand that the unknown can often be frightening. At
Vital Psych MD, we believe that disclosure is a crucial component of any clinical interaction. The mental health evaluation is a conversation and any discussion regarding your mental state that has the potential to help you feel better.
Disclaimer: The following information is for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. If you or someone you know is having a mental health crisis or emergency, please call/text 988 in the United States or go to the nearest emergency room.
What Is a Psychiatric Evaluation?
A psychiatric evaluation is a thorough assessment of the patient’s mental state conducted by a doctor, psychiatrist or psychiatric nurse practitioner who determines the treatment for the patient’s disorder. It is a process of asking questions in order for the medical professional to understand the patient’s needs and come to an accurate diagnosis. Having obtained a complete picture of your mental and physical health, your doctor will be able to determine appropriate courses of action, which may include psychotherapy and medication.
What Happens During a Psychiatric Evaluation?
During a psychiatric evaluation, the mental health professional will inquire about your symptoms, medical and family history, and current state of life. They will ask all of those questions to identify your needs, confirm a diagnosis, and establish a successful course of treatment.
Despite the range of symptoms, different combinations of medications, and the variance of age and state of life, most comprehensive psychiatric evaluations involve a similar set of procedures. The general outline of assessment includes the following:
- Check-in and basic information collection
- Discussion of why you are seeking care
- Review of current symptoms
- Mental health and medical history review
- Family, social, and lifestyle history
- Medication and substance-use review
- Mental status examination
- Screening questionnaires or additional testing (when appropriate)
- Diagnostic discussion or clinical impressions
- Treatment and follow-up planning
Below is a detailed walkthrough of each step so you know precisely what to expect.
Step 1: Check-In and Getting Started
Whether you have an appointment at the office or by telepsychiatry, you will be asked to check in and provide your identification and insurance information, plus any other intake paperwork. After you meet with your therapist for the first time, they will spend some time talking with you to establish a rapport and explain confidentiality and how the sessions will be structured.
Step 2: Why You Are Seeking Help
The clinical interview, as a rule, begins with the most straightforward and simple question, such as “What seems to be the problem?” or “How can I help you today?” In medical terms, this type of question is referred to as the statement of your chief complaint.
You should not be concerned about using the specific terminology to describe your symptoms. It is enough simply to say what the issue is in your opinion, for instance, “I cannot sleep at night due to excessive worrying” or “I have been feeling tired and depressed for the last month," etc.
Step 3: Discussing Your Current Symptoms
Once you explain the reason for your call, the provider will conduct a symptom review, asking additional questions to further clarify your symptoms. They will ask about the degree of severity, frequency, and duration of your symptoms. The providers will also ask how your symptoms are affecting your activities of daily living, such as work, school, and family roles.
Step 4: Reviewing Your Mental Health History
The provider will ask if the patient has ever been treated for psychiatric problems, been under psychotherapy or been hospitalized for mental disorders in the past. If the patient has been treated, it is important to know what helped and what did not help him or her in order to plan the future treatment.
Step 5: Reviewing Your Medical and Medication History
Due to the close connection of the brain with the body, a psychiatric evaluation also includes a medical examination. The provider will ask questions about the patient’s general health, existing chronic diseases, and history of surgeries.
Physiological factors such as hormone levels, vitamin shortages, and sleep patterns can imitate psychiatric symptoms. In addition, the providers will make a list of all drugs, vitamins, and over-the-counter medications that the patient takes regularly to ensure there are no adverse effects.
Step 6: Discussing Family, Social, and Lifestyle Factors
Mental illnesses can be genetic; therefore, the provider will ask if there is a history in the immediate family of depression, anxiety, bipolar disorder, or other disorders.
The provider will want to know about your lifestyle: how much sleep you get, your diet, your level of physical activity, and whether you are homeless or living in unstable housing. The provider will also ask about current substance use and abuse, including alcohol, tobacco, and recreational drugs. It is essential that you be completely honest when answering these often uncomfortable questions, since the provider is not judging you but trying to help you get the best possible care.
Step 7: The Mental Status Examination
The term "mental status examination" sounds very frightening, but it is not something that you have to study for. The MSEs are simply observations during the interview. The provider notes your:
- Appearance and general behavior
- Speech patterns (e.g., speaking very fast or very slowly)
- Mood and affect (how you say you feel vs. how you appear to feel)
- Thought process and thought content
- Memory and concentration
Step 8: Questionnaires, Screening Tools, or Additional Testing
Depending on the symptoms that you report, your provider might ask you to complete a brief screening questionnaire such as the PHQ-9 for depression or the GAD-7 for anxiety. If a physical cause for your symptoms is suspected, your provider may also order some simple blood tests but not always.
Step 9: Discussing Possible Diagnoses or Clinical Impressions
At the end of the appointment, your psychiatrist or psychiatric provider will tell you what they think the issue is. They will explain what is causing the symptoms that concern you. Sometimes, the psychiatric professional can give you a diagnosis right away. Other times they may need to see you a few times and observe your behavior and symptoms before they can decide on a diagnosis.
Step 10: Creating a Treatment and Follow-Up Plan
Finally, you will develop a treatment plan together. You will discuss possible variants of psychotherapy, lifestyle changes and drugs if necessary. It is essential that the physician explain the drugs’ mechanism of action, the reason for their prescription, side effects, expected results and the estimated time of the treatment’s progress.
What Questions Will a Psychiatrist Ask During an Evaluation?
Every clinical interview is tailored to the individual, but you can generally expect questions similar to the following:
- When did you start experiencing the symptoms?
- Did the symptoms affect your work, sleep, or eating habits?
- What makes your symptoms better or worse?
- Was there a time when you felt very energetic, could not get enough sleep or made foolish decisions?
- Do you have a history of abuse or extreme stress?
- How many alcoholic drinks do you have per week?
- Have you ever had thoughts of hurting yourself or ending your life? (This is one of the routine screening questions for everyone.)
- What do you hope to achieve by undergoing treatment?
What Should You Bring to a Psychiatric Evaluation?
Being prepared can reduce anxiety and help the appointment run smoothly. We recommend having the following ready:
- A valid photo ID and current health insurance information
- List of all your current medications, including the dosages (psychiatric and non-psychiatric)
- List of any vitamins, herbs, or supplements you are taking
- Records of past psychiatric treatment or hospitalizations, if available
- Contact information for your primary care physician or current therapist
- Brief list of your symptoms and questions
How Should You Prepare for a Psychiatric Evaluation?
The best preparation is to be honest during the exam. There is no need to rehearse a detailed history of your life. However, it might help to track your symptoms a few days beforehand. Try to note when you feel anxious, depressed, or irritable and try to note how long these feelings typically last.
In the event that you get nervous and forgetful during the exam, write down your questions on a piece of paper or on your phone before the exam starts if there is a chance that you will have access to them during the exam.
| Part of Evaluation | What We Discuss | Why It Matters |
|---|---|---|
| Medical History | Past illnesses, surgeries, thyroid issues, head trauma. | Physical ailments can cause or worsen mental health symptoms. |
| Medication List | Prescriptions, supplements, over-the-counter drugs. | To prevent negative drug interactions and monitor side effects. |
| Social History | Living situation, stress levels, support systems. | Environmental stress heavily impacts mental health and recovery. |
| Family History | Relatives with mental health or substance use disorders. | Many mental health conditions have strong genetic links. |
Is a Psychiatric Evaluation the Same as a Psychological Evaluation?
No, they are different procedures performed by different professionals.
A psychiatric evaluation is performed by a medical professional (either psychiatrist or psychiatric NP). During this procedure, a professional assesses your medical history and current symptoms in order to determine your diagnosis and develop a treatment plan that may involve a course of pharmacotherapy.
A psychological evaluation is typically performed by a psychologist (Ph.D. or Psy.D.), who spends hours, even days, poring over standardized tests and IQ tests and observing a person's behavior to ascertain their intelligence, learning capabilities, or any underlying personality disorders that may require treatment. A psychologist is not authorized to prescribe drugs in most states.
Can a Psychiatric Evaluation Be Done Online?
Yes. Telepsychiatry is a very effective, safe, and convenient way to receive care. Studies have shown that online psychiatric evaluations are just as accurate as in-person evaluations for the purposes of diagnosis and treatment of most mental health issues.
Vital Psych MD offers secure HIPAA-compliant telehealth services, meaning you can have your first consultation and all medication management appointments from the comfort of your own home.
How Long Does a Psychiatric Evaluation Take?
A complete initial psychiatric evaluation normally takes between 45 and 90 minutes. This allows sufficient time to go over your background, perform a mental status exam, and go over your treatment options. Follow-up visits to talk about medications normally last between 15 and 30 minutes.
If you are wondering about the exact timeline, you can read our detailed breakdown of
how long a psychiatric evaluation actually takes to finish.
What Happens After a Psychiatric Evaluation?
At the end of your appointment, your provider will go over their findings with you. If you need medication, it will be sent to your preferred pharmacy. Your provider will let you know when to come back in to check in on your progress and adjust the treatment plan as needed.
Depending on your specific needs, your provider may also refer you to a therapist for talk therapy such as CBT or other therapies, as a combination of medication and talk therapy is often most effective.
How We Approach Psychiatric Evaluations
At Vital Psych MD, our approach to treatment is centered around understanding, evidence-based practice, and listening to patients closely. When making a psychiatric evaluation, we treat you as our partner because we are committed to listening to you closely, discussing the options thoroughly, and understanding what you are willing to try. We encourage you never to accept an explanation that you cannot understand or do not want to accept. A full psychiatric evaluation must always instill confidence and provide patients with hope.
Key Takeaway
A psychiatric evaluation is not something to be afraid of. It is just a medical checkup to figure out what's going on. Talking to a doctor about your mental and emotional state is a way to put yourself on a path to recovery.
If you are having a crisis in regards to your mental health, the professionals here at Vital Psych MD are here to help.
Please contact us to set up an appointment for your psychiatry evaluation and assessment.
Frequently Asked Questions
Does insurance cover online psychiatry?
Yes, most insurance plans cover online psychiatry. Due to mental health parity laws and the rise of telehealth, many insurers are covering virtual mental health services the same as in-person visits, so long as it's with an in-network provider.
How much does a psychiatrist cost with insurance?
Your costs for a psychiatrist with insurance will depend on your specific benefits. You may only be responsible for a copay per visit, such as $20 to $50. If you haven't met your annual deductible, you may be responsible for the full contracted rate until you have met your deductible.
Can I find an online psychiatrist that takes insurance?
So, finding an online psychiatrist who accepts insurance is simple now. Various practices, such as Vital Psych MD, take most insurances and offer telemedicine services from all over the state to use your in-network benefits from your own home.
How do I know if a psychiatrist is in-network?
To check if a psychiatrist is in your network, you can contact the member services number on the back of your insurance card. Provide the representative with the provider's name and location, and they can confirm whether the professional is in-network.
Does insurance cover psychiatric medication management?
Yes, medication management is considered a medical necessity treatment, so any type of follow-up visits that are needed to properly manage your meds would be covered under most insurance plans with behavioral health benefits.
