What happens at this appointment?
This article is designed to provide you with a clear understanding of what happens at that appointment and how CRG psychiatrists use the information you share to try to help you. The initial psychiatric evaluation is the first meeting between you and your psychiatrist. You may have met with several other mental health professionals at CRG or this may be your first meeting with a professional at CRG. The purpose of this evaluation is 1) to develop a trusting relationship in which you can speak openly and honestly about your concerns and 2) to tell the story of what brings you in. Your psychiatrist will give you time to tell your story but will also guide you into other areas about your life and functioning that he/she needs to know about. If you are under the age of 18, your parents will probably help you tell your story or may tell their story about you and let you tell your own story about yourself. Chances are, you will be seen alone and also with your parents. Your parents may also be seen alone to speak about you. If you are an adult, you may choose to bring a significant other who may be with you for some or all of the evaluation. You may of course choose to come alone. If your psychiatrist wants to meet with other members of your support network to better understand you, he/she will ask for your permission.
We want you to be comfortable during this and all visits. We also understand that talking with someone you may have never met about very personal topics is not easy and may be stressful. It is fine for you to say, “I don’t want to talk about that.” Keep in mind, though, that your psychiatrist can be of better service when you answer even the more difficult or personal questions. Remember, if you feel uncomfortable with certain questions 1) say so and 2) bring someone you trust and who knows you well if that will help you be more comfortable, open, and honest.
Your psychiatrist will collect a lot of information about your present and past functioning, what brings you in to CRG, and why you are coming in now. Your CRG psychiatrist will pay close attention to many things: what you say, how you say it, and how your way of being and communicating feels during and after the interview. While psychiatrists do use traditional instruments of physical diagnosis such as the stethoscope and reflex hammer, the most important tool may be his/her reaction to you during the initial psychiatric evaluation. For instance, if you are a very depressed young man who talks about seeing no way of feeling better, it would not be unusual for your CRG psychiatrist to have feelings of sadness or hopelessness during the interview. Often these feelings help your CRG psychiatrist better understand the depth of your depression and the importance of developing a safety plan with you.
Your CRG psychiatrist will ask whether your thoughts, emotions, or behaviors are problematic for you or for someone else and whether your daily functioning is impaired. He/she will ask whether you have thought about ending your life or someone else’s and how complete a plan you have for this activity. He/she will ask about past history of suicide, violence, legal problems, substance abuse, and other high risk activities. The psychiatrist will also ask whether you have had mental health problems in the past and when you first developed them. He/she will ask about any medical problems you have. If you are a child or teen, he/she will ask about your mom’s pregnancy with you and also about your development as an infant and toddler. He/she may also ask about mental and physical health problems that have impaired any of your blood relatives and what it was like for you (and your parents and siblings) growing up in your family. Finally, your CRG psychiatrist will conduct a mental status exam. This involves all the psychiatrist’s observations of you throughout the interview. If you take certain medications or have noticed problems with your thinking or memory, the mental status exam may include parts of a neurologic exam and more specific questions about your memory.
One of the important roles of your psychiatrist will be that of an educator. Understand that, for this to happen, YOU will be TEACHING him/her about yourself. If sufficient information is produced during this initial meeting, your psychiatrist will communicate to you what he/she has learned so far. This verbal or written synthesis of biological, psychological, and social information about you is called a biopsychosocial formulation. Understand that this formulation is not written in stone but is based on the information your psychiatrist understands about you at a particular moment in time. As time goes on, as you change and develop, as he/she gets to know more about you, this formulation may change. Your CRG psychiatrist will let you know if and when his/her understanding of you is changing.
Why is this formulation important?
A biopsychosocial formulation, based on comprehensive assessment information, is important because it leads to a diagnosis (or diagnoses). It also leads to the creation of a biopsychosocial treatment plan.
What is a biopsychosocial treatment plan?
Understand that you did not get to where you are overnight and it will take time AND EFFORT to get where you want to go. Whatever you do, DON’T GIVE UP. If you feel like giving up, COMMUNICATE this to your psychiatrist. Your biopsychosocial treatment plan is the plan of action that may include a range of services from more than one provider that you and your psychiatrist agree upon. This could include, for example, individual or family psychotherapy, a medical workup, psychopharmacologic intervention (medications), ADHD coaching, strategies for college success, assistive technology services, and/or speech therapy.
Using depression as an example, the plan takes you from where you are now (i.e., depressed) to where you want to be (i.e., feeling great). “Bio” refers to biological factors that may be contributing to your diagnosed condition. If you have depression, you may have insufficient thyroid hormone production. Correcting this biological condition could, by itself, resolve your depression.
“Psycho” refers to psychological factors that may contribute to your depression. For instance, you may have been maltreated as a child, resulting in repeated challenges with trust and relationships in adulthood. For some, these interpersonal challenges can lead to depression. Certain types of talk therapy, such as interpersonal therapy and cognitive behavioral therapy, can be very useful treatments for psychiatric conditions such as depression.
“Social” refers to social factors contributing to your diagnosed condition. For instance, loss of a relationship such as a spouse or even a beloved pet can contribute to issues such as depression. Your psychiatrist may also recommend behavioral strategies to help yourself feel better. Activities such as exercise, reaching out to friends (even though you don’t feel like it), structuring your day, avoiding all naps, optimizing night time sleep with no technology in the bedroom, and avoiding substances can all help combat depression.
Will your CRG psychiatrist always prescribe medications?
As you can see, there are many effective treatments, activities, and techniques that can be used alone or in combination with medications. There may be situations in which your psychiatrist wants you to have a further medical workup (e.g., blood work) before considering medication intervention. Medication or pharmacological intervention is only one of many tools that your CRG psychiatrist may choose to use. All the psychiatrists at CRG are interested in not only treating the psychiatric disorders but also preventing psychiatric disorders from ever occurring, if possible. For instance, adolescent girls have seven times the risk of marijuana abuse if their mother smokes marijuana. Successfully treating a mother-to-be for marijuana abuse SUBSTANTIALLY decreases the risk of her daughter to abuse marijuana. By teaming up with a psychiatrist at CRG, you can enhance your own daily functioning and future health and that of others. Family members and even friends may take note of your ability to confront difficulties openly, effectively, and courageously and may feel more able to do the same if needed.
If your biopsychosocial treatment plan includes medication intervention, you and your psychiatrist will need to continue building a trusting relationship with honest communication. Working together, you will need to establish 1) what you are targeting with the medicine and how you will know if it helps, 2) the importance of daily adherence to your medicine regimen for improvement to occur, 3) how long it will take for you to notice improvement and how much improvement, 4) potential side effects, 5) alternative forms of medicine and non-medicine treatments that may be relevant, and 6) a cost/benefit analysis of treating and not treating the disorder with medicine. This should include biological (i.e., sensitivity to medicine side effects), psychological (i.e., core beliefs such as weak or crazy people take psychotropic medicines), and social (i.e., my family does not believe in mental health treatment) barriers to treatment and ways you can overcome these barriers.
This process of evaluation and formulation is an ongoing one that CRG psychiatrists begin during the initial appointment and ends on the last day of treatment.
What are the advantages of seeing a CRG psychiatrist for an initial psychiatric evaluation?
When CRG first started, our focus was on children. That changed many years ago. Today, all CRG psychiatrists have extensive training in child, adolescent, adult, and family psychiatry. This means that they understand the impact of a psychiatric disorder on the individual diagnosed as well as on other systems in a patient’s life including family, school, and community. They also understand the potential influence of these systems on the individual, be it positive or negative. They understand the importance of involving the family system, when appropriate, in treatment. They understand that the ultimate goal of treatment is treatment of your psychiatric disorder until you are functioning optimally as well as prevention of psychiatric disorders in future generations. CRG psychiatrists are in a position to be family psychiatrists, educating you on the best ways to enhance resilience in yourself and your family to protect against mental illness. Diagnosing and addressing mental disorders early on in their development makes them much easier to treat.
CRG psychiatrists take a full 90 minutes for your initial psychiatric evaluation. Unfortunately, this is an unusually long period of time in 2012 to spend with patients compared to the amount of time spent for initial psychiatric evaluations in other private practices. Given the complexity of the patients we see and the emphasis CRG places on building the doctor-patient relationship, however, we feel that this time is not only well spent but essential for the multiple goals we have set for the initial psychiatric evaluation.
The CRG psychiatrist often has a lot of information about you before you see him/her, from old records or a recent CRG psychological evaluation. You may be coming in for a one-time consultation or an ongoing treatment relationship. This background information is helpful but not a substitute for the CRG psychiatrist’s own evaluation, diagnostic formulation, and treatment plan.
Psychiatrists at CRG communicate with your primary care physician with your permission, sending him/her an initial psychiatric evaluation report if and when you sign a release of information form.
If for any reason you do not feel comfortable with your CRG psychiatrist, it is best to tell him/her DIRECTLY AND NOW. Being open about your discomfort may feel awkward but may also bring relief. You will have the opportunity to problem solve, either by working things through and continuing together or working out a thoughtful plan for moving forward that may include a referral to another psychiatrist. Remember, your CRG psychiatrist is probably not the first person with whom you have not felt comfortable. Learning how to sort through this challenge honestly and directly will be helpful in future relationships as well. Your psychiatrist is trained to understand your honesty and make your needs paramount.
Psychiatrists at CRG are surrounded by talented colleagues, from the individuals who answer the phone and schedule your appointments, to those who gather valuable information about you, to individuals with expertise in a variety of areas including speech and language pathology, clinical and school psychology, learning disabilities, technology, nursing, social work, and fellow psychiatrists. We share a passion to stay cutting edge and provide outstanding patient care. Working with this amazing group creates a positive energy and momentum that leads to great patient care. We consider it an honor to work with you.