Psychiatric Diagnostic Evaluations
Comprehensive evaluations to understand your history, needs, and goals.
We perform comprehensive, structured assessments designed to identify the reason for a patient's presentation, establish rapport, and determine whether a psychiatric condition is present.
The American Psychiatric Association (APA) recommends that this process include a direct interview, review of medical records, collateral information from family or other clinicians, and, when indicated, physical examination and diagnostic testing.[1-2]
Our Approach
Key components include a detailed history of present illness, psychiatric history (including prior diagnoses, treatments, and response), substance use history, medical history, family history (with attention to psychiatric and behavioral issues), and personal/social history (including psychosocial stressors, trauma exposure, and cultural factors).[1-2] The evaluation also incorporates a mental status examination, assessing general appearance, speech, mood, thought content and process, perception, cognition, and risk factors for suicide or aggression.[1][3]
The APA emphasizes the importance of understanding the patient’s goals, preferences, and view of illness, as well as collaborative decision-making regarding treatment options. Quantitative measures of symptoms, functioning, and quality of life may be included. The evaluation may require multiple sessions, especially in complex cases or when gathering collateral information is necessary.[2-3]
Documentation should include an estimate of suicide and aggression risk, rationale for treatment selection, and a plan for ongoing care, with explicit discussion of differential diagnosis and treatment risks and benefits.[1] The APA guidelines highlight the need for sensitivity to cultural, linguistic, and cognitive factors throughout the assessment.[1][3]
References
- Silverman JJ, Galanter M, Jackson-Triche M, et al. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults. American Journal of Psychiatry. 2015;172(8):798–802. doi:10.1176/appi.ajp.2015.1720501
- American Psychiatric Association. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. 2020.
- American Psychiatric Association. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults. 2016.