Dennis B. Kottler, MD
Westlake Village, CA
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The initial psychiatric assessment requires skillful questioning and observation, since the clinician is presented with a single "snapshot" of the patient's situation. A careful history will give further perspective on the presenting problems and, if appropriate, family members can often be very informative. While it is often useful to base the evaluation on a series of visits, sometimes treatment decisions must be made right from the start.
A good assessment should focus both on the presenting symptoms as well as the psychiatrist's own observations of the patient (the mental status examination). It should also include a psychiatric and medical history, a family history, and a personal history, although some of this information might have to be obtained in future visits.
The psychiatrist must always consider the signs and symptoms presented in CONTEXT. Thus it is important to consider such factors as cultural background, developmental stage, accompanying medical conditions, and family and social environment.
And above all the psychiatrist must be aware of, and sensitive to, the effect he or she is having on the patient. The assessment should strive to be a positive experience for the patient and it should be collaborative in nature. The psychiatrist is the consultant; treatment must be agreed upon by both parties.
In the evaluation of the very young, the elderly, or the severely impaired, special considerations may be necessary to complete a thorough assessment.
Factors to Consider in Choosing a Psychiatrist
If possible, it is generally best to see a psychiatrist who is either board "certified" or, at the least, board "eligible." Psychiatrists are certified by the American Board of Psychiatry and Neurology. Board "eligibility" means the psychiatrist has completed a psychiatric residency (usually 4 years of post-medical training) and is eligible to take the psychiatric boards. Board certification means the psychiatrist has passed the psychiatric boards (a lengthy test combining written and oral components both in the field of psychiatry and neurology).
However, board eligibility or certification is only the start. Further considerations include the following:
1. The psychiatrist must be experienced and up to date in the area of the patient's particular problems.
2. The psychiatrist must be experienced in the physical/developmental age of the patient.
3. The psychiatrist must have at his disposal a range of treatment strategies.
This last point requires elaboration. Psychiatrists vary in their approaches to particular problems. Some psychiatrists focus mainly on medication, others offer psychotherapy of various sorts, and still others combine these approaches.
When dealing with a serious psychiatric problem, it is often most useful to see a psychiatrist who can offer both medication assessment and treatment, as well as psychotherapy.
While recommendations from other physicians and mental health providers are a good initial way to select a psychiatrist, the patient must ultimately come to his own conclusions about the suitability of the choice. When concerns arise, they should be addressed to the psychiatrist directly, who should welcome such discussions as an important part of the treatment process.
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