A consultation with a psychiatrist

  What will happen if your GP refers you to a psychiatrist? Practice varies but follows a broadly predictable pattern. It will almost certainly be an interview – most consultations are entirely conversational with no physical examinations or blood tests. It will usually last between 30 and 60 minutes.

  The first thing the psychiatrist is likely to do is ask you to tell him or her in your own words what has been going on, what is distressing you, and what you think the problem is. Although the GP will have summarized this in the referral letter, most of us like to hear it from you and get a really clear picture. From then on the psychiatrist is likely to steer the discussion to get a broader picture of you and your life (your ‘history’). He will find out about your upbringing and your family and usually ask detailed questions about family illnesses (especially psychiatric ones). After that he will ask about your health – both physical and psychiatric – over your lifetime and (particularly in younger people) about drug and alcohol use, as these often have a major impact on psychiatric problems. More detailed questioning is likely about areas relevant to your specific problem (important relationships, work stresses, etc.).

  After taking a history the psychiatrist conducts what is called a ‘mental state assessment’. This is a detailed evaluation of your symptoms – worries, mood, sleep, preoccupations. Usually this is also carried out as a conversation although sometimes there may be some quite formal questions and simple tests of memory. These are generally brief and not difficult – it’s not like doing an IQ test.

  After taking a history and conducting a mental state examination the psychiatrist will usually have come to an opinion of what the problem is (often called a ‘formulation’). This formulation usually includes a diagnosis plus much more, such as thoughts about current difficulties and stresses that have brought on the problem. He will discuss these with you to get your opinion and then talk through the various options he thinks appropriate. This can involve a range of treatments (talking or tablets) or, rarely, a hospital admission. Surprisingly often, however, advice and reassurance is all that is needed. Nearly a quarter of referrals to psychiatrists in the UK are one-off consultations resulting in advice to the patient or GP.

  Because so many psychiatric problems affect family members, psychiatrists will often want to talk with them, both to get a clearer understanding of what is going on but also to explain any proposed treatments to them (they may be very worried) and how best to help. Obviously this is not always appropriate – the circumstances may be very personal and private and adult patients have the right to total confidentiality if they wish it.

  What the psychiatrist will not do is read your mind or ask trick questions. Sometimes it can seem this way because he appears to know much more than you’ve told him. There is nothing magical about this – it is simply that he will have heard similar stories before and will understand what is going on. That is, after all, his job – to know what depression and anxiety feel like and know how people cope with difficulties in their lives. Many find this, in itself, reassuring – that their problems are not unique; others have had similar difficulties and got over them. Similarly psychiatrists are not there to ‘catch you out’ with trick questions. They want to know what you are going through and give advice on how to manage it. What will also not happen is a sudden admission to hospital against your will. There are no psychiatric diagnoses that require immediate compulsory hospitalization. That only happens when there is overwhelming evidence of real risk and usually after much discussion and with a lot of involvement of family and GP.

  Having made his assessment and discussed the treatment with you he may make a further appointment either for you to see him or another member of the team for treatment (e.g. a nurse or psychologist) or say that you don’t need to come back. Whichever happens he will write to your GP and keep him informed.

  So we now know a bit about the scope of psychiatry – how it fits into the other approaches to understanding the mind, what sort of disorders or illnesses it treats, and the major treatment approaches. You may by now regret having started reading – so many uncertainties, overlaps, and contradictions. Couldn’t it have been simpler? Well probably not. If we were to invent psychiatry from scratch it would be different. What we have, however, developed piecemeal over the last two centuries. It is the product of powerful competing forces and momentous historical developments and is confronted just now by truly remarkable advances in the neurosciences. So keep reading and by the end it should make some sort of sense – you will remember that you were never promised certainty.