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Mental Health Medications

What are mental health medications.

Medications can play an important role in treating mental disorders and conditions. They are often used in combination with other treatments, such as psychotherapy and brain stimulation therapy . Medications can affect people in different ways, and it may take several tries to find the medication that works best with the fewest side effects. It’s important to work with a health care provider or a mental health professional to develop a treatment plan that meets your individual needs and medical situation.

Information about medications is updated frequently. The U.S. Food and Drug Administration (FDA) has Medication Guides  with the latest information, warnings, and approved medications. MedlinePlus also provides information on drugs, herbs, and supplements  , including side effects and warnings.

This page provides basic information on mental health medications. It is not a complete source for all medications available. It should not be used as a guide when making medical decisions.

What are antidepressants?

Antidepressants are medications used to treat depression . In some cases, health care providers may prescribe antidepressants to treat other health conditions, such as anxiety , pain  , and insomnia  .

Commonly prescribed types of antidepressants are:

• Selective serotonin reuptake inhibitors (SSRIs)
• Serotonin-norepinephrine reuptake inhibitors (SNRIs)
• Norepinephrine-dopamine reuptake inhibitors (NDRIs)

These medications are commonly prescribed because they improve the symptoms of a broad group of depressive and anxiety disorders. They are also associated with fewer side effects than older antidepressants. Although older antidepressants, such as tricyclics and monoamine oxidase inhibitors (MAOIs), are associated with more side effects, they may be the best option for some people.

Antidepressants take time—usually 4−8 weeks—to work, and problems with sleep, appetite, energy, and concentration often improve before mood lifts. Giving a medication a chance to work is important before deciding whether it is right for you.

Common side effects of SSRIs and other antidepressants include upset stomach, headache, or sexual dysfunction. The side effects are generally mild and tend to go away with time. People who are sensitive to the side effects of these medications sometimes benefit from starting with a low dose, increasing the daily dose very slowly, and changing when or how they take the medication (for example, at bedtime or with food).

Esketamine  is an FDA-approved medication for treatment-resistant depression, which may be diagnosed when a person’s symptoms do not improve after trying at least two antidepressants. Esketamine is delivered as a nasal spray in a health care provider’s office, a clinic, or a hospital. It often acts rapidly, typically within a couple of hours, to relieve depression symptoms. People usually continue to take an oral antidepressant to maintain the improvement in their symptoms.

Combining antidepressants with other medications or supplements that act on the serotonin system, such as triptans (often used to treat migraine headaches) and St. John’s wort (a dietary supplement), can cause a rare but life-threatening illness called serotonin syndrome  . Symptoms of serotonin syndrome include agitation, muscle twitches, hallucinations (seeing or hearing things others do not see or hear), high temperature, and unusual blood pressure changes. For most people, the risk of such extreme reactions is low. It is important for health care providers to consider all possible interactions and use extra care in prescribing and monitoring medication combinations that have an above-average risk.

Note : In some cases, children, teenagers, and young adults under 25 may experience an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting the medication or when the dose is changed. People of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment.

If you or someone you know is struggling or having thoughts of suicide, call or text the 988 Suicide & Crisis Lifeline   at 988 or chat at 988lifeline.org   . In life-threatening situations, call 911 .

What are anti-anxiety medications?

Anti-anxiety medications help reduce symptoms of anxiety , such as panic attacks and extreme fear and worry.

Many medications used to treat depression—including SSRIs and SNRIs—may also be used to treat anxiety. In the case of panic disorder or social anxiety disorder , health care providers typically start with SSRIs or other antidepressants as the initial treatment because they have fewer side effects than other medications.

Benzodiazepines are another common type of anti-anxiety medication used to treat some short-term anxiety symptoms. They are sometimes used to treat  generalized anxiety disorder .

Health care providers may also prescribe beta-blockers off-label to treat short-term anxiety symptoms, even though the medication is not approved for that specific purpose. For instance, people with a phobia —an overwhelming and unreasonable fear of an object or situation like spiders or public speaking—often experience intense physical symptoms, such as rapid heart rate, sweating, and tremors. Beta-blockers can help manage these symptoms.

Benzodiazepines and beta-blockers are useful as needed to reduce severe anxiety in the short-term. However, taking benzodiazepines over long periods may lead to drug tolerance or even dependence. To avoid these problems, health care providers usually prescribe benzodiazepines for short periods and taper them slowly to reduce the likelihood of withdrawal symptoms or renewed anxiety symptoms. Beta-blockers generally are not recommended for people with asthma or diabetes because they may worsen the symptoms of both conditions.

Buspirone  is a different type of anti-anxiety medication that can be used to treat anxiety over longer periods. In contrast to benzodiazepines, buspirone must be taken every day for 3−4 weeks to reach its full effect, and it is not effective for treating anxiety on an as-needed basis.

What are stimulants?

Health care providers may prescribe stimulant medications to treat attention-deficit/hyperactivity disorder (ADHD) and narcolepsy  . Stimulants increase alertness, attention, and energy. They can also elevate blood pressure, heart rate, and breathing.

Prescription stimulants improve alertness and focus for most people, regardless of diagnosis. These medications can markedly improve daily functioning for people with significant focus problems, such as people with ADHD. Although motor hyperactivity associated with ADHD in children usually goes away by the time they reach adolescence, people with ADHD may continue to experience inattention and have difficulty focusing into adulthood. As such, stimulant medications can be helpful for adults, as well as for children and adolescents, with ADHD.

Stimulants are safe when taken under a health care provider’s supervision and used as directed. Some children may report feeling slightly different or unlike their usual selves while taking the medication. Most side effects of stimulants are minor and not seen at low doses.

Some parents worry that stimulants may lead to misuse or dependence, but evidence shows this is unlikely when the medications are used as prescribed. Other challenges with stimulant treatment, such as sleep disturbance and slowed growth, can generally be safely managed by a health care provider.

What are antipsychotics?

Antipsychotic medications are typically used to treat psychosis , a condition that involves some loss of contact with reality. People experiencing a psychotic episode often experience delusions (false beliefs) or hallucinations. Psychosis can be related to drug use or a mental disorder such as schizophrenia , bipolar disorder , or severe depression (also known as psychotic depression).

Health care providers may also prescribe antipsychotics in combination with other medications to relieve symptoms of delirium  , dementia  , or other mental health conditions that are more common in older adults. The FDA requires that all antipsychotics include a black box warning stating that the medications are associated with increased rates of stroke and death in older adults with dementia.

Older, first-generation antipsychotic medications are sometimes called typical antipsychotics (or neuroleptics). Long-term use of typical antipsychotics may lead to a condition involving uncontrollable muscle movements called tardive dyskinesia  , which can range from mild to severe. People who think they might have tardive dyskinesia should check with a health care provider before stopping their medication.

Newer, second-generation medications are sometimes called atypical antipsychotics. Several atypical antipsychotics are available. They are commonly used because they treat a broader range of symptoms compared with older medications. For example, atypical antipsychotics are sometimes used to treat bipolar depression or depression in people that have not responded to antidepressant medication alone. Health care providers may ask people taking atypical antipsychotics to participate in regular monitoring of weight, glucose levels, and lipid levels.

Some symptoms, such as agitation and hallucinations, typically go away within days of starting antipsychotic medication. Other symptoms, such as delusions, usually go away within a few weeks. However, people may not experience the full effects of antipsychotic medication for up to 6 weeks.

If a person’s symptoms do not improve with usual antipsychotic medications, they may be prescribed an atypical antipsychotic called  clozapine  . People who take clozapine must have regular blood tests to check for a potentially dangerous side effect that occurs in 1%–2% of people.

What are mood stabilizers?

Mood stabilizers are typically used to treat bipolar disorder and mood changes associated with other mental disorders. In some cases, health care providers may prescribe mood stabilizers to augment the effect of other medications used to treat depression.

Lithium  , an effective mood stabilizer, is approved for the treatment of mania and bipolar disorder. Some studies indicate that lithium may reduce the risk of suicide among people taking it for long-term symptom maintenance. Health care providers generally ask people who are taking lithium to participate in regular monitoring to check lithium levels and kidney and thyroid function.

Mood stabilizers are sometimes used to treat depression (usually along with an antidepressant), schizoaffective disorder, disorders of impulse control, and certain mental illnesses in children. For people with bipolar depression, health care providers typically prescribe a mood stabilizer and an antidepressant to reduce the risk of switching into mania (known as rapid cycling).

Some anticonvulsant medications may also be used as mood stabilizers, as they work better than lithium for certain people, such as people with “mixed” symptoms of mania and depression or those with rapid-cycling bipolar disorder. Health care providers generally ask people taking anticonvulsants to participate in regular monitoring to check medication levels and assess side effects and potential interactions with other common medications.

What should certain groups of people consider before taking mental health medications?

All people can take mental health medications, but some groups have special needs and considerations.

Children and adolescents

Many medications used to treat mental disorders are safe and effective for children and adolescents. However, it is important to know that children may experience different reactions and side effects than adults, and some medications have FDA warnings about potential side effects for younger people.

In some cases, a health care provider may prescribe an FDA-approved medication on an off-label basis to treat a child’s symptoms, even though the medication is not approved for the specific mental disorder or for use by people under a certain age. Although there has been less research on mental disorders in children than adults, there is evidence that medications can be helpful for children. It is important to monitor children and adolescents who take medications on an off-label basis.

A health care provider may suggest trying non-medication treatments first, such as psychotherapy , and add medication later, if necessary. In other cases, a health care provider may suggest non-medication treatment in combination with medication. The National Institute of Mental Health (NIMH) provides more information on common treatment options for children and adolescents .

Older adults

People over age 65 should take extra care with medications, especially if they are taking multiple medications. Older adults are often more sensitive to medications and can have a higher risk of experiencing drug interactions. Even healthy older adults react to medications differently than younger people because older adults’ bodies often process and eliminate medications more slowly.

Before starting a medication, older adults and their family members should talk to a health care provider about any effects the medication may have on physical and mental functioning. The health care provider can also discuss strategies to make it easier to follow the treatment plan, helping ensure that older adults take the correct dose at the correct time.

The National Institute on Aging has information and practical tips to help older adults take their medications safely  .

People who are pregnant or may become pregnant

Researchers are continuing to investigate mental health medications during pregnancy. The risks associated with taking medication during pregnancy depend on the type of medication and the stage of pregnancy. While no medication is considered universally safe during pregnancy, untreated mental disorders can also pose risks to the pregnant person and the developing fetus.

Pregnant people should work with a health care provider to develop a personalized treatment plan that considers their individual needs and circumstances. It is important to weigh the benefits and risks of all available treatment options, including psychotherapies , medications, brain stimulation therapies , or a combination of these options. Health care providers may closely monitor a person’s physical and mental health throughout pregnancy and after delivery to look for signs of perinatal or postpartum depression .

Certain medications taken during pregnancy, including some benzodiazepines, mood stabilizers, and antipsychotic medications, have been linked with birth defects, but the risks vary widely and depend on the specific medication.

Antidepressants, especially SSRIs, are generally considered safe for use during pregnancy. Although antidepressants can cross into the placenta and reach the fetus, the risk of birth defects and other problems is very low. Some studies have found an association between third-trimester SSRI exposure and certain symptoms, including breathing problems, in newborns. However, the FDA does not find sufficient evidence for a causal link  and recommends that health care providers treat depression during pregnancy according to the person’s specific needs.

Visit the FDA website for more information on medications and pregnancy  .

Postpartum people

Researchers are also investigating medications to help people who experience mental disorders after pregnancy and during the postpartum period. Much of this research has focused on one of the most common postpartum mental disorders— postpartum depression .

The FDA has approved two medications specifically to treat severe postpartum depression. The first is brexanolone  , which is administered through an IV by a health care professional during a brief hospital stay. The other is zuranolone  , which is an oral medication taken in pill form. In clinical trials, both medications reduced postpartum depression symptoms more quickly and effectively than traditional antidepressants.

Postpartum people should work with a health care provider to determine the best treatment plan based on their prenatal health and current symptoms. Like with mental disorders during pregnancy, it is important to weigh the benefits and risks of all treatment options and closely monitor physical and mental health during treatment.

The Office on Women’s Health has more information on treatments for postpartum depression  .

What should I know about mental health medications?

People respond to medications in different ways, and it may take several tries to find the medication that is most effective with the fewest side effects. In some cases, people find that a medication helps for a while and then their symptoms return. It often takes some time for a medication to work, so it is important to stick with the treatment plan and take medication as prescribed.

People should not stop taking a prescribed medication, even if they are feeling better, without the help of a health care provider. A provider can adjust the treatment plan to slowly and safely decrease the medication dose. It’s important to give the body time to adjust to the change. Stopping a medication too soon may cause unpleasant or harmful side effects.

If you are prescribed a medication:

• Tell a health care provider about all other medications, vitamins, and supplements you are already taking.
• Remind a health care provider about any allergies. Tell them about any problems you had with medications in the past.
• Make sure you understand how to take the medication before you start using it, and take the medication as instructed.
• Talk to a health care provider about possible side effects and what to expect when taking a medication.
• Do not take medications prescribed for another person. Do not give your prescribed medication to someone else.
• Call a health care provider right away if you have problems with your medication or are worried that it might be doing more harm than good. The provider will work with you to address the problems and determine next steps.
• Report serious side effects to the FDA MedWatch Adverse Event Reporting Program  .

How do I contact FDA MedWatch?

The FDA is responsible for protecting public health by ensuring the safety, efficacy, and security of medications, biological products, and medical devices. Contact FDA MedWatch  to voluntarily report a:

• Serious adverse effect
• Product quality problem
• Product use error
• Product failure that you suspect is associated with an FDA-regulated drug, biologic, medical device, dietary supplement, or cosmetic

You or a health care provider can make a report online or by calling 1-800-332-1088. You can also report suspected counterfeit medical products to the FDA through MedWatch.

Subscribe to MedWatch safety alerts

FDA MedWatch also offers several ways to help stay informed about medical products. You can sign up to receive the MedWatch E-list  , which delivers safety information to your email. You can also follow MedWatch on X (formerly Twitter) @FDAMedWatch   .

Where can I learn more about mental health medications?

Finding help.

NIMH is the lead federal agency for research on mental disorders. NIMH does not provide medical advice, endorse or recommend specific medications, or offer treatment referrals.

NIMH has information on ways to get help and find a health care provider or access treatment . You can also find an NIMH-supported clinical research study .

The Substance Abuse and Mental Health Services Administration has an online tool  to find mental health services in your area.

Reports from the Agency for Healthcare Research and Quality

The Agency for Healthcare Research and Quality (AHRQ) is the lead federal agency charged with improving the safety and quality of America’s health care system. AHRQ develops the knowledge, tools, and data needed to improve the health care system and help the public, health care professionals, and policymakers make informed health decisions.

Examples of AHRQ reports on mental health include:

• Adverse Effects of Pharmacological Treatments of Major Depression in Older Adults   : This systematic review assesses adverse events related to antidepressant medications in adults over 64 years.
• Anxiety in Children   : This systematic review compares the effectiveness and harms of psychotherapy and medications for treating anxiety disorders in children.
• Attention Deficit Hyperactivity Disorder: Diagnosis and Treatment in Children and Adolescents   : This review evaluates strategies for diagnosing, treating, and monitoring children and adolescents with ADHD, including the effectiveness of stimulant medications and non-medication treatments.
• Diagnosis and Management of Obsessive Compulsive Disorders in Children   : This systematic review presents findings from studies on tools to identify children and adolescents with obsessive compulsive disorder and psychological and pharmacological treatments for the disorder.
• Evaluation of Mental Health Mobile Applications   : This technical brief provides a framework to assess and select mental health mobile applications.
• Maternal, Fetal, and Child Outcomes of Mental Health Treatments in Women: A Systematic Review of Perinatal Pharmacologic Interventions   : This systematic review assesses the benefits and harms of pharmacologic interventions for pregnant and postpartum people with mental disorders.
• Nonpharmacologic Treatment for Maternal Mental Health Conditions   : This systematic review assesses the effectiveness and harms of psychological treatments for pregnant and postpartum people with mental disorders and how they compare to pharmacological treatments.
• Pharmacologic and Nonpharmacologic Treatments for Posttraumatic Stress Disorder: An Update of the PTSD Repository Evidence Base   : This review assesses the effectiveness, benefits, and harms of psychological and pharmacological treatments for adults with post-traumatic stress disorder.
• Psychosocial and Pharmacologic Interventions for Disruptive Behavior in Children and Adolescents   : This review evaluates the evidence for psychosocial and pharmacological treatments for children and adolescents with disruptive behavior disorder.
• Treatment for Adults With Schizophrenia   : This systematic review evaluates the evidence for schizophrenia treatments, including second-generation antipsychotics, first-generation antipsychotics, and psychosocial interventions.
• Treatment for Bipolar Disorder in Adults: A Systematic Review   : This systematic review assesses the effectiveness of treatments for acute mania or depression in adults with bipolar disorder, including lithium and atypical antipsychotics.
• Treatment of Depression in Children and Adolescents   : This systematic review evaluates the effectiveness, benefits, and harms of available treatments for children and adolescents with depression.

Resources from the National Library of Medicine

The National Library of Medicine (NLM)  , part of the  National Institutes of Health  , is the world’s largest medical library. NLM produces electronic information resources on a range of topics:

• DailyMed   : Contains labeling for prescription and nonprescription drugs for human and animal use and for additional products, such as medical gases, devices, cosmetics, dietary supplements, and medical foods
• MedlinePlus: Antidepressants   : Provides information and resources on antidepressant medications
• MedlinePlus: Drugs, Herbs and Supplements   : Provides information and resources on drugs, herbs, and supplements

Last Reviewed: December 2023

Unless otherwise specified, the information on our website and in our publications is in the public domain and may be reused or copied without permission. However, you may not reuse or copy images. Please cite the National Institute of Mental Health as the source. Read our copyright policy to learn more about our guidelines for reusing NIMH content.

• What to Expect at a Psychiatry Appointment

May is Mental Health Awareness Month. Psychiatry is a vital part of mental health treatment. In the United States, one in six people takes psychiatric medications. These medicines help people to live balanced, healthier lives.

Even with the prevalence of treatment options and prominence of medications, a stigma exists. These factors can make seeking treatment a daunting task.  

Psychiatry today

There are approximately 28,000 psychiatrists in the United States. These doctors play an important role in health care, especially in the wake of the opioid crisis . Recruitment for psychiatrists is second only to family physicians.

In a previous post, we discussed the differences between psychiatry and psychology . Now, we’ll take a closer look at what it’s like to visit a psychiatrist.

Psychiatrists are medical doctors. These physicians can also practice psychotherapy. But the primary job of a psychiatrist is medication management. Larger practices may consist of a team of people.

These teams include various medical professionals capable of making diagnoses and prescribing medications. These include psychiatric nurse practitioners (NP) and physicians assistants (PA).

There may also be psychologists, licensed professional counselors and social workers. These team members may also be doctors, but they hold Ph.D.s and cannot prescribe medication.

Psychiatry appointment

Seeing a psychiatrist for the first time can be intimidating, but there is no need to worry. The following list tells you what to expect at a psychiatric appointment.

The first visit is the longest.

Phone a friend., write it down., a simple physical., get to know your psychiatrist., treatment plan., shorter sessions., psychiatry is worth it.

Dealing with a mental health diagnosis is as important as physical health. It may be new territory, but it is worth it to get you on a healthy path. It is often suggested to see a psychologist along with your psychiatrist. In the best case scenario, these doctors will work together on your treatment.

To facilitate this, both doctors will offer you a release form. These forms give them your permission to communicate freely to create the best treatment plan for your health. A psychologist spends more time with you and knows more details about your current state. They can share this information with your psychiatrist. Both doctors will help you achieve your mental health goals. If you’re looking to start your psychiatry journey, the Holiner Group team is here to help. We have locations in Dallas and McKinney . We have a talented staff and want to assist you. Contact us, today.

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What to expect at a psychiatry appointment?

Seeking help for mental health concerns is a significant step toward better emotional well-being. If you’ve scheduled a psychiatry appointment, it’s natural to have questions about what to expect. This guide aims to provide a comprehensive overview of what typically occurs during a psychiatry appointment, including what you should prepare for, common procedures, and how to make the most out of your visit. Whether you’re attending your first psychiatry appointment or seeking to understand the process better, this article will help you feel more informed and at ease.

Improve your mental health in Brooklyn —seek help today!

What to expect at a psychiatrist appointment?

Visiting a psychiatrist can be a daunting experience, but knowing what to expect can ease your anxiety and ensure you get the most out of your appointment. Here’s a breakdown of the typical psychiatry appointment process:

Intake and Assessment

• Paperwork Party: Buckle up for paperwork! You’ll likely fill out forms about your medical history, mental health concerns, and personal background.
• Meet & Greet: The psychiatrist will introduce themselves and ask questions about your current symptoms, triggers, and how long you’ve been experiencing them. Don’t worry, they’re not judging you, just trying to understand your situation.

Discussion and Evaluation

• Talk Time: This is where you get to share your story. Be open and honest about your experiences, emotions, and any specific issues you’re facing. The more information you provide, the better the psychiatrist can understand you and develop a personalized treatment plan.
• Mind Games: The psychiatrist might use questionnaires or diagnostic tools to assess your mental state. This helps them get a clearer picture of what’s going on and rule out any underlying medical conditions.

Diagnosis and Treatment Plan

• The Verdict: Based on the assessment and discussion, the psychiatrist will provide a diagnosis if applicable. This can be helpful in understanding your condition and guiding treatment.
• Charting the Course: Now comes the treatment plan! This might include therapy, medication, lifestyle changes, or a combination of these. The psychiatrist will discuss the options with you and address any questions or concerns you might have.

Medication Management (If Prescribed)

• Med Talk: If medication is part of your plan, the psychiatrist will explain its purpose, potential side effects, dosage, and how to take it properly. They’ll also encourage you to ask questions and express any concerns you have about medication.
• Follow-Up is Key: The psychiatrist will likely schedule follow-up appointments to monitor your progress and adjust the medication if needed. Remember, open communication is essential, so let them know if anything feels off or changes.
• Bring a Support Person:  If you feel comfortable, consider bringing a trusted friend or family member to your appointment for moral support and note-taking.

Remember, seeking help is a sign of strength, and your psychiatrist is there to guide you on your journey toward mental well-being. Take a deep breath, be prepared, and trust the process. You’ve got this!

Do psychiatrists prescribe medication first visit?

Whether a psychiatrist prescribes medication during an initial consultation depends on various factors. Understanding these can help set realistic expectations for your first visit.

Severity of Symptoms: If symptoms are intense and significantly disrupt your life, immediate medication might be considered as a primary treatment.

Nature of Symptoms: For certain conditions like major depression or schizophrenia, which often respond well to medication, early consideration of pharmaceutical intervention is common.

Medical History: The psychiatrist will evaluate your existing medical conditions and any current medications to prevent potential adverse interactions.

Personal Preferences: Your opinion matters. The psychiatrist should discuss medication pros and cons and respect your decision on whether to use medication.

Typically, psychiatrists do not rush to prescribe medication during a first visit, unless there’s an urgent need. The initial session usually involves:

Understanding Your Background: Expect discussions about your symptoms, medical history, and lifestyle.

Diagnosing: Using gathered information, the psychiatrist aims to diagnose your mental health condition.

Creating a Treatment Plan: This plan may include medication, therapy, and lifestyle modifications.

If medication is prescribed, it usually starts at a low dose with close monitoring for side effects. You’ll receive clear instructions on medication use and have the opportunity to ask questions.

Additional Considerations

• Medication Isn’t Always the Answer: It’s a valuable tool but not always necessary or effective for everyone.
• Effectiveness Varies: You might need to try different medications or combinations to find what works for you.
• Be Aware of Side Effects: Know the potential side effects and communicate with your doctor if you experience any issues.
• You’re Not Alone: Help is available for mental health challenges. Reach out to healthcare professionals, support groups, and community resources.

This information should provide a comprehensive view of what to expect regarding medication prescription during your first psychiatric visit and the factors influencing such decisions.

A psychiatry appointment is a significant step in addressing and managing mental health concerns. Knowing what to expect, from gathering information and preparing questions to the appointment process itself, can help you feel more confident and informed during your visit. Remember that your psychiatrist is there to support you on your journey to better mental health, and open communication is key to a successful treatment plan. By actively participating in your care and following the recommended treatment, you can work towards improved emotional well-being and a healthier future.

Frequently Asked Questions (FAQs)

How long does a psychiatry appointment typically last.

Psychiatry appointments can vary in length, but the initial evaluation appointment is often longer, ranging from 45 minutes to an hour. Follow-up appointments are typically shorter, lasting around 15 to 30 minutes.

Do I need a referral to see a psychiatrist?

In some cases, a referral from a primary care physician or another healthcare provider may be required to see a psychiatrist. However, many individuals can schedule appointments with psychiatrists directly, depending on their healthcare coverage and specific circumstances.

What if I don’t agree with the treatment plan proposed by the psychiatrist?

It’s essential to communicate openly with your psychiatrist if you have concerns or questions about the proposed treatment plan. Discuss your reservations, ask for alternative options, and collaborate with the psychiatrist to make decisions that feel right for you.

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What to Expect at Your First Psychiatrist Appointment

Amy Morin, LCSW, is a psychotherapist and international bestselling author. Her books, including "13 Things Mentally Strong People Don't Do," have been translated into more than 40 languages. Her TEDx talk,  "The Secret of Becoming Mentally Strong," is one of the most viewed talks of all time.

Prepare for the First Appointment

Make a list of concerns, during the appointment, after your first appointment, frequently asked questions.

It's normal to be a little nervous when you go to your first appointment with a psychiatrist, psychologist , or another mental health professional . You're probably not sure what to expect, which can lead to making you feel out of control.

While it can be nerve-wracking, there is nothing to fear. Your psychiatrist is there to help you learn more about the process and help you decide which steps to take next. It might take some time to find the right psychiatrist for you , but your mental health is worth the investment of time and energy.

This article discusses what you can expect during your first psychiatrist appointment. It covers how to prepare for your appointment, what to bring, and what you should do during and after your visit.

It's normal to feel a bit apprehensive before your first psychiatrist appointment. After all, discussing sensitive personal information with a stranger can be daunting for anyone. Your psychiatrist is a highly trained professional who is there to help, and there are steps you can take to make your first appointment a success.

Paperwork and Payment

Before your first psychiatrist appointment, you'll need to provide some basic information about yourself, such as your contact information, medical history, and insurance information. It may be possible to do this online before your appointment, but you can also often do this at the office when you arrive.

You should also sort out your payment details before your first appointment. Check with your insurer beforehand to see if your visit will be covered. Your insurance provider can also tell you if you need to get a referral from your primary care provider before your appointment.

Schedule your first appointment at a time when you can have a relaxed conversation with your psychiatrist. Avoid scheduling appointments when you're likely to be tired or stressed.

Medical History

Write down important information about your medical history. This should include:

• Any mental health diagnoses
• Medications you're taking
• Any psychiatric hospitalizations
• Any past therapy or treatment for a mental health condition

If you have any medical conditions that might affect your mental health, such as thyroid disease, diabetes, or heart disease, be sure to mention them to your psychiatrist.

Family medical history can also be relevant, so be sure to note if there is a history of psychiatric issues in your family.

Doctor's Questions

Your psychiatrist will want to know why you are seeing them, so they will ask questions such as:

• "Can you tell me what brings you here today?"
• "How are you feeling?"
• "What do you need help with?
• "What can I do to help you?"

The purpose of asking these questions is to get a better idea of your symptoms and their effects on your life. To prepare for your appointment, you might find it helpful to write down some of your symptoms to feel better able to answer these types of questions.

Pre-Appointment Anxiety

Your anxiety over this first appointment may be causing you to assume the worst or think treatment will be tougher than it actually is. For instance, you may think you have too many problems to tackle.

However, the reality is that your therapist will likely focus on just one or two issues, to begin with and move on from there. Being prepared for your first appointment can help you manage your anxiety and nervousness.

You can prepare for your first appointment by filling out paperwork, taking care of payment details, writing down your medical history, and thinking about questions your psychiatrist might ask. Remember that some nervousness is perfectly normal, and your therapist is there to help.

Prior to your appointment, make a list of everything you are feeling and any questions you have for your doctor or healthcare professional. You will also want to write down any details about triggers, as well as how your life is affected by each item.

For example, if you're feeling paranoid , you need to list not just the feeling but what you feel paranoid about and how it affects your life. List exactly what you are feeling and experiencing and how your life is affected.

When you break down your feelings and how they are affecting your daily life, you paint a very clear picture for the doctor. It's very difficult to do that on the spot in a short visit when your brain is spinning and you aren't prepared, so make the list ahead of time.

Try to avoid putting labels on your feelings or triggers as you talk to your therapist. Let the doctor do that. Therapists could inadvertently be influenced by your labels, affecting their diagnosis or treatment recommendations.

There are a number of things you can do during your appointment to make the process easier and ensure that you are getting the most out of the experience. 

Be Open and Honest

It's important to be candid with your psychiatrist. In order to provide the best possible care, you need to be as honest and open as you can. 

This often means talking about sensitive information of a highly personal nature. You might discuss topics such as your sexual history, family relationships, and drug use. While this may be difficult to share, it is important to remember that your psychiatrist can provide appropriate treatment unless they fully understand your situation.

Ask Questions

If you need more information or don't understand something your psychiatrist has said, ask for clarification. You might ask questions in the moment, or you might write them down so you can discuss them later.

Bring a Supportive Person

If you're feeling anxious about your first appointment, you may want to bring a supportive friend or family member with you. This person can provide emotional support and can help you remember what the psychiatrist says after the appointment.

It's normal to feel overwhelmed by all the information you might be taking in during that first appointment. You may find it helpful to take notes throughout your session. This can help you remember what you discussed, but it can also be a great way to reflect back on each session to think about what to talk about during your next appointment.

During your appointment, be honest with your psychiatrist, and don't be afraid to ask questions. You might opt to bring a trusted friend or take notes during your session so you can remember important details about your appointment.

When you arrive home after your first appointment, you may wish to add notes to your list. While the visit is fresh in your mind, make notes for things you wish to talk about in more depth in the future or feelings which you did not have time to address during the visit.

Take a moment as well to ask yourself if you want to keep seeing this person or if, instead, you would rather see a different mental health care provider. An important part of coping with any mental health condition is to develop a solid relationship with a psychiatrist or therapist you can trust.

Research suggests that the therapeutic alliance, or the rapport and relationship between you and your therapist, plays an essential role in treatment outcomes.

Mental health professionals, like all people, have a wide range of personalities, strengths, and weaknesses, and it's important to find the one who is right for you as an individual.

A Word From Verywell

Creating a detailed list can make your first appointment with a mental health professional go much more smoothly. Your doctor will appreciate your preparation, too. Remember to keep your list simple and limit it to feelings and experiences, taking care not to fill in diagnoses that could mislead both you and your therapist.

The length of your first appointment may vary depending on the individual therapist and your specific situation. In some cases, it might be the length of a regular session, which often lasts somewhere between 45 and 60 minutes. In other cases, your intake session will be the longest appointment, lasting between one and two hours.

Be sure to bring your insurance information to your first appointment. Also, take a list of all the medications you are currently taking. Note any psychiatric medications you may have taken in the past. 

Copies of medical records can be helpful, but you can also bring handwritten information about your medical history. If you've been tracking information about your symptoms, moods, triggers, and self-care practices, be sure to bring those notes as well.

If you don't like your psychiatrist, then it is probably best to look for a different mental health provider. It is perfectly normal to not feel comfortable with every therapist you meet, so don't be afraid to keep looking. You might simply say that you don't feel like it's a good match and ask if they or your primary care physician can refer you to a different professional. 

National Institute of Mental Health. Chronic illness and mental health: Recognizing and treating depression .

Sweeney A, Gillard S, Wykes T, Rose D. The role of fear in mental health service users' experiences: a qualitative exploration .  Soc Psychiatry Psychiatr Epidemiol . 2015;50(7):1079–1087. doi:10.1007/s00127-015-1028-z

Crits-Christoph P, Rieger A, Gaines A, Gibbons MBC.  Trust and respect in the patient-clinician relationship: preliminary development of a new scale .  BMC Psychol . 2019;7(1):91. doi:10.1186/s40359-019-0347-3

Carey TA. Beyond patient-centered care: Enhancing the patient experience in mental health services through patient-perspective care . Patient Experience J. 2016; 3(2):46-49.

National Alliance on Mental Illness. How to prepare for your first psychiatric appointment . 

By Marcia Purse Marcia Purse is a mental health writer and bipolar disorder advocate who brings strong research skills and personal experiences to her writing.

Mindfulness and the Medication Management Visit

• J. Christopher Muran, PhD

Engaging in mindfulness activities either individually or with patients who come to us for brief medication visits can have a profound influence on the therapeutic process.

Poor adherence to psychotropic medication regimens is one of the major roadblocks to improved clinical outcomes. In today’s time-pressed practice of psychiatry, with its emphasis on the brief medication management visit, clinicians and patients often feel rushed and disconnected, which results in a poor therapeutic alliance. When the therapeutic alliance is positive, medication adherence is better and treatment outcomes should improve . 1

Integrating mindfulness into our practices may help foster the therapeutic alliance and ultimately medication adherence.

Engaging in mindfulness activities either individually or with patients who come to us for brief medication visits can have a profound influence on the therapeutic process. Mindfulness can help us and our patients settle down and be more present during the session. This can provide the catalyst for more meaningful engagement and better therapeutic outcome. While there is no universally agreed on definition of mindfulness, it is helpful to understand the concept as embracing humanness and accepting one’s body, thoughts, feelings, and emotions without judgment.

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• Mental illness

To determine a diagnosis and check for related complications, you may have:

• A physical exam. Your doctor will try to rule out physical problems that could cause your symptoms.
• Lab tests. These may include, for example, a check of your thyroid function or a screening for alcohol and drugs.
• A psychological evaluation. A doctor or mental health professional talks to you about your symptoms, thoughts, feelings and behavior patterns. You may be asked to fill out a questionnaire to help answer these questions.

Determining which mental illness you have

Sometimes it's difficult to find out which mental illness may be causing your symptoms. But taking the time and effort to get an accurate diagnosis will help determine the appropriate treatment. The more information you have, the more you will be prepared to work with your mental health professional in understanding what your symptoms may represent.

The defining symptoms for each mental illness are detailed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. This manual is used by mental health professionals to diagnose mental conditions and by insurance companies to reimburse for treatment.

Classes of mental illness

The main classes of mental illness are:

• Neurodevelopmental disorders. This class covers a wide range of problems that usually begin in infancy or childhood, often before the child begins grade school. Examples include autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD) and learning disorders.
• Schizophrenia spectrum and other psychotic disorders. Psychotic disorders cause detachment from reality — such as delusions, hallucinations, and disorganized thinking and speech. The most notable example is schizophrenia, although other classes of disorders can be associated with detachment from reality at times.
• Bipolar and related disorders. This class includes disorders with alternating episodes of mania — periods of excessive activity, energy and excitement — and depression.
• Depressive disorders. These include disorders that affect how you feel emotionally, such as the level of sadness and happiness, and they can disrupt your ability to function. Examples include major depressive disorder and premenstrual dysphoric disorder.
• Anxiety disorders. Anxiety is an emotion characterized by the anticipation of future danger or misfortune, along with excessive worrying. It can include behavior aimed at avoiding situations that cause anxiety. This class includes generalized anxiety disorder, panic disorder and phobias.
• Obsessive-compulsive and related disorders. These disorders involve preoccupations or obsessions and repetitive thoughts and actions. Examples include obsessive-compulsive disorder, hoarding disorder and hair-pulling disorder (trichotillomania).
• Trauma- and stressor-related disorders. These are adjustment disorders in which a person has trouble coping during or after a stressful life event. Examples include post-traumatic stress disorder (PTSD) and acute stress disorder.
• Dissociative disorders. These are disorders in which your sense of self is disrupted, such as with dissociative identity disorder and dissociative amnesia.
• Somatic symptom and related disorders. A person with one of these disorders may have physical symptoms that cause major emotional distress and problems functioning. There may or may not be another diagnosed medical condition associated with these symptoms, but the reaction to the symptoms is not normal. The disorders include somatic symptom disorder, illness anxiety disorder and factitious disorder.
• Feeding and eating disorders. These disorders include disturbances related to eating that impact nutrition and health, such as anorexia nervosa and binge-eating disorder.
• Elimination disorders. These disorders relate to the inappropriate elimination of urine or stool by accident or on purpose. Bed-wetting (enuresis) is an example.
• Sleep-wake disorders. These are disorders of sleep severe enough to require clinical attention, such as insomnia, sleep apnea and restless legs syndrome.
• Sexual dysfunctions. These include disorders of sexual response, such as premature ejaculation and female orgasmic disorder.
• Gender dysphoria. This refers to the distress that accompanies a person's stated desire to be another gender.
• Disruptive, impulse-control and conduct disorders. These disorders include problems with emotional and behavioral self-control, such as kleptomania or intermittent explosive disorder.
• Substance-related and addictive disorders. These include problems associated with the excessive use of alcohol, caffeine, tobacco and drugs. This class also includes gambling disorder.
• Neurocognitive disorders. Neurocognitive disorders affect your ability to think and reason. These acquired (rather than developmental) cognitive problems include delirium, as well as neurocognitive disorders due to conditions or diseases such as traumatic brain injury or Alzheimer's disease.
• Personality disorders. A personality disorder involves a lasting pattern of emotional instability and unhealthy behavior that causes problems in your life and relationships. Examples include borderline, antisocial and narcissistic personality disorders.
• Paraphilic disorders. These disorders include sexual interest that causes personal distress or impairment or causes potential or actual harm to another person. Examples are sexual sadism disorder, voyeuristic disorder and pedophilic disorder.
• Other mental disorders. This class includes mental disorders that are due to other medical conditions or that don't meet the full criteria for one of the above disorders.

Your treatment depends on the type of mental illness you have, its severity and what works best for you. In many cases, a combination of treatments works best.

If you have a mild mental illness with well-controlled symptoms, treatment from your primary care provider may be sufficient. However, often a team approach is appropriate to make sure all your psychiatric, medical and social needs are met. This is especially important for severe mental illnesses, such as schizophrenia.

Your treatment team

Your treatment team may include your:

• Family or primary care doctor
• Nurse practitioner
• Physician assistant
• Psychiatrist, a medical doctor who diagnoses and treats mental illnesses
• Psychotherapist, such as a psychologist or a licensed counselor
• Social worker
• Family members

Medications

Although psychiatric medications don't cure mental illness, they can often significantly improve symptoms. Psychiatric medications can also help make other treatments, such as psychotherapy, more effective. The best medications for you will depend on your particular situation and how your body responds to the medication.

Some of the most commonly used classes of prescription psychiatric medications include:

• Antidepressants. Antidepressants are used to treat depression, anxiety and sometimes other conditions. They can help improve symptoms such as sadness, hopelessness, lack of energy, difficulty concentrating and lack of interest in activities. Antidepressants are not addictive and do not cause dependency.
• Anti-anxiety medications. These drugs are used to treat anxiety disorders, such as generalized anxiety disorder or panic disorder. They may also help reduce agitation and insomnia. Long-term anti-anxiety drugs typically are antidepressants that also work for anxiety. Fast-acting anti-anxiety drugs help with short-term relief, but they also have the potential to cause dependency, so ideally they'd be used short term.
• Mood-stabilizing medications. Mood stabilizers are most commonly used to treat bipolar disorders, which involves alternating episodes of mania and depression. Sometimes mood stabilizers are used with antidepressants to treat depression.
• Antipsychotic medications. Antipsychotic drugs are typically used to treat psychotic disorders, such as schizophrenia. Antipsychotic medications may also be used to treat bipolar disorders or used with antidepressants to treat depression.
• Psychotherapy

Psychotherapy, also called talk therapy, involves talking about your condition and related issues with a mental health professional. During psychotherapy, you learn about your condition and your moods, feelings, thoughts and behavior. With the insights and knowledge you gain, you can learn coping and stress management skills.

There are many types of psychotherapy, each with its own approach to improving your mental well-being. Psychotherapy often can be successfully completed in a few months, but in some cases, long-term treatment may be needed. It can take place one-on-one, in a group or with family members.

When choosing a therapist, you should feel comfortable and be confident that he or she is capable of listening and hearing what you have to say. Also, it's important that your therapist understands the life journey that has helped shape who you are and how you live in the world.

Brain-stimulation treatments

Brain-stimulation treatments are sometimes used for depression and other mental health disorders. They're generally reserved for situations in which medications and psychotherapy haven't worked. They include electroconvulsive therapy, repetitive transcranial magnetic stimulation, deep brain stimulation and vagus nerve stimulation.

Make sure you understand all the risks and benefits of any recommended treatment.

Hospital and residential treatment programs

Sometimes mental illness becomes so severe that you need care in a psychiatric hospital. This is generally recommended when you can't care for yourself properly or when you're in immediate danger of harming yourself or someone else.

Options include 24-hour inpatient care, partial or day hospitalization, or residential treatment, which offers a temporary supportive place to live. Another option may be intensive outpatient treatment.

Substance misuse treatment

Problems with substance use commonly occur along with mental illness. Often it interferes with treatment and worsens mental illness. If you can't stop using drugs or alcohol on your own, you need treatment. Talk to your doctor about treatment options.

Participating in your own care

Working together, you and your primary care provider or mental health professional can decide which treatment may be best, depending on your symptoms and their severity, your personal preferences, medication side effects, and other factors. In some cases, a mental illness may be so severe that a doctor or loved one may need to guide your care until you're well enough to participate in decision-making.

More Information

• Mental health providers: Tips on finding one
• Deep brain stimulation
• Electroconvulsive therapy (ECT)
• Transcranial magnetic stimulation
• Vagus nerve stimulation

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Lifestyle and home remedies

In most cases, a mental illness won't get better if you try to treat it on your own without professional care. But you can do some things for yourself that will build on your treatment plan:

• Stick to your treatment plan. Don't skip therapy sessions. Even if you're feeling better, don't skip your medications. If you stop, symptoms may come back. And you could have withdrawal-like symptoms if you stop a medication too suddenly. If you have bothersome drug side effects or other problems with treatment, talk to your doctor before making changes.
• Avoid alcohol and drug use. Using alcohol or recreational drugs can make it difficult to treat a mental illness. If you're addicted, quitting can be a real challenge. If you can't quit on your own, see your doctor or find a support group to help you.
• Stay active. Exercise can help you manage symptoms of depression, stress and anxiety. Physical activity can also counteract the effects of some psychiatric medications that may cause weight gain. Consider walking, swimming, gardening or any form of physical activity that you enjoy. Even light physical activity can make a difference.
• Make healthy choices. Maintaining a regular schedule that includes sufficient sleep, healthy eating and regular physical activity are important to your mental health.
• Don't make important decisions when your symptoms are severe. Avoid decision-making when you're in the depth of mental illness symptoms, since you may not be thinking clearly.
• Determine priorities. You may reduce the impact of your mental illness by managing time and energy. Cut back on obligations when necessary and set reasonable goals. Give yourself permission to do less when symptoms are worse. You may find it helpful to make a list of daily tasks or use a planner to structure your time and stay organized.
• Learn to adopt a positive attitude. Focusing on the positive things in your life can make your life better and may even improve your health. Try to accept changes when they occur, and keep problems in perspective. Stress management techniques, including relaxation methods, may help.

Coping and support

Coping with a mental illness is challenging. Talk to your doctor or therapist about improving your coping skills, and consider these tips:

• Learn about your mental illness. Your doctor or therapist can provide you with information or may recommend classes, books or websites. Include your family, too — this can help the people who care about you understand what you're going through and learn how they can help.
• Join a support group. Connecting with others facing similar challenges may help you cope. Support groups for mental illness are available in many communities and online. One good place to start is the National Alliance on Mental Illness.
• Stay connected with friends and family. Try to participate in social activities, and get together with family or friends regularly. Ask for help when you need it, and be upfront with your loved ones about how you're doing.
• Keep a journal. Or jot down brief thoughts or record symptoms on a smartphone app. Keeping track of your personal life and sharing information with your therapist can help you identify what triggers or improves your symptoms. It's also a healthy way to explore and express pain, anger, fear and other emotions.

Preparing for your appointment

Whether you schedule an appointment with your primary care provider to talk about mental health concerns or you're referred to a mental health professional, such as a psychiatrist or psychologist, take steps to prepare for your appointment.

If possible, take a family member or friend along. Someone who has known you for a long time may be able to share important information, with your permission.

What you can do

Before your appointment, make a list of:

• Any symptoms you or people close to you have noticed, and for how long
• Key personal information, including traumatic events in your past and any current, major stressors
• Your medical information, including other physical or mental health conditions
• Any medications, vitamins, herbal products or other supplements you take, and their dosages
• Questions to ask your doctor or mental health professional

Questions to ask may include:

• What type of mental illness might I have?
• Why can't I get over mental illness on my own?
• How do you treat my type of mental illness?
• Will talk therapy help?
• Are there medications that might help?
• How long will treatment take?
• What can I do to help myself?
• Do you have any brochures or other printed material that I can have?
• What websites do you recommend?

Don't hesitate to ask any other questions during your appointment.

What to expect from your doctor

During your appointment, your doctor or mental health professional is likely to ask you questions about your mood, thoughts and behavior, such as:

• When did you first notice symptoms?
• How is your daily life affected by your symptoms?
• What treatment, if any, have you had for mental illness?
• What have you tried on your own to feel better or control your symptoms?
• What things make you feel worse?
• Have family members or friends commented on your mood or behavior?
• Do you have blood relatives with a mental illness?
• What do you hope to gain from treatment?
• What medications or over-the-counter herbs and supplements do you take?
• Do you drink alcohol or use recreational drugs?

Your doctor or mental health professional will ask additional questions based on your responses, symptoms and needs. Preparing and anticipating questions will help you make the most of your time with the doctor.

• Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed April 8, 2019.
• Dual diagnosis. National Alliance on Mental Illness. https://www.nami.org/Learn-More/Mental-Health-Conditions/Related-Conditions/Dual-Diagnosis. Accessed April 8, 2019.
• Practice Guidelines for the Psychiatric Evaluation of Adults. 3rd ed. Arlington, Va.: American Psychiatric Association; 2013. http://psychiatryonline.org. Accessed April 1, 2019.
• Understanding psychotherapy and how it works. American Psychological Association. https://www.apa.org/helpcenter/understanding-psychotherapy. Accessed April 1, 2019.
• Asher GN, et al. Complementary therapies for mental health disorders. Medical Clinics of North America. 2017;101:847.
• Complementary health approaches. National Alliance on Mental Illness. https://www.nami.org/Learn-More/Treatment/Complementary-Health-Approaches. Accessed April 4, 2019.
• Warning signs of mental illness. American Psychiatric Association. https://www.psychiatry.org/patients-families/warning-signs-of-mental-illness. Accessed April 4, 2019.
• Helping a loved one cope with mental illness. American Psychiatric Association. https://www.psychiatry.org/patients-families/helping-a-loved-one-cope-with-a-mental-illness. Accessed April 4, 2019.
• What is mental illness? American Psychiatric Association. https://www.psychiatry.org/patients-families/what-is-mental-illness. Accessed April 4, 2019.
• For friends and family members. MentalHealth.gov. https://www.mentalhealth.gov/talk/friends-family-members. Accessed April 4, 2019.
• For people with mental health problems. MentalHealth.gov. https://www.mentalhealth.gov/talk/people-mental-health-problems. Accessed April 4, 2019.
• Brain stimulation therapies. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml. Accessed April 4, 2019.
• Mental health medications. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml. Accessed April 4, 2019.
• Psychotherapies. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/psychotherapies/index.shtml. Accessed April 4, 2019.
• Muesham D, et al. The embodied mind: A review on functional genomic and neurological correlates of mind-body therapies. Neuroscience and Biobehavioral Reviews. 2017;73:165.
• Suicide in America: Frequently asked questions. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/suicide-faq/index.shtml. Accessed April 10, 2019.
• Types of mental health professionals. National Alliance on Mental Illness. https://www.nami.org/Learn-More/Treatment/Types-of-Mental-Health-Professionals. Accessed April 8, 2019.
• Risk and protective factors. Substance Abuse and Mental Health Services Administration. Accessed April 8, 2019.
• Newman L, et al. Early origins of mental disorder — Risk factors in the perinatal and infant period. BMC Psychiatry. 2016;16:270.
• Treatment settings. National Alliance on Mental Illness. https://www.nami.org/Learn-More/Treatment/Treatment-Settings. Accessed April 10, 2019.
• Hall-Flavin DK (expert opinion). Mayo Clinic, Rochester, Minn. May 18, 2019.
• Intervention: Help a loved one overcome addiction
• Mental health: Overcoming the stigma of mental illness

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PSYCH-MENTAL HEALTH HUB

essential resources, learning, and support

The Intake & Follow-Up Notes in Psych

This post is long overdue and caution, it is LONG. Here’s a collection of documentation formats and particular words to not only be accurate but also neutral/non-judgmental, clear, and most importantly increase efficiency and getting PAID. Countless businesses and health facilities have FAILED because they don’t know how to bill or capture services. And I’ve discussed it before . This is important for ALL providers, if you’re documentation/care doesn’t reflect standards, there’s a risk of not getting a return. 

This was a recent email response to someone in billing asking me why insurance kept sending back the NP’s paperwork: … When services aren’t getting covered it may be because of the state (if you need a collaborative physician) and if the collab is not signing off on the billable services/medications, it won’t get covered. It may be the actual insurance company; state insurance truly doesn’t cover that much. If you continue to have issues with billing you may want to consider switching to cash/credit options. Here’s another secret, sometimes I’ll call the insurance company and actually speak to someone about how things are not getting covered and what to do about it… sometimes it’s a misunderstanding etc. or the clinical note isn’t sufficient to bill for the services.

My collaborative physician is not literally working in the office with me, but I need the doctor’s information ( DEA/NPI ) with our EMR for insurance, prescribing, and signing off the documents. The front desk/medical staff also need the information for the prior auths (PAs) and for billing such as how you rank the psych disorders… If you’re charting well, this shouldn’t be a train wreck where people are constantly bothering you about what needs to be added, corrected, etc. 

Lastly, before I go into the formats, I’ve seen and found many different kinds that were acceptable for billing but for me (or you) – stick to what will help you the most. Like my collab said, “I can’t help but to write in sentences because I’ve been taught to write sentences” lol and that’s right! I learn, read, memorized, write, and talk in SENTENCES so writing a narrative is the easiest for me but I’ll show the alternative as examples as well.

Just to be clear an outline/checkbox format is simply just a “narrative” without sentences. I took out the “checkboxes” below just to make it easier to view and tailor online. Overall, I recommend copying/pasting the information into another document ( I use google docs ) and tailoring it to your own liking or whatever is the most convenient.  I also feel like people need to understand the burden of charting in psych so they know what they’re getting into schools/professors/providers let them KNOW! and here we go: 

My General (Narrative) Intake  

• Pros: best format for complicated patients and special populations, most accurate and clear
• Cons: least time-efficient, focused on the past, the bigger picture, and everything between -some people may think it’s too much unnecessary added information but that’s how it is in CMH…

Chief Complaint: “what is the reason why the patient/client is present” I usually put if the eval was in-person vs telehealth, first/last name, age, ethnicity, and pertinent current information; a lack of sleep, appetite, etc.  Problem 1, Plan: problem (my diagnosis), plan: the medication, and education about the med or educating about ETOH cessation.  Rating Scales: PHQ/GAD (screening tool) results or they can just be uploaded in the EMR…   History of Present Illness: I usually put the 1st encounter with the patient. The history of the issues, c/c, and pertinent past information; SI attempts or witnessing SI, HI, or other trauma.   Developmental Hx: the product of vaginal/c-section birth, FT (full-term) or 36 weeks, + any issues with birth, milestones, ACES, highest grade completed…  Past Psychiatric History: hx of inpatient, hospitalizations, the reason, outcomes, etc.  ROS: any other problems today? at least cover neuro, resp, skin, cardiac, GI  Med/Surg: past/current medical and surgical information, allergies, height/weight  LMP: birth ctrl methods and the hx of menses; heavy, irregular, painful, PMS?   Current Medications: psych and medical; Past RX; medication (reasons for d/c)  Scheduled Opioid Report: no conflicts, prescription hx consistent    Family History: psych and substance abuse, pertinent medical i.e. DM, CA, or heart disease  Past, Family, and/or Social History (PFSH) An age-appropriate review of past and current activities… ( ACC.org ) -pertinent for state insurance billing . who the patient lives with, job, housing, current school, or activities, safety risks such as homelessness, domestic issues, etc.  Substance Abuse History: (current or past use, hx of rehab/OD) ETOH, cigarettes, substances  Legal: current or past legal issues  Mental Status Exam: appearance, tone/rate/content of speech, eye contact, orientation  Impression: what and why this diagnosis was given, stability (written here or above with problems), and possible rule-outs.  Plan: conclusion of this meeting and what’s the plan for the next meeting…

 Documentation (Narrative Examples) 

Stable: Tolerable Issues, Mood/Conditions Balanced, Maintenance  

CC: follow-up in-person/office.  JB is a 23 y/o WM reports no issues with mood or medications, “I feel fine”. No concern with sleep or appetite denies thoughts or intent to harm self or others, denies AVH (audible/visual hallucinations) . Agreed to f/u within 4 weeks. Reports no additional concerns.

• Problem 1 GAD: JB feels more anxious in the morning. Plan: increase sertraline dose to 50mg BID. ( problems prioritized or ranked just like with billing )
• Problem 2 ADHD…

HPI: last encounter with patient was 3/3/22. Pt. has a hx of GAD, ADHD and discussed decreasing quetiapine to 50mg from 100mg r/t grogginess. Pt. was on this dose for 3 years but report not having as severe sleep problems as previously mentioned. No prior medications or hospitalizations related to mental health or SI.

ROS: Neuro- denies dizziness, headaches, denies syncope, seizures. GI- no N/V/D, abdominal pain, constipation. SKIN: denies rash, swelling, Psych- no SI, HI, AH, VH. MEDICATIONS:  sometimes automatically generated in the EMR PMP Score: 0 conflicts Med/Surg: denies, 5’11 #189. NKDA PFSH: patient lives alone, and started working at Costco, afternoon shift. MSE: JB continues to be cooperative and adheres to treatment. Good insight to needs and strengths. Aware of improving coping skills. Thought content was with no psychotic or suicidal thoughts. John was cooperative, well-groomed, good eye contact. Communicates needs appropriately. Thought content was with no psychotic, suicidal, or harmful thoughts. PLAN: 

• Adhere to treatment/medication/therapy -I usually just say “treatment” to cover everything
• Encourage ETOH cessation (or whatever lifestyle behavior/changes that were discussed)
• Medication changes (if any): it could be placed here and/or in the CC
• RTC (return to clinic) within 4 weeks or sooner for concerns or seek immediate assistance

Unstable: SI, HI, Psychosis, Manic, Aggressive, Unpredictable  

CC: follow-up completed in the office. AH is a 37y/o who reports being pregnant and “seeing shadows and bugs” for the last couple of days. HX of BPI, DM, HTN, GAD, MDD. She’s currently in an abusive relationship but her partner is the “only support system”. AH reports she has been getting “angrier” and “deserves to be hit in the head”. AH reports the last time she was assaulted was the past weekend and has been hallucinating since. Expressed not wanting to report the incident because she had +LOC, and doesn’t remember what happened, “I don’t want to make anything worse”. She hasn’t seen the OB since the positive pregnancy and hasn’t been taking prenatals “I feel too overwhelmed”. Reports taking her medications off/on ( or not adhering with treatment ) and worried about relapsing on heroin. Endorsing hallucinations but r/o possible head injury. Agreed to f/u <2 weeks.

• Problem 1 BP1 (unstable): AH hasn’t been taking her cariprazine (Vraylar) and her behaviors are becoming more riskier. Plan: collaborate with OB, confirm the pregnancy, and inquire about restarting medications and possibly adding Suboxone.
• Problem 2 GAD…
• Problem 3 MDD…

Rating Scales: n/a due to ruling out hallucinations HPI: last encounter with patient was 3/3/22. AH adherence with medications and treatment is off/on. Sometimes unreliable hx due to difficult memory and moods. Past aggressive behaviors include yelling and pacing. Limited social support and was homeless last year due to losing employment and substance abuse. Hx of impulsivities, BP1, GAD, MDD, Opioid Abuse. Hospitalized x3 for OD and SI >5 years ago, unsure of dates, locations, or treatment. Past hx of drug-induced hallucinations but it also occurs with increased stress. Denies rehab hx, and reports getting sober for her youngest child but he was raised by other family members and she relapsed multiple times. Last use of [substance(s)] was 12/2021. ROS: headache off/on, +n/v r/t “pregnancy”, feet swelling, -dizzy,  no chest pain, -SOB uses an inhaler as needed for anxiety Med/Surg: NKDA HTN, cholesterol, DM, back surg Dec/2020. 5’4, #210. Medications: Lisinopril, Metformin, Albuterol. NKDA PFSH: lives with boyfriend and 4y/o son, collects SSD MSE: AH was cooperative but restless, and paranoid throughout the meeting. Communicate concerns and issues appropriately. Low insight, aware of the concern with impulses and relapsing. Thought content with no suicidal thoughts but possible AVH. PLAN: 

• Encouraged to adhere with treatment and therapy
• Developed a safety plan with social services
• Consent with sharing information with OB/PCP/etc.
• Consult with Case Management
• RX test next meeting
• RTC 2 weeks or sooner for concerns or seek ER services

-sidenote, if this was one of my real narratives (which isn’t that much different) it’ll seriously be longer but for the sake of this post, I just wanted to quickly showcase how the flow of the charting will go and with charting “complicated cases”, the MORE the merrier… This is also how you justify 99214-99215s.   

I probably need to make another post about “aggression” or “crises” documentation itself so below are just standard phrases/formats for general outpatient settings – more than likely, I’ll add more in the respective areas :

Narrative Format Part 2

Chief Complaint (symptom, problem, condition, diagnosis): HPI History (HPI, review of systems, PFSH): Medical Comorbidity (current status) Allergies: Medical/Surgical HX: Family HX: Past Psych HX Substance Abuse: MSE: DEVELOPMENTAL HISTORY: EDUCATIONAL HISTORY: SOCIAL HISTORY: LEGAL HISTORY:

Narrative Format Part 3

Pertinent HX: HPI: ROS: Psych HX: Prior Meds: Family HX: Father: Mother: Siblings/Other (grandparents, child): Developmental HX: Legal: denies current probation, warrants, or court dates. Substance HX: Non-Psychiatric Medical/Surgical History/Allergies: Educational HX: Personal HX: Mental Status Examination Narrative: Summary of Findings/Biopsychosocial Formulation: Assessment of Risk Factors: Summary and Treatment Recommendations: Projected Length of Treatment: Prognosis: Discharge Criteria:

Progress/Follow-up Narrative Formate

-Please note how you can just add from the intake (or the previous note) in the respective areas and tweak the information to reflect current changes, so charting should be easier moving forward…

• CC: rating scales can be done q3-6months after intake 
• Problem/Condition: New/Established, Improve/Worsening, Co-Morbities; stable, complications/side-effects, independent or additional assistance required, interference with the primary problem

An Outlined/Checkbox Intake

• Pros: great for follow-ups, high caseloads, and low acuity patients, the most practical
• Cons: vague, not detailed so it can be confusing or inadequate charting

CC: HPI: Family HX: father, mother, siblings, extended -(psych hx & notes) Personal & Social:   Gestation and Birth: 

• Intrauterine Exposures: none, alcohol, tobacco, psychotropic medications, others:        exposures were: Term, Preterm 
• Delivery: Normal, Spontaneous, Induced, Vaginal Delivery, C-section, Forceps Delivery
• Birth Complications: none, breach, nuchal cord, anoxia, apnea,  abnormal APGAR, jaundice, meconium aspiration

Early Development and Health: 

• Developmental Milestones: Early, Normal, Delayed, healthy childhood, significant for:      

Childhood Family Social Position and Home Atmosphere:

• Normal, Supportive, Parental Fighting, Parental Violence, Financial Difficulties, Frequent Moving

Childhood Behavior Symptoms:

• Tantrums, Enuresis, Encopresis, Running Away from Home, Fighting, Truancy, School Refusal, Suspensions, Expulsions, Stealing, Property Damage, Fire-Setting, Animal Cruelty

School/Education:

• School phobia, Fighting, Detentions, Expulsions, Class Failures, Repetition of Grades, Special Education, Remedial Classes, Speech Classes, Tutoring, Accommodations
• HS graduate,  Bachelor’s Degree, Master’s Degree, MBA, Ph.D., Law Degree, MD Degree
• Standardized Test Performance:      

Occupations:

• Employed, Unemployed, Retired, Disability
• Longest Employment:      
• Longest Unemployment:      

Living Situations:

• Alone, Roommates, Family, Group Home, Homeless

Menstrual and Sexual History:

• Menses beginning at age:      
• Premenstrual symptoms: dysphoria, cramps, appetite change, bloating, sleep disturbance, Pregnancies, Miscarriages, Abortions
• Orientation: Heterosexual, Homosexual, Bisexual, Other: 

Abuse History:

• Sexual Abuse, Physical Abuse, Verbal Abuse, non-confidentiality warning given
• history of abuse by:      
• type of abuse:      
• Report:   not applicable, –or made to:      

Relationships:

• Single, Relationship, Never Married, Married, Partnered, Divorced, Widowed
• Longest Relationship:      
• Extramarital Affairs:      
• Current relationship (name, length):
• Never married
• First married at age:      
• Total number of marriages:      
• Divorced/reason for divorce(s):       

Children: (note ages, custody, psychiatric problems, substance abuse) Legal: Religious/Spiritual: Substance Abuse History:

• Age of Onset
• Current Amount Used and Frequency (with time period identified)
• Maximum Amount Used and Frequency (with time period identified)
• Longest Duration of Abstinence (with time period identified)
• Abstinence Symptoms
• CAGE SCORE:  
• History of Detoxification/Rehabilitation Programs (inpatient/outpatient, AA/NA):
• How are substances financed/obtained?: 
• Substance-Related Legal Issues (including DWI/DUI):
• Tobacco Use:
• Caffeine Use:

Medical History 

• Medical Issues: 
• Surgical History:
• Allergies: 
• Current Medications: 
• Outpatient Primary Care Provider with Contact Number:
• Last Visit:      
• Last Laboratory Work/EKG:      

Medical ROS:  Past Psych HX:

• Psychiatric History (age of onset, symptoms, diagnoses):      
• History of Neuroimaging:      
• History of EEG/Functional Imagining:      
• History of Lost of Consciousness/Traumatic Brain Injury/Concussions:      
• History of Neuropsychological Testing:      
• Past Psychiatric Hospitalizations (dates, locations, diagnoses, treatments, disposition):      
• Past Treatments (specifics of medication, ECT): 
• Self-Injurious Behavior:
• Current Outpatient Mental Health Providers and Contact Numbers:

MSE:        Physical Exam: vitals, etc.  Plan:

Outlined Format Follow-Up/Progress Notes 

CC: “I am having less stress” HPI: 24 y/o hx of GAD and MDD. Needs to go to work soon, no issues with medications, hydroxyzine “helps” Stressors (medical/family/relationship/financial/employment/educational/housing): works in an HS, lives with girlfriend Mood: “overwhelmed” Sleep: 7 hours off/on Appetite: no issues Psychomotor: denies agitation or slowing Use of PRNS: propanolol QD Impulsivity: denies Drug/ETOH/Substance: denies Scheduled Reports: 0 issues AIMS: Denies any abnormal movement ROS: negative per pt self-report Impression: condition is stable but still feel overwhelmed despite regular use of prescribed medications. DX: MDD, GAD rule out PTSD Plan: Continue propanolol, consider the addition of buspirone, RTC 4 weeks

Different ROS Formats 

Constitutional: no fever, weight, loss or gain, anorexia, fatigue Eyes: no double vision or blurry vision ENT: no tinnitus, dry mouth Cardiovascular: no fainting/palpitations or other cardiac problems. Respiratory: no SOB, DIB GI: no constipation or diarrhea GU: no urinary hesitation, incontinence Musculoskeletal: no muscle twitches, chronic pain Skin: no rash, lesions, psoriasis, pruritus Neurological: no ataxia, tremor, vertigo, headache Heme/lymph: no easy bruising or bleeding Endocrine: no polyuria, polydipsia, heat or cold intolerance Allergy/Immunology: no hives Psychiatric: see above for positives

GEN: (+)cooperative with exam, (+)well-groomed, (+)well developed, (+)well-nourished, (+)overweight, (+)obese, (+)morbidly obese, (+)emaciated, (+)appears to be stated age, (+)appears older than stated age, (+)appears younger than stated age HEART/RESP: denies DIB, chest discomfort GI: denies n/v/d, GI pain NEURO: normal gait and station, normal gait, normal station PSYCH: alert and oriented to time, place, and person, normal mood, normal affect

GENERAL: Denies weakness, fatigue, malaise, chills, fever, night sweats, weight gain/loss INTEGUMENTARY: Denies rash, jaundice or other skin issues NEUROLOGIC: Denies headaches, weakness, tremors or syncopal episodes or seizures HEENT: Denies tinnitus, vertigo, visual changes, hearing impairment, sore throat CARDIOVASCULAR: Denies chest pain palpitations, negative edema. RESPIRATORY: Denies any shortness of breath, asthma, OSA GASTROINTESTINAL: Denies dysphagia, nausea, vomiting, hematemesis, or abdominal pain. GENITOURINARY: Denies increased frequency, urgency, dysuria, incontinence. MUSCULOSKELETAL: joint pain, stiffness, weakness, or back pain PSYCHIATRIC: no acute issues ROS negative for fever, cough, sob, pain

PSYCHIATRIC ROS No Anxiety/Panic, No Depression, No Insomnia, No Personality Changes, No Delusions, No Rumination, No SI/HI/AH/VH, No Social Issues, No Memory Changes, No Violence/Abuse Hx., No Eating Concerns Major depressive/dysthymic symptoms Manic or hypomanic symptom Psychotic symptoms Generalized anxiety disorder Panic disorder Obsessive-compulsive disorder Dementias Eating disorders Dissociative disorders PTSD

Systems Reviewed Below with Pertinent Positives/Negatives if Clinically Indicated: Constitutional: No Weight Change, No Fever, No Chills, No Night Sweats, No Fatigue, No Malaise ENT/Mouth: No Hearing Changes, No Ear Pain, No Nasal Congestion, No Sinus Pain, No Hoarseness, No sore throat, No Rhinorrhea, No Swallowing Difficulty Eyes: No Eye Pain, No Swelling, No Redness, No Foreign Body, No Discharge, No Vision Changes Cardiovascular: No Chest Pain, No SOB, No PND, No Dyspnea on Exertion, No Orthopnea, No Claudication, No Edema, No Palpitations Respiratory: No Cough, No Sputum, No Wheezing, No Smoke Exposure, No Dyspnea Gastrointestinal: No Nausea, No Vomiting, No Diarrhea, No Constipation, No Pain, No Heartburn, No Anorexia, No Dysphagia, No Hematochezia, No Melena, No Flatulence, No Jaundice Genitourinary: No Dysmenorrhea, No DUB, No Dyspareunia, No Dysuria, No Urinary Frequency, No Hematuria, No Urinary Incontinence, No Urgency, No Flank Pain, No Urinary Flow Changes, No Hesitancy Musculoskeletal: No Arthralgias, No Myalgias, No Joint Swelling, No Joint Stiffness, No Back Pain, No Neck Pain, No Injury History Skin: No Skin Lesions, No Pruritis, No Hair Changes, No Breast/Skin Changes, No Nipple Discharge

AIMS AIMS: all 0’s or none (0=None to 4=Severe) Muscles of Facial Expression Lips and Perioral Area (puckering, smacking, pouting) Jaw (biting, chewing, lateral movement, mouth opening) Tongue (increase in movement both in and out of mouth) Upper Extremity (choreic or athetoid movements, does not include tremors) Lower Extremity (tapping, squirming) Trunk Movements (rocking, twisting, squirming) Overall Severity Incapacitation due to abnormal movements Patient’s awareness of abnormal movements

Answers and communicates appropriately, proper temperament, and cooperative. Has moderate insight into actions and consequences. Capable of communicating appropriately and following instructions. Behavior and mood is consistent. Client is able-bodied without learning disabilities. No obvious/major concerns or distress. Patient is able-bodied but uncooperative with family, treatment, and following instructions. Needs to be more engaging with care and accountability. Poor insight with consequences of actions or how to control anger and behaviors.

The patient’s speech and tone was normal. Thought processes were logical, relevant, and thoughts were completed normally. Thought content was normal. Thought content was normal with no psychotic or suicidal thoughts. The patient’s judgment was realistic with normal insight into their present condition. Mental status included: correct time, place, person orientation, normal recent and remote memory, normal attention span and concentration ability. Language skills included the ability to correctly name objects. Fund of knowledge included normal awareness of current and past events.

The patient’s speech was normal, sharing conversation with normal laryngeal efforts. Appropriate mood and affect were seen on the exam. Thought processes were logical, relevant, and thoughts were completed normally. Thought content was normal with no psychotic or suicidal thoughts. The patient’s judgment was realistic with normal insight into their present condition. Mental status included: correct time, place, person orientation, normal recent and remote memory, normal attention span and concentration ability. Fund of knowledge included normal awareness of current and past events. Emotionally the patient appeared alert. Attitude in the interview consisted of cooperation. the effect was depressed. Speech was normal and calm. Appropriate mood and affect were seen on the exam. Thought processes were logical and relevant with no psychotic or suicidal thoughts. The patient’s judgment was realistic with fair insight into her present condition but continues to have impulsive patterns. 

Appearance: Well-groomed, well dressed, well-nourished Behavior: Cooperative, calm, pleasant, consistent eye contact Speech: Clear, spontaneous, regular rate, rhythm, and volume Mood: stable, content, down-casted Affect: full-range, congruent to mood Thought Process: goal-directed, logical, linear, organized Thought Content: denies SI/HI, denies AH/VH, denies delusions, denies intrusive thoughts Sensorium: person, place, time/date & situation Cognition: grossly intact Insight: Good as evidenced by the recognition of symptoms needing tx Judgment:

Documentation for Conditions/Symptoms 

These options of symptoms can go into the documented “psych problems 1,2,3, etc.” EX. Problem 1 anxiety; Michael continues to have excessive worrying and panic attacks. Plan: increase fluoxetine BID and encourage marijuana cessation.  Symptoms can also go into the chief complaint and/or the “impression” of diagnosis category…

• ADHD: Inattention:1) fails to give close attention to details/makes careless mistakes in school/work/activity. 2) difficulty sustaining attention in task or play, 3) does not seem to listen when spoken to,4) does not follow through on instructions and fails to finish work/duties, 5) difficulty organizing tasks/activities, 6) avoids, dislikes, is reluctant to engage in tasks that require sustained mental effort, 7) loses things necessary for tasks or activities, 8) easily distracted by extraneous stimuli, 9) forgetful in daily activities Hyperactivity: 1) fidget/squirms, 2) leaves situation when remaining seated is expected, 3) feelings of restlessness, 4) difficulty in engaging in leisure activities quietly, 5) often on the go or acts as if driven by a motor, 6) talks excessively Impulsivity: 1) blurts our answers before questions completed, 2) difficulty waiting turn, 3) interrupts/intrudes on others.
• Anxiety: anxiety, nervousness, excessive worrying,  specific phobias, panic attacks (sudden fear/going to die), agoraphobia, repeated behaviors, impulsive, interference with ADLS…
• Borderline PD: identity problems, moodiness, emptiness, suicidal feelings, paranoia, dissociative sx, abandonment fears, impulsivity, rage, relationship instability, doctor shopping, lawsuits against MD’s, immediate idealization, excessive interest in your personal life
• Depersonalization/Derealization, etc. (Dissociative Disorders): memory loss (amnesia) of certain time periods, events, people, and personal information, a sense of being detached from yourself and your emotions, a perception of the people and things around you as distorted and unreal, a blurred sense of identity, significant stress or problems in your relationships, work or other important areas of your life, inability to cope well with emotional or professional stress
• Depression: sad, irritable, suicidal thoughts, homicidal thoughts, poor sleep, poor  energy, poor concentration, poor appetite, weight changes, anhedonia, worthlessness, hopelessness, helplessness, psychomotor agitation, psychomotor retardation
• Eating Disorders: feeling overweight/underweight, fear of fatness. dieted, laxative use, purging behavior, bingeing history
• Mania: elevated mood, increased energy, grandiosity, racing thoughts, pressured speech, distractability, increased goal-directed behavior, decreased need for sleep, hypersexuality, poor judgment, flight of ideas
• Psychosis: auditory hallucinations, visual hallucination, olfactory hallucinations, gustatory/tactile hallucinations, delusional beliefs (paranoia, ideas of reference, thought-broadcasting, thought insertion) loose association, thought disorder
• PTSD: Exposed to a traumatic event, response involved fear, helplessness…Reexperienced: 1) rec, intrusive thoughts 2) rec dreams 3) feeling like it is happening again 4) psychological distress at exposure, cues 5) physiologic response to cues Avoidance: 1) Avoid thoughts, feelings assoc w event 2) Avoid act. that arouse recollection 3) inability to recall imp parts of trauma 4) decreased interest in activities 5) detachment  6) restricted range of effect 7) sense of foreshortened future Arousal: 1) diff sleeping 2) irritability, outbursts 3) diff concentrating 4) hypervigilance 5) exaggerated startle
• Sleep: Difficulty falling asleep, broken sleep, early morning awakening, snoring, night terrors, vivid dreams, napping, narcolepsy
• Substance Abuse: unable cut-down , annoyed by concern, guilt, eye-opener, impulsive/binge patterns

Documentation for Educating about Medications

I usually edit these into dx/problem/plan area as what was discussed or patient education and/or the patient’s response…

Antidepressants: discussed s/e including GI, sexual dysfunction, headache, anxiety, dizziness, dry mouth, and insomnia. Commonly shared side effects (often dose-related) include abdominal pain, constipation, diarrhea, dyspepsia, nausea, and vomiting. An uncommon, but potentially serious side-effect is serotonin syndrome. Due to the increased risk of suicidality with antidepressants, patients and their family members or caregivers were instructed to immediately report any sudden changes in mood, behaviors, thoughts, or feelings.

Atypical Antipsychotics -we discussed risks of atypical antipsychotic use including side effects, benefits, and alternatives of the medication and the client was offered patient education material. The client understands the need for periodic lab testing with the possibility of the medicine increasing serum glucose and lipids. They also verbalize understanding the other possible metabolic abnormalities that could result from the medicine including weight gain as well as the need to eat a proper diet and get exercise as tolerated. The client verbalizes understanding that the medication can also cause dyskinesias including tardive dyskinesia (uncontrollable movements of the face, torso, limbs, finger and/or toes) and is advise to monitor for signs/symptoms of neuroleptic malignant syndrome including but not limited to fever, confusion, muscular rigidity, variable blood pressure, sweating, and tachycardia.

Bupropion: discussed common s/e of bupropion: agitation, anxiety, constipation, dryness of mouth. Rare S/E includes: ringing in ear, fast or slow heartbeat, muscle pain. Very rare s/e, but potentially life-threatening: Seizures –increases in patient with a history of seizures, head trauma, CNS tumor, abrupt discontinuation of sedative-hypnotics or ethanol. Confusion, hallucination Black box warning–Suicidal Ideation

Benzodiazepienes: BZs are meant for short-term or intermittent use due to their long term-risks, including physical dependence. BZs have a black box warning for risks when combined with opioids and the risks of abuse, addiction, physical dependence, and withdrawal. Serious risks: injuries/falls/broken bones,car accidents (legally considered a DUI), breathing problems, suicidal/violent thoughts, overdose/overdose death. Long-term risks: memory loss, osteoporosis, tolerance, physical dependence, withdrawal symptoms, addiction, For Women: Taking BZs while pregnant carries a risk of miscarriage and can cause risk to the newborn– including breathing and breastfeeding problems, flaccid muscles, and withdrawal syndrome. For Elderly: Patients over age 65 have an especially high risk of side effects like falls, fractures, and problems with thinking and memory, partly due to slower metabolism of the drug from aging. You should not combine this medication with alcohol, Z-drugs (such as Ambien or Lunesta), other BZs, opioids, or any other drug that causes sedation like gabapentin. Doing so can put me at risk of overdose and death due to combined effects on breathing.

Benzodiazepines: discussed the risks including side effects (amnesia, confusion, GI disturbances, falls, blurred or double vision, long-term use may be linked to increased risk of Alzheimer’s disease), benefits, and alternatives of benzodiazepine use and the client was offered patient education material. We discussed that these types of medications may be potentially addictive and they should not share with others, let other people know they are taking them, or take extra doses beyond what is prescribed. The client verbalizes understanding the medications will not be refilled early. The client verbalizes understanding they are to avoid alcohol and illicit drug use while taking this medication and should be very cautious when using this medication with other sedating medications. The client verbalizes understanding that they will be cautious and get used to how the medicine makes them feel prior to driving a motor vehicle or engaging in any other activity that could be potentially dangerous due to the possible sedating effects of the medication. 

Carbamazepine (Tegretol)-female patients -We discussed the risks, including side effects, benefits, and alternatives of Tegretol and the client was offered patient education material. We discussed how Tegretol can affect the hepatic, hematologic, and dermatologic systems of the body. The client verbalizes understanding on how to recognize the signs and symptoms of dysfunction in those areas including but not limited to rash, unusual bleeding/bruising, mouth sores, infections, sore throat, purpura, and sedation. The client is advised about the need for periodic lab monitoring to assess the Tegretol level as well as liver function and complete blood count. We also discussed how Tegretol can interfere with certain types of hormonal contraception and how the client should have a form of barrier type contraception or practice abstinence to prevent getting pregnant because of the risk of teratogenic effects.

Carbamazepine (Tegretol)-male patients -We discussed the risks, including side effects, benefits, and alternatives of Tegretol and the client was offered patient education material. We discussed how Tegretol can affect the hepatic, hematologic, and dermatologic systems of the body. The client verbalizes understanding on how to recognize the signs and symptoms of dysfunction in those areas including but not limited to rash, unusual bleeding/bruising, mouth sores, infections, sore throat, purpura, and sedation. The client is advised about the need for periodic lab monitoring to assess the Tegretol level as well as liver function and complete blood count.

Depakote – discussed the risks including side effects (including but not limited to sedation, tremor, dizziness, GI upset, headache, weight gain, alopecia, tachycardia or bradycardia), benefits, and alternatives of Depakote and client was offered patient education material. We discussed how Depakote can have effects on hematologic (easy bruising, excessive bleeding), pancreatic (pancreatitis-abdominal pain, nausea, vomiting, anorexia), hepatic (malaise, weakness, lethargy, facial edema, anorexia, vomiting, jaundice), and dermatologic (jaundice, alopecia) systems. The client knows how to watch for signs of dysfunction in those areas. They are also advised of periodic lab testing to assess the Depakote level, liver function, and blood counts. The client verbalized understanding to watch for signs and symptoms of rash with Depakote use and is advised if rash occurs they are to notify primary care provider or emergency department immediately. 

Lamotrigine: patient advised of the risk of possibly fatal rash (i.e., Stevens-Johnson Syndrome) and agrees to stop medication, and seek medical attention immediately if any rash or rash or blistering of the mucosal surfaces develop given the potential for lethality and requirement for evaluation by a physician to rule this out. The patient further advised that the risk of this reaction increases if proper dose titration is not adhered to carefully and that not taking this medication for 2 days or more will require a retitration process, and, therefore the patient should not restart at the previous dose, but call me immediately for instructions on how to retitrate.

Lamotrigine -We discussed the risks including side effects, benefits, and alternatives of Lamictal and the client was offered educational material. We reviewed the need for a titration schedule with Lamictal because of possibility of increased incidence of rash, both benign and severe, when starting the Lamictal at higher doses and increasing it more quickly. The client verbalizes understanding of the possibility of a serious rash including Stevens-Johnson syndrome as a result of taking the medication. They are advised to stop taking the medication and contact the clinic if they are experiencing these symptoms. They are advised to go to the emergency room if they develop signs of more severe rash including but not limited to painful red or purplish rash, spreading of rash, blister formation on skin and/or mucous membranes of the mouth, nose, eyes, and/or genitals, shedding of skin, facial swelling, and/or swollen lips. 

Lithium -We discussed the risks, including side effects (including but not limited to weight gain, hair loss, memory problems, irregular heartbeat or pulse, fatigue, and decreased thyroid function), benefits, and alternatives of Lithium. The client was offered educational material. We discussed how lithium can have effects on the kidneys and thyroid functioning and we discussed how to recognize signs in symptoms in those areas. The client verbalizes understanding the need to stay well hydrated as well as the need for periodic lab testing to monitor lithium levels. We discussed some of the prescriptions and over-the-counter medications to avoid when taking lithium. The client verbalizes understanding how to recognize signs of increased lithium levels including lithium toxicity including but not limited to tremors, thirst, diuresis, diarrhea, vomiting, drowsiness, muscle weakness, coordination problems, blurred vision, tinnitus, slurred speech, and decreased LOC. 

Pregnancy – discussed that some medications can have effects on pregnancy and some can cause teratogenic results. I recommend the client strongly consider the use of family planning methods including contraceptives or other forms of birth control. We discussed that if the client is planning to get pregnant that a discussion needs to be held of what to do with medications and other treatments. I do recommend that the client take supplemental folic acid to prevent birth defects in any case. 

Mirtazapine (Remeron) – discussed the risks including side effects, benefits, and alternatives of mirtazapine, and the client was offered educational material. The client verbalizes understanding that the use of mirtazapine strictly for sleep or anxiety is considered off-label however that it also can confer some extra antidepressant effect in any case. 

Serotonin Syndrome – discussed how these medications target the neurotransmitter serotonin. We discussed that taking medications that affect this chemical can have an increased risk for too much of the chemical resulting in serotonin syndrome. The client verbalizes understanding the signs and symptoms associated with this disorder including but not limited to rapid/irregular heartbeat, shakiness, hallucinations, blood pressure fluctuations, increased agitation, mental status changes, fever, dilated pupils, and muscle rigidity. Patient is advised to seek immediate medical attention if these symptoms occur. 

Sleep Medication -We discussed the risks including side effects, benefits, and alternatives of utilizing medication indicated for sleep including sleep hygiene recommendations including but not limited to avoiding screen time one hour prior to bed, minimizing caffeine, nicotine and alcohol intake, sticking to a sleep schedule, daily exercise, avoiding large meals and/or beverages prior to bed, relaxation activities prior to bed, and maintaining a good sleep environment. We reviewed that sleep medications can cause drowsiness the next morning and they should be careful when operating machinery or other tasks that require sustained attention. The client also verbalizes understanding that sleep medications can cause parasomnias including sleep driving. The client is also advised to use other medications that cause sedation with extreme caution. 

Stimulant Risks 

• Denies family history of unexplained sudden death of less than 30 years.
• Denies family history or personal history of heart disease.
• Denies family history or personal history of chest pain, palpitations, or fainting during exertion.
• Denies history of dizziness while exercising.
• Denies family history or personal history of prolonged QT Syndrome.

Stimulant Education  Stimulants and related medications are generally well-tolerated and safe although there are no long-term studies on safety with adult treatment. The most common adverse reactions to stimulants and related medications are loss of appetite, upset stomach, insomnia, and headache. Increases in heart rate and blood pressure have also been seen as a result of the sympathomimetic properties of stimulant medications. Serious risks include:

• Cardiovascular events such as stroke, MI, death
• Peripheral Vasculopathy, Including Raynaud’s Phenomenon
• Risk of Priapism with Methylphenidate Products
• Rhabdomyolysis with Stimulant Drugs
• Risk of Psychiatric Adverse Events such as psychosis, SI and mania
• Abuse and Misuse of Stimulant Medications
• Significant abuse potential

Stimulants -We discussed the risks including side effects, benefits, and alternatives of stimulant medication use and the client was offered patient education material. We talked about the fact that these medications are Schedule II controlled substances as well as the risks of potential addiction. We discussed how this medication will not be refilled early, the medication should not be shared or taken in any manner outside of as prescribed. We discussed the patient should not inform other people she is taking a stimulant. We discussed about the potential for decreased appetite, weight loss, and cardiac effects.

Topiramate (Topamax)-female patients -We discussed the risks including side effects, benefits, and alternatives of Topiramate and client was offered education material. We discussed that while client is taking Toprimate there is the possibility of metabolic acidosis, decrease sweating, fever, increased intraocular pressure as well as kidney stones. The client verbalizes understanding how to stay well hydrated and how to recognize the signs of these potential side effects and what to do if these symptoms occur. Advised client that the use of this medication for this indication is considered off-label. We also discussed how Topiramate can interfere with certain types of hormonal contraception and how the client should have a form of barrier type contraception or practice abstinence to prevent getting pregnant because of the risk of possible teratogenic effects of Topiramate. 

Topiramate (Topamax)-male patients – discussed the risks including side effects, benefits, and alternatives of Topiramate, and the client was offered education material. We discussed that while client is taking Toprimate there is the possibility of metabolic acidosis, decrease sweating, fever, increased intraocular pressure as well as kidney stones. The client verbalizes understanding how to stay well hydrated and how to recognize the signs of these potential side effects and what to do if these symptoms occur. Advised client that the use of this medication for this indication is considered off-label.

Trazadone female patients – We discussed the risks including side effects, benefits, and alternatives of Trazadone and the client was offered patient education material. The client verbalizes understanding that the use of Trazadone strictly for sleep or anxiety is considered off-label however that it also can confer some antidepressant effect in any case. 

Trazadone male patients – We discussed the risks including side effects, benefits, and alternatives of Trazadone and the client was offered patient education material. We discussed how this medication may cause priapism. The client is advised if they experience this rare but serious side effect they are to seek immediate medical attention. The client verbalizes understanding that the use of Trazadone strictly for sleep or anxiety is considered off-label however that it also can confer some antidepressant effect in any case. 

Documentation Kids-Specific

Preschool : frequent unexplained stomachaches, headaches, and fatigue, over activity/excessive restlessness, frequent sadness, low tolerance for frustration, irritability, loss of pleasure in previously enjoyed activities, tendency to portray world as bleak or sad, denies suicidal ideations, no plan or intent, no previous attempts, has support system in place

School-aged : frequent and unexplained physical complaints, low self-esteem, excessive worrying, change in sleep patterns, tearfulness, unprovoked hostility and aggression, school refusal/reluctance, drop in grades, little interest in playing with others, poor communication, thoughts and efforts about running away, morbid/suicidal thoughts, and low tolerance for frustration, denies suicidal ideations, no plan or intent, no previous attempts, has support system in place

Adolescents : drop in grades, behavior problems at school, feelings of sadness and hopelessness, low self-esteem, fatigue, changes in sleep, anhedonia, bad attitude, self-stimulation by smoking/chemical use, self-destructive behavior, difficulty in relationships, eating-related problems, antisocial/delinquent behavior, social isolation, inattention to appearance, extreme sensitivity to rejection or failure, physical slowness/agitation, morbid thoughts, denies suicidal ideations, no plan or intent, no previous attempts, has support system in place. 

Moods/Bipolar: mania includes mood swings, elevated mood and irritability, pressured speech and hypertalkative, distractible, increase in goal-directed behavior with no follow-through, excessive involvement/risky behaviors, flight of ideas and racing thoughts, decreased need for sleep, bursts of energy, grandiosity, agitation, increase in activities (spending, sex), psychotic symptoms. 

Children: euphoric mood, extreme irritability that is severe and persistent, aggressive episodes and violent behaviors, dysphoric outbursts, intensely emotional with fluctuating but overriding negative mood, ready to go in am, sexually preoccupied. 

Childhood Disorders :

• ADHD:  poor attention to detail, difficulty sustaining attention in tasks, doesn’t listen, no follow through and poor multitasking, disorganized, avoids attention sustaining activities, loses things easily, forgetful, easily distracted, fidgets, unable to stay in seat, runs about, difficulty sustaining attention at play, on the go, hyper talkative, blurts, interrupts, unable to wait turn. 
• ODD: negative attitude, loses temper, defies rules and does not comply with adult requests, deliberately annoys others, blames others, is touchy, angry and resentful, spiteful and vindictive.
• Conduct Disorder: negative attitude, loses temper, defies rules and does not comply with adult requests, deliberately annoys others, blames others, is touchy, angry and resentful, spiteful and vindictive, bullies, threatens or intimidates others, starts fights, has used a weapon to cause physical harm, cruel to animals/people, stoles trivial items, forced sexual activity, destruction of property, fire setting, lies and cons others for gain, stays out late at night <13, run away >2, truant <13. 
• PDD:  impaired social interaction, poor eye contact, lack of emotional or social reciprocity, lack of spontaneous sharing or interests or enjoyment, communication impairments, repetitive movements, lack of make believe or spontaneous play, restricted interests, inflexible, delays/abnormal functioning in social, language or symbolic or imaginative play. 
• RAD-disinhibited type: defused attachment, indiscriminate sociability/excessive familiarity with strangers, lack of selectivity of attachment figures, history of repeated changes in primary caregiver, history of persistent disregard for child’s basic physical and emotional needs.
• RAD-inhibited type:  persistent failure to initiate or respond to most social interactions, inhibited, hypervigilant, highly ambivalent and contradictory responses, avoidant, resistant to comforting, history of repeated changes in primary caregiver, history of persistent disregard for child’s basic physical and emotional needs.

SOCIAL COMMUNICATION AND INTERACTION:

• Deficits in social-emotional reciprocity.
• Deficits in nonverbal communicative behaviors used for social interaction.
• Deficits in developing, maintaining, and understanding relationships.

REPETITIVE PATTERNS OF BEHAVIOR / INTERESTS / ACTIVITIES:

• Stereotyped or repetitive motor movements, use of objects, or speech.
• Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior.
• Highly restricted, fixated interests that are abnormal in intensity or focus.
• Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment

Pediatric Intake 

CC: HPI: Current Medications: OTC: Allergies (medications, seasonal, or food): Past Psychiatric/Past Pertinent History: (refer to PFSH obtained on MM/DD/YYY ) Providers: Therapist: Diagnoses: Medications: Hospitalizations: Past suicide attempts: Past ECT or TMS: Family Psychiatric/Medical History: Mental Health: Substance Abuse: Medical: Past Medical History/Medications and Chronic Health Conditions: Primary Care Provider: Date of last physical: Gravida: N/A Para: N/A Birth Control: N/A Denies asthma, seizures, head injuries, headaches, diabetes, HTN, thyroid, or cardiac problems. Past Surgical History: Previous Hospitalizations: Previous Head Trauma: Developmental History: patient is a product of full-term birth, 38 weeks, vaginal/c-section Non-Contributory. No prenatal exposure to alcohol, tobacco, or drugs. Uncomplicated pregnancy and birth, full term at birth, all developmental milestones met on time. No learning disabilities. Intellectual Functioning is appropriate to patient’s age. Family/Social/Peer History: Religious Preference/Spiritual Beliefs/Cultural Preferences: Education History/Level of Education: Legal History: Legal Guardian: None Legal Offenses: None History of disability: None CPS Involvement: None Abuse History: Denies physical, emotional, sexual abuse/assault, or domestic violence. Psychiatric Physical Exam/Mental Status Examination: Constitutional: Height, weight – vitals as noted on chart General appearance: well-developed, well-groomed and well-nourished Musculoskeletal: normal gait, station, muscular strength and tone Eye Contact: Rapport: Mood: Anxiety: Affect: Suicidal Thoughts: Homicidal Thoughts: Psychomotor behavior: Speech: normal rate, rhythm, volume, spontaneity Judgment: Insight: Thought Processes: Associations: Psychotic Thoughts: none observed Obsessions or compulsions: none observed Alert and oriented x3: Recent and remote memory: intact Attentions span and concentration: Language: normal for naming objects and repetition of phrases Fund of knowledge: normal for current events, past history, and vocabulary Review of Systems: Constitutional: no fever, weight, loss or gain, anorexia, fatigue Eyes: no double vision or blurry vision ENT: no tinnitus, dry mouth Cardiovascular: no fainting/palpitations or other cardiac problems. Respiratory: no SOB GI: no constipation or diarrhea GU: no urinary hesitation, incontinence Musculoskeletal: no muscle twitches, chronic pain Skin: no rash, lesions, psoriasis, pruritus Neurological: no ataxia, tremor, vertigo, headache Heme/lymph: no easy bruising or bleeding Endocrine: no polyuria, polydipsia, heat or cold intolerance Allergy/Immunology: no hives Psychiatric: see above for positives Dental Status – Current problems with teeth or dentures? Comments: none Status of condition: baseline Patient’s Strengths and Abilities: Patient Limitations: current symptoms Additional Data Reviewed: previous notes Clinical Goal(s): improve symptoms Treatment Services: Pharmacotherapy: After standard cautions were discussed, patient and parents/guardian gave informed consent to start or change the following medication: Medication Psychoeducation: Discussed and provided Lab Tests: on Hold Psychotherapy: Psychological Evaluation: none Other Services: None Referrals to other agencies/services/community support: None at this time Return to clinic: <4 weeks

Documentation for Safety, Patient Education  

A healthy diet and lifestyle were discussed with the patient, the patient requested to routinely follow up with primary care doctor for general medical checkup. The patient is encouraged to refrain from drugs and alcohol for physical mental health. The patient is future-oriented at this point the patient on the phone does not present as grossly psychotic, manic or depressed in regards to her clinical symptoms that would require a higher level of care. Patient encouraged to utilize emergency services ifs she’s experiencing any thoughts of harm to self or anybody else or is experiencing a medical emergency.

Treatment Plan/Recommendations:

• Medication Changes (informed consent was given for current and new medications):

Education Reviewed with the Patient:

• A treatment plan was reviewed with the patient
• Reviewed risk/benefits, common side effects with the patient including Black Box Warnings (where applicable), and risk of adverse effects and/or death of combining medications with alcohol.
• Discussed risks of medication non-adherence/non-compliance Patient consents to prescribed medications.
• Reinforced physical/emotional benefits of exercise
• Reinforced the negative effect that alcohol use/abuse has on current complaints.
• Risks vs. benefits, as well as side effects with the patient, reviewed alternative treatments, including no treatment discussed, and answered any questions.

I spent a total of ( 35 ) minutes on the date of this encounter:

• Meeting with the patient
• Reviewing documentation/coordinating care
• Ordering/Discussing diagnostic results or prior studies
• Need for further testing
• Biopsychosocial Impressions
• Clinical course, Prognosis
• Treatment options, Medication Issues, Risks, and benefits of management options
• Instructions for management and/or follow-up
• Education/counseling
• Supportive psychotherapy
• Post-visit documentation
• Communicating with other medical professionals

Safety Plan: the patient agrees to utilize their available support system as documented above if in emotional distress. If the emotional distress persists, worsens or the patient becomes suicidal, homicidal, or psychotic the patient agrees to contact the appropriate emergency personnel (911) or go to the nearest emergency department if safe to do so.

Documentation about Substance Abuse

Prescription Monitoring Program (OD Risk Score) 

• No Opioid Risks: currently no prescribed conflicts or issues, neg history of using opioids or scheduled meds
• Low to Mild risk: patient recently had an opioid filled, but consistently takes medication as prescribed, score:
• Mild-High Risk: patient agreed to weekly dosing and rx testing hx of diversions, score:
• High Risk: the patient doesn’t qualify for a benzodiazepine at this time and agreed to f/u with the pain clinic.
• Favorable with cessation of all illegal substances and adhering to medication, treatment, and social services. 
• Favorable with cessation of illegal substances and adhering to medication, treatment, and improving social services and support. 
• Low to favorable with cessation of poly substances and improving social support and adhering with therapy and treatment.
• Mild to favorable with complete cessation of ETOH, therapy, and adhering with treatment and medications.
• Poor to favorable with complete cessation of ETOH, therapy, and adhering with treatment and medications.

Risk factors including age, gender, substance use, lack of medication compliance, intoxication, homelessness, and poor support, can disinhibit patients and can lead to chronically elevated risk of impulsive behaviors including overdose, accidental and or intentional, and suicide attempts. The current risk for violence toward self or others at this time is low. The patient has been compliant with treatment, not engaging in substance use, no recent thoughts or attempts for SI or HI

Documentation for Telehealth 

This telehealth patient encounter was conducted via secure, live, face-to-face video conferencing with the patient. This visit was conducted via telehealth instead of face-to-face because of the risk of COVID-19 exposure inherent in being physically present in the company of others.

• Patient’s location during the encounter:
• Demographics and emergency contact names and telephone numbers are up to date:
• Emergency plan: In the event of an emergency, the provider may ask the patient and/or family member/caregiver to contact 911. If it is not possible for the patient or someone at their location to contact 911, the provider will contact 911 and provide the patient’s location. The patient was informed of this safety plan and verbally consented to it.

MSE (with parent alone/without child): N/A visit completed via telehealth with parent/guardian alone. Denies additional concerns or distress.

MENTAL STATUS EXAM with Patient Present on Video:  General Appearance: well-groomed/Bizzare/inappropriate/poor/casually dressed, fair grooming Gait: cannot assess via video Station: cannot assess via video Abnormal Movements: none; no tics Speech: normal/low/soft volume, short answers, and often does not answer Mood: “I don’t know” Affect: congruent/impaired/hard to see as the patient frequently moves out of the frame Eye Contact: good/mild/fair/poor/cannot assess via telehealth Thought Process: intact/hard to assess given limited speech Associations: intact/hard to assess given limited speech Thought Content: No evidence of responding to internal stimuli Suicidal Ideation: denies Violent Ideation: None reported Memory: not formally assessed, grossly intact Attention: Intact/Delayed/Impaired Language: wnl for age Fund of Knowledge: not formally tested; grossly wnl for age Insight: Good/Fair/Impaired Judgment: Intact/Impaired

Additional References & Information

Proper documentation is critical to justifying medical necessity and selection of codes for billing. It tells the story of a patient visit by recording pertinent facts, findings and observations. Payers will use this documentation to verify coding choices, site of service, medical necessity, appropriateness and accurate reporting of furnished services. Each office note must tell a complete story and be able to stand alone. For example, auditors interested in services provided on Aug. 18, 2019 will only review that note; they will not look at notes from other visits unless they are referenced in your note from Aug. 18, 2019. -Links for proper documentation – American College of Cardiology/ACC

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Psychiatric medication management.

Hours of Service

Monday through Friday : 8 a.m. to 5 p.m.

Saturday and Sunday : Closed

Patient Eligibility

• University of Nebraska students from all campuses

Services Covered By Student Fees

• Psychiatric Medication Management services are not covered by student fees

Medication and Expert Care to Help You Manage Mental, Emotional and Behavioral Concerns

Our robust team of psychiatric providers offers evaluation, education and medication management for a wide array of conditions, such as depression, anxiety, life stressors, eating disorders, ADD/ADHD, bipolar disorder, insomnia, schizophrenia and more.

If you would like to explore medication options in treating your mental health symptoms, please call 402.472.5000 to schedule an initial evaluation with one of our psychiatry providers. For those who are unsure or do not want to take medication, we recommend scheduling a therapy appointment with Counseling and Psychological Services by calling 402.472.7450. Best practices show that therapy combined with medication management prove to have the most positive outcomes in treating mental health disorders. Therefore, we recommend therapy with CAPS or a therapist in the community along with our medication management services in order to provide you with the best treatment possible.

Appointments

We provide psychiatric care Monday through Friday from 8 a.m. to 5 p.m. To make an appointment, call 402-472-5000 .

Psychiatric medication management visits are considered specialty appointments and are not covered by student fees. There are charges for each visit. To determine how much your visit will cost, we recommend contacting your health insurance provider for coverage information. Patients are responsible for any charges not covered by insurance.

Learn more about cost and insurance .

Please be advised, mental health appointments with a health center general medical provider are also not covered by student fees and will incur a charge.

Mental Health Prescriptions

The University Health Center pharmacy can fill orders for most mental health medications. Contact your psychiatric provider to transfer your prescriptions. If we do not have the medication in stock at our pharmacy, we can usually order it for you. We can also send your medications to the pharmacy of your choice.

Urgent Concerns

If you are having a problem with a psychiatric medication, call the health center at 402-472-5000 . Follow the prompts if you are calling after hours. If your problem is urgent or involves serious side effects, call or go to the nearest emergency room. The nearest emergency room to campus is Bryan Medical Center West (2300 S 16th St).

If you are experiencing a mental health crisis, call Counseling and Psychological Services at 402-472-7450 and follow the prompts. Help is available 24/7.

Meet Our Staff

Stephanie Sutton, MD

Undergraduate: University of Nebraska-Lincoln Medical School: University of Nebraska Medical Center (UNMC) Residency: Combined program with UNMC and Creighton University Medical Center

I was born and raised in Lincoln and moved to Omaha for medical school and psychiatry residency. I enjoy working with undergraduate and graduate students. My special interest is treating anxiety and depression. I also focus on mental wellness including positive thinking, goal-setting, and incorporating healthy diet and exercise in the treatment plan for mental health. In my free time I enjoy spending time with my family, eating gourmet food, exercising, and traveling.

Amber Bond, PA-C

Undergraduate: Indiana Wesleyan University Masters of Science in Medicine: Trevecca Nazarene University Physician Assistant Fellowship in Psychiatry: Cherokee Mental Health Institute

I have been a PA since 2006 and have worked in various settings. I decided to specialize in psychiatry in 2013, which is how I got from Kentucky to Nebraska. I love what I do and find joy in teaching, encouraging and offering students hope. I also enjoy art/craft projects, being outdoors and spending time with my family, friends and cat.

Kayla Fink, PA-C

Undergraduate: University of Nebraska-Lincoln Masters of Physician Assistant Studies: University of Nebraska Medical Center

I grew up in Maryland and currently live in Lincoln. I have practiced in psychiatry since graduating from PA school. I truly enjoy this field of medicine and appreciate the opportunity to care for students at the health center. Outside of work, I enjoy traveling and spending time with family and friends.

Chelsie Sutton, APRN

Undergraduate: University of Nebraska-Lincoln and University of Nebraska Medical Center Graduate: Masters of Arts in Counseling from the University of Missouri at Kansas City and Masters of Science in Nursing from UNMC

I grew up in Kansas and moved to Nebraska for my education. I have always known I wanted to work in mental health, but wasn't exactly sure which avenue I would take. I got my masters degree in counseling and then decided to become a psychiatric mental health nurse practitioner so I could combine counseling with medication management. I have worked in both inpatient and outpatient settings and found I truly love working with students. My hope is that we can work together to create a treatment plan that supports you where you are at and helps move you towards the positive goals you are trying to achieve. In my free time, I love spending time with my family and friends, going for runs and shopping.

Frequently Asked Questions

This may happen if you are experiencing mental health symptoms that could benefit from medication. This referral can come from a primary care provider, a counselor or an advisor. A student can also refer themselves for a psychiatric screening. Symptoms that may lead to a psychiatric screening referral include depression, anxiety, insomnia, suicidal thinking, etc.

The first step is to call 402.472.5000 to schedule an in-person or telehealth psychiatric appointment. During the 60-minute initial appointment, you will discuss your current and past psychiatric history and collaborate with the psychiatry provider on a recommended treatment plan. At the end of the screening, you will usually be instructed to schedule a follow-up appointment.

Your first appointment is scheduled for 60 minutes. It begins similar to a regular doctor’s appointment. After you’ve checked in at the front desk, a nurse will call you back from the waiting room and will gather your vital signs, review your allergies and medications and go over your health history. When this is completed, you will then meet with a psychiatric team member. Plan on being asked a lot of questions about your physical health (past or current illnesses, injuries or surgeries), social history (school, work, hobbies, relationships, gender identity, spiritual beliefs, drug/alcohol use, etc.) and mental health history (any treatment you may have received prior to this appointment). Of course, time will also be spent discussing the concerns that prompted you to schedule the appointment.

At the end of the evaluation, the psychiatric provider will talk with you about your symptoms and possible diagnosis, go over your treatment options (which may or may not include medication), answer any questions you may have and schedule a return appointment.

After you’ve been established with one of our psychiatric providers, follow-up appointments are scheduled to see if your symptoms are improving, if any changes should be made and to address any additional questions or concerns you may have. Follow-up appointments are scheduled on average for 30 minutes but can vary depending on your needs. How often you will follow up with your psychiatric provider is determined by you and your provider. Usually, you meet monthly once medications are prescribed. However, this varies on a case-by-case basis. Visit frequency can range from weekly to every three months depending on symptoms, side effects, diagnoses, and patient/provider preference.

These decisions are based on several criteria, such as your symptoms, if you have any other medical conditions, what medications/herbal supplements you are currently taking, what medications you’ve already tried, etc.

Remember, responses to medication are highly individualized. A medicine that works well for one person (even if a family member) may work very differently for you. It may require trying a few different medications to find the right one that works for you. It is also important to remember that any medication can take up to eight weeks or longer to achieve the full benefit.

In many cases, if you are still unsure about a medication after the provider explains the benefits and risks, you can take time after the appointment to think about the medication and read more about it from information that the provider gives you. You can schedule a follow-up appointment after you have decided about the medication.

No. The goal of treatment is to stabilize brain chemistry and relieve your symptoms so you can feel like yourself again. Think of it like having a broken leg. Putting a cast on your leg doesn’t change who you are. Instead, it stabilizes your leg so you’re more capable of being who you are. It is very important to take your medication consistently in order to improve your symptoms.

No. Treating mental health issues with medication is no different than taking medication for medical conditions like allergies, asthma, infections or diabetes.

No. These medications are not addictive. Although any time your body becomes used to taking a daily medication, patients may experience discontinuation symptoms if they were to stop the medication abruptly. There are some medications in other drug classes used by medical providers that can be habit forming. Your provider will discuss this with you should it become a concern. At any time, feel free to ask questions.

This charge may vary. Please call 402.472.5000 and select the billing and insurance option to discuss the current cost with a staff member. The amount you pay is determined by your insurance plan. If you do not have health insurance and cannot afford medical care, you may be eligible to apply for the financial assistance program.

Usually, you meet monthly once medications are prescribed. However, this varies on a case-by-case basis. Visit frequency can range from weekly to every three months depending on symptoms, side effects, diagnoses, and patient/provider preference. For students receiving ADHD stimulant medication, we require visits at least every three months.

Medications may be covered by your insurance company. Give your insurance card to the pharmacy when you pick up the medication. You might have a copay even if the medication is covered by insurance. When possible, the provider tries to pick an affordable medication. Sometimes the medication is not covered by insurance, which can make it expensive. Other times, the medication is covered by your insurance, but it is still expensive. If this is the case, the provider will work with you to find a medication that is cost-effective for you. The health center has programs available for students who need financial assistance.

If you are 18 or older, parental permission is not required to receive mental health care, including psychiatry. If you are on your parents’ insurance plan, you may choose to pay cash for medications and/or visits instead of submitting them to insurance so that your parents do not receive an Explanation of Benefits.

Some medications are indicated for short-term use. Other medications are indicated for longer-term use. Talk with your psychiatric provider about the recommended length of your treatment. This is determined on a case-by-case basis by considering diagnosis, symptom severity, previous psychiatric history, environmental stressors, etc.

Side effects vary depending on which class of medication you are prescribed. Your provider will discuss potential side effects with you before you start a medication. However, common side effects of psychiatric medications include nausea, lightheadedness, dizziness and headache. In general, side effects should go away within the first few days or weeks of starting the medication or changing the dose. If side effects persist, talk with your psychiatric provider about this.

Yes, please be open and honest with your provider about this. The nurse will usually ask you about all the medications you are taking at the beginning of your visit.

A financial assistance program is available to those who qualify. You must provide certain documentation and complete a lengthy application process to be considered for approval. Call 402.472.5000 and select the billing and insurance option to discuss this with a staff member. You are responsible for all your costs. Prescription copay assistance options are available. The health center pharmacy staff offers free enrollment assistance.

Students can fill out a release of information that gives consent to allow communication between their therapist and their medical provider.

This is determined on a case-by-case basis. For most students who remain in Nebraska during summer and winter breaks, we can continue to provide in-person or telehealth provide care. For out-of-state patients, sometimes you will be asked to find a primary care provider or psychiatrist back home who can see you over break and provide medication. Other times, we may be able to give you refills of your medication to cover you over the break. Determining factors include recent medication changes, diagnoses, level of stability, etc.

Yes, you can start a medication in the spring even if you plan on leaving Lincoln for the summer. If you remain in Nebraska, we can offer telehealth appointments even while you are in a different city. If you leave the state, we can decide on appropriate summer treatment plans, including whether you need to find a provider back home. Your psychiatry provider can help you locate a provider if you need assistance.

Psychological testing is the gold standard in making the most accurate diagnosis of ADD/ADHD. Our psychiatric providers do not provide that sort of assessment. Because so many other conditions can look like ADD/ADHD, we recommend contacting Counseling and Psychological Services at 402-472-7450 to schedule an appointment with a therapist and further discuss your symptoms. If psychological testing is recommended, then a referral to a psychologist in the community will be provided. Our psychiatric providers can also provide you with community referrals if needed. Please be advised, in most cases, ADD/ADHD medication will not be prescribed without a formal ADD/ADHD diagnosis. The decision will be up to your psychiatric provider and is made on a case-by-case basis.

No need to worry. Our psychiatric team is more than willing to coordinate care with your psychiatric provider at home. Every effort is made to be sure the transitions between home and school are as seamless as possible.

The best option is to have your psychiatric provider at home write a prescription that you can have refilled at the health center pharmacy. Our psychiatric team cannot refill medications without having an initial evaluation and routine follow-up appointments.

Yes, but maybe not the kind of genetic testing that first comes to mind. The genetic testing offered at the health center evaluates how well a person metabolizes various medications. It does not provide any information on ethnicity or medical conditions. The test can only be ordered by a medical provider and will require a full psychiatric evaluation if you have not already established care with one of our psychiatric providers. This test is not free and is not covered by most insurance companies. Please visit the Gene Sight website or talk with your psychiatric provider for more information.

If you are feeling stressed or need to talk to someone, contact the experts at Counseling and Psychological Services . They provide free short-term counseling, group therapy and other options to help you manage your concerns.

Big Red Resilience and Well-being offers many resources to students. You can visit their office located on level one of the University Health Center or visit their website .

The Office for Students with Disabilities can help if your condition leads to difficulties with your academic success. Accommodations may be available.

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How and When to See a Psychiatrist

• Conditions Treated
• When to See a Psychiatrist
• During an Appointment
• Finding a Psychiatrist
• Training and Certification

A psychiatrist is a licensed provider and medical doctor (MD) or a doctor of osteopathic medicine (DO) specializing in mental health conditions. These professionals evaluate and diagnose mental health conditions and treat patients by prescribing medications. The term " psychiatrist " is often confused with " psychologist ," but there are important distinctions between the two mental health professionals.

Psychiatrists are medical doctors who can prescribe medication, whereas psychologists are trained mental health providers who do not hold a medical degree and cannot prescribe medication without additional training.

This article discusses psychiatrists, the conditions they treat, how to find a psychiatrist, and what to expect during an appointment.

Illustration by Mira Norian for Verywell Health

Psychiatry and Conditions Treated

Psychiatry is the field of medicine focused on mental health conditions. The most common mental health disorders are anxiety and depressive disorders. However, psychiatrists are qualified to treat various conditions defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Examples of mental health conditions that psychiatrists treat include:

• Post-traumatic stress disorder (PTSD)
• Personality disorders
• Eating disorders

Psychiatrists vs. Psychologists

Psychiatrists are medical doctors who treat the mental and physical symptoms of mental health disorders using medications, psychotherapy, and brain stimulation treatment. Psychologists are mental health providers with an advanced degree, who treat mental health disorders with psychotherapy .

When to See a Psychiatrist 

Anyone with symptoms who suspects a mental health condition or who has a diagnosis but is struggling with their mental health should seek the support of a psychiatrist or another mental health provider. Mental health conditions are treatable, and getting prompt care leads to better outcomes.

Symptoms of mental health disorders may include:

• Changes in mood
• Decreased desire to participate in activities
• Emotional challenges
• Energy changes
• Loss of control
• Physical body pain
• Sleep pattern changes
• Thoughts or feelings that interfere with daily life

Suicide Prevention Hotline

If you or someone you know is having suicidal thoughts, dial  988  to contact the  988 Suicide & Crisis Lifeline  and connect with a trained counselor. For more mental health resources, see our  National Helpline Database.

Those experiencing a mental health crisis or having thoughts of suicide should seek emergency care by calling the 988 Suicide & Crisis Lifeline or going to the nearest emergency room. Psychiatrists and other mental health professionals are available at hospitals through emergency departments. After a mental health diagnosis, it is essential to continue to follow up with a psychiatrist or other mental health professional for ongoing care.

During a Psychiatric Appointment

An appointment with a psychiatrist typically involves a conversation that considers the following:

• Your current symptoms and concerns
• Your medical and mental health histories
• Your family history
• How your symptoms affect your daily life

Mental health providers such as psychiatrists also use standard questionnaires to evaluate for mental health disorders. For example, the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) is an effective tool for identifying depression and anxiety . Such evaluation tools may be a form you fill out, or someone may verbally ask you (or a caregiver ) questions.

How to Find a Psychiatrist 

Finding a psychiatrist may begin with an appointment with a primary care practitioner. These providers can do an initial evaluation and help to determine if an appointment with a psychiatrist or other mental health provider is warranted. While it can be challenging to find a provider and receive care, virtual appointments and online treatment may be more accessible, and these options are effective in treating mental health conditions such as anxiety and depression.

The process of finding a psychiatrist for mental health concerns may be different for people without insurance vs. those with insurance.

Through Insurance

Many insurance plans offer mental health coverage, including psychiatric appointments. Additionally, there are laws to promote mental health that help to make mental health services more accessible through insurance. Check with your insurer to determine what services and providers are covered; some insurance companies may require a referral for you to see a psychiatrist. Insurance companies can provide a list of psychiatrists that are in-network and covered by the plan.

Without Insurance 

Even when insurance their plans cover mental health services, some people choose to seek care from a psychiatrist or other mental health professional without getting the services covered by insurance. Opting for care outside of what's covered by insurance allows you more freedom to choose a provider. Nearly half of psychiatrists do not accept insurance, resulting in out-of-pocket expenses for the patient.

Some providers offer services on a sliding scale to accommodate different abilities to pay. If you are considering services without insurance coverage and are concerned about the cost, contact providers for options.

Psychiatrist Training and Certification 

The psychiatrist training and certification process begins with four years of medical school. They then receive specialized training in the mental health field and become licensed to practice. While preparation to become a psychiatrist does involve some training in talk therapy , there is more of a focus on treating with medications. This training differs from psychologists who receive doctorate degrees, do not go to medical school, and focus primarily on talk therapy when treating mental health concerns.

The American Board of Psychiatry and Neurology (ABPN) provides board certification for licensed psychiatrists after they pass an examination and meet all requirements. Continued education is also part of maintaining a license to practice psychiatry and helps improve the quality of care.

Psychiatrists are medical doctors specializing in mental health who evaluate, diagnose, and treat mental health disorders such as depression, anxiety, and substance abuse. Anyone struggling with mental health concerns or experiencing symptoms of a mental health disorder should seek the support of a mental health provider such as a psychiatrist. Finding a psychiatrist may be challenging, but primary care practitioners and insurance providers can help.

American Psychiatric Association. What is psychiatry? 2024.

Dattani S, Rodés-Guirao L, Ritchie H, Roser M. Mental health .  Our World in Data . 2023.

McGorry PD, Ratheesh A, O’Donoghue B. Early intervention—an implementation challenge for 21st century mental health care .  JAMA Psychiatry . 2018;75(6):545-546. doi:10.1001/jamapsychiatry.2018.0621

Kroenke K, Wu J, Yu Z, et al. Patient health questionnaire anxiety and depression scale: initial validation in three clinical trials .  Psychosomatic Medicine . 2016;78(6):716. doi:10.1097/PSY.0000000000000322

Bisby MA, Balakumar T, Scott AJ, Titov N, Dear BF. An online therapist-guided ultra-brief treatment for depression and anxiety: a randomized controlled trial .  Psychol Med . 2024;54(5):902-913. doi:10.1017/S003329172300260X

American Psychological Association. Does your insurance cover mental health services? 2014.

Donohue JM, Goetz JL, Song Z. Who gets mental health care? —the role of burden and cash-paying markets .  JAMA Health Forum . 2024;5(3):e240210-e240210. doi:10.1001/jamahealthforum.2024.0210

American Psychiatric Association. Certification and licensure . 2024.

By Ashley Olivine, Ph.D., MPH Dr. Olivine is a Texas-based psychologist with over a decade of experience serving clients in the clinical setting and private practice.

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Complementary Health Approaches

Ect, tms and other brain stimulation therapies, getting treatment during a crisis, mental health medications, psychosocial treatments, psychotherapy, treatment settings, types of mental health professionals.

Innovations in the range of evidence based medications, therapy and psychosocial services such as psychiatric rehabilitation, housing, employment and peer supports have made wellness and recovery a reality for people living with mental health conditions.

Choosing the right mix of treatments and supports that work for you is an important step in the recovery process. Treatment choices for mental health conditions will vary from person to person. Even people with the same diagnosis will have different experiences, needs, goals and objectives for treatment. There is no “one size fits all” treatment.

When people are directly involved in designing their own treatment plan, including defining recovery and wellness goals, choosing services that support them and evaluating treatment decisions and progress , the experience of care and outcomes are improved.

There are many tools that can improve the experience on the road to wellness: medication, counseling (therapy), social support and education. Therapy, for example, can take many forms, from learning relaxation skills to intensively reworking your thinking patterns. Social support, acceptance and encouragement from friends, family and others can also make a difference. Education about how to manage a mental health condition along with other medical conditions can provide the skills and supports to enrich the unique journey toward overall recovery and wellness.

Together with a treatment team you can develop a well-rounded and integrated recovery plan that may include counseling, medications, support groups, education programs and other strategies that work for you.

Mental health professionals all have different roles. Understanding who can prescribe and monitor medication and provide therapy and counseling can offer can help you decide which is right for you.

Psychotherapy, also known as “talk therapy,” is when a person speaks with a trained therapist in a safe and confidential environment to explore and understand feelings and behaviours and gain coping skills.

Mental health crisis response services are a vital part of any mental health service system. A well-designed crisis response system can provide backup to community providers, perform outreach by connecting first-time users to appropriate services and improve community relations by providing reassurance that the person’s needs are met in a mental health crisis.

Treatment for mental health conditions is not a one size fits all approach. Treatment can include private doctors, community mental health centers, emergency rooms, hospitalization and substance abuse centers. Knowing where to look and what to expect can help reduce confusion and stress.

Some people find medications to be an important part of their treatment plan. Understanding their risks and benefits can help you make the right choice.

Psychosocial treatments look at someone’s psychological development and how it contributes to the way that they act in and respond to their social environment.

Complementary and alternative methods can help with recovery when traditional methods do not seem to be enough.

When treatments such as medication and therapy aren’t able to relieve the symptoms of depression or another mental health condition, brain stimulation therapies can be an option.

Know the warning signs of mental illness

Learn more about common mental health conditions

NAMI HelpLine is available M-F, 10 a.m. – 10 p.m. ET. Call 800-950-6264 , text “helpline” to 62640 , or chat online. In a crisis, call or text 988 (24/7).

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A mental health billing service, the definitive guide to psychiatry cpt codes [+cheat sheet pdf].

Psychiatry CPT Codes are numerous and nuanced.  This guide will teach you the most common psychiatry CPT codes, psychiatry addon codes, psychiatry evaluation and management codes, and how to bill psychiatry CPT codes.

There are quite a few medical billing CPT codes for Psychiatry services and psychiatrists to use, some reimbursed more often or at higher rates than others.

We at TheraThink provide a billing service that can help de-code which psychiatry CPT codes to use.  This guide will also help you find out which codes to pick.

We will offer you a quick guide on most common psychiatry CPT Codes, explain evaluation and management (E/m) codes, and then provide an exhaustive list of all Psychiatry CPT codes.

Common Psychiatric CPT Codes

Diagnostic, Evaluation, Intake CPT Code:

• 90791 – Psychiatric Diagnostic Evaluation without medical services ( usually just one/client is covered )
• 90792 – Psychiatric Diagnostic Evaluation with medical services

Outpatient Mental Health CPT Codes :

• 90832 – Psychotherapy, 30 minutes ( 16-37 minutes ).
• 90834 – Psychotherapy, 45 minutes ( 38-52 minutes ).
• 90837 – Psychotherapy, 60 minutes ( 53 minutes and over) .
• 90846 – Family or couples psychotherapy, without patient present.
• 90847 – Family or couples psychotherapy, with patient present.
• 90839 – Psychotherapy for crisis, 60 minutes ( 30-74 minutes ).
• +90840 – Add-on code for an additional 30 minutes ( 75 minutes and over ). Used in conjunction with 90839.

Psychotherapy CPT Codes with Evaluation & Management Services:

• 90833 – Evaluation and Management with 30 Minutes Psychotherapy
• 90836 – Evaluation and Management with 45 Minutes Psychotherapy
• 90838 – Evaluation and Management with 60 Minutes Psychotherapy

Psychiatry CPT Code Cheat Cheat PDF

Here is a downloadable Psychiatry CPT Code Cheat Sheet PDF:

Psychiatry CPT Code Cheat Sheet PDF

Or in image format:

Download Part 1

Download Part 2

If you need help choose the right CPT code to use for your insurance claims, we help translate billing into English with our mental health billing service .

Evaluation and Management Psychiatric CPT Codes

Here is a list of the most common evaluation and management psychiatry CPT codes:

• 99201 – 10 Minutes
• 99202 – 20 Minutes
• 99203 – 30 Minutes
• 99204 – 45 Minutes
• 99205 – 60 Minutes

• 99211 – 5 Minutes
• 99212 – 10 Minutes
• 99213 – 15 Minutes
• 99214 – 25 Minutes
• 99215 – 40 Minutes
• 99241 – 15 Minutes
• 99242 – 30 Minutes
• 99243 – 40 Minutes
• 99244 – 60 Minutes
• 99245 – 90 Minutes
• 99251 – 20 Minutes
• 99252 – 40 Minutes
• 99253 – 55 Minutes
• 99254 – 80 Minutes
• 99255 – 110 Minutes

Reimbursement Rates for Psychiatrists

Please check out our extensive guide to 2021 reimbursement rates for psychiatrists .

Psychiatry CPT Codes List

It’s extremely important to note that many of these codes will not be covered by a client’s insurance policy, may require authorization, or may have specific modifiers required depending on how services are rendered.

If you don’t want to manage any of this work, we’re happy to help do the insurance billing for your psychiatry practice .

Extended Session Add-On CPT Codes for Psychiatric Services

Psychiatry cpt code modifiers.

Here is a short list of the most common CPT Code modifiers that would be used while rending psychiatric services.

CPT Code Modifier 22

• Unusual Procedure Services

This modifier is used when the work associated with the service provided is greater than that usually required for the listed code.

CPT Code Modifier 25

• Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

This modifier is used to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual pre- and postoperative care associated with the procedure performed.

CPT Code Modifier 26

• Professional Component

This modifier is used for procedures that are a combination of a physician component and a technical component.

When the physician component is reported separately, this modifier is added to the usual procedure.

CPT Code Modifier 52

• Reduced Services

This modifier is used to report a service that is reduced in time.

Setting & Documentation Guidelines for Psychiatric Services

These services are typically set in an office location.

Please review the Medicare guidelines for E/M guidelines and documentation for exhaustive detail:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

Unusual Psychiatry CPT Code Descriptions

These descriptions are directly copied from the American Psychiatric Association’s coding pamphlet.

Please refer to their documentation here: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Practice-Management/Coding-Reimbursement-Medicare-Medicaid/Coding-Reimbursement/cpt-primer-for-psychiatrists.pdf

These services are often not reimbursed by insurance companies.  Call their insurance plan to obtain authorization or have a mental health billing service like ours help.

CPT Code 90865

Narcosynthesis for Psychiatric Diagnostic and Therapeutic Purposes (e.g. sodium amobarbital (Amytal) interview)

This procedure involves the administration, usually through slow intravenous infusion, of a barbiturate or a benzodiazepine in order to suppress inhibitions, allowing the patient to reveal and discuss material that cannot be verbalized without the disinhibiting effect of the medication. This code is reimbursed by most insurers.

CPT Code 90867

Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS) initial treatment, including cortical mapping, motor threshold determination, delivery and management

CPT Code 90868

Subsequent TMS Delivery and Management, per session

CPT Code 90869

Subsequent TMS Motor Threshold Re-Determination with Delivery and Management

CPT Code 90870

Electroconvulsive Therapy (Includes Necessary Monitoring); Single seizure

This code is for electroconvulsive therapy (ECT), which involves the application of electric current to the patient’s brain for the purposes of producing a seizure or series of seizures to alleviate mental symptoms. ECT is used primarily for the treatment of depression that does not respond to medication.

The code includes the time the physician takes to monitor the patient during the convulsive phase and during the recovery phase. When the psychiatrist also administers the anesthesia for ECT, the anesthesia service should be reported separately, using an anesthesia code. ECT is covered by most insurance plans.

CPT Code 90875

Individual Psychophysiological Therapy Incorporating Biofeedback

Training by any Modality (face-to-face with the patient), With Psychotherapy (e.g., insight-oriented, behavior modifying, or supportive psychotherapy); approximately 20-30 minutes and,

CPT Code 90876

approximately 45-50 minutes

These two procedures incorporate biofeedback and psychotherapy (insight oriented, behavior modifying, or supportive) as combined modalities conducted face-to-face with the patient.

They are distinct from biofeedback codes 90901 and 90911, which do not incorporate psychotherapy and do not require face-to-face time. Medicare will not reimburse for either of these codes

CPT Code 90880

Hypnotherapy

Hypnosis is the procedure of inducing a passive state in which the patient demonstrates increased amenability and responsiveness to suggestions and commands, provided they do not conflict seriously with the patient’s conscious or unconscious wishes.

Hypnotherapy may be used for either diagnostic or treatment purposes. This procedure is covered by most insurance plans .

CPT Code 90882

Environmental Intervention for Medical Management Purposes on a Psychiatric Patient’s Behalf With Agencies, Employers, or Institutions

The activities covered by this code include physician visits to a work site to improve work conditions for a particular patient, visits to community-based organizations on behalf of a chronically mentally ill patient to discuss a change in living conditions, or accompaniment of a patient with a phobia in order to help desensitize the patient to a stimulus.

Other activities include coordination of services with agencies, employers, or institutions. This service is covered by some insurance plans, but because some of the activities are not face-to-face, the clinician should check with carriers about their willingness to reimburse for this code.

CPT Code 90885

Psychiatric Evaluation of Hospital Records, Other Psychiatric Reports, Psychometric and/or Projective Tests, and Other Accumulated Data for Medical Diagnostic Purposes

Although this would seem to be a very useful code, because reviewing data is not a face-to-face service with the patient, Medicare will not reimburse for this code and some commercial carriers have followed suit.

Medicare considers the review of data to be part of the pre-/postwork associated with any face-to-face service.

CPT Code 90887

Interpretation or Explanation of Results of Psychiatric, Other Medical Examinations and Procedures, or Other Accumulated Data to Family or Other Responsible Persons, or Advising Them How to Assist Patient

Medicare will not reimburse for this service because it is not done face-to-face with the patient, and clinicians should verify coverage by other insurers to ensure reimbursement. It is appropriate to use an E/M code in the hospital where floor time is expressed in coordination of care with the time documented.

CPT Code 90889

Preparation of Report of Patient’s Psychiatric Status, History, Treatment, or Progress (Other Than for Legal or Consultative Purposes) for Other Physicians, Agencies, or Insurance Carriers

Psychiatrists are often called upon to prepare reports about the patient for many participants in the healthcare system. This code would be best used to denote this service. However, because this is not a service provided face-to-face with a patient, Medicare will not reimburse for this code either, and clinicians should verify coverage by other insurers.

CPT Code 90899

Unlisted Psychiatric Service or Procedure

This code is used for services not specifically defined under another code. It might also be used for procedures that require some degree of explanation or justification.

If the code is used under these circumstances, a brief, jargon-free note explaining the use of the code to the insurance carrier might be helpful in obtaining reimbursement. If it is used for a service that is not provided face-to-face with a patient, the psychiatrist should check with the patient’s insurer regarding reimbursement.

CPT Codes 95970, 95974, 95975

Neurostimulators, Analysis–Programming

These codes have been approved for vagus nerve stimulation (VNS) therapy for treatment-resistant depression. Clinicians performing VNS therapy should use the appropriate code from the 95970, 95974, and 95975 series of codes found in the neurology subsection of the CPT manual. Medicare will not reimburse for these codes.

Brief Office Visit for the Sole Purpose of Monitoring or Changing Drug

Prescriptions Used in the Treatment of Mental Psychoneurotic and Personality Disorders – M0064 is not, in fact, a CPT code. It is a HCPCS Level II code (CPT codes are HCPCS Level I), part of the HCPCS system used by Medicare and Medicaid. M0064 should only be used for the briefest medication check with stable patients

Source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Practice-Management/Coding-Reimbursement-Medicare-Medicaid/Coding-Reimbursement/cpt-primer-for-psychiatrists.pdf

Other Source: https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/business_of_practice/cpt/2018_CPT_module_revised_March_2018.pdf

e/m codes evaluation and management codes mental health billing psych codes psych cpt codes psychiatry billing psychiatry codes psychiatry cpt codes psychiatry reimbursement rates

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