Psychiatric evaluation is, by necessity, highly individualized to the patient and to the treatment setting, making the development of rigorous research designs challenging. Nonetheless, a number of aspects of psychiatric interviewing and assessment may lend themselves to formal study and are discussed in further detail below. In addition, the research agenda for DSM-V (228) provides suggestions for research relating to psychiatric diagnosis, which has many areas of overlap with research on psychiatric assessment.


A. Interviewing Approaches

Some research, predominantly conducted in primary care settings, has examined the differences between specific interviewing approaches. For example, approaches to enhancing reporting and recall of historical information have been evaluated (229, 230). Additional studies have assessed the effects of communication style and vocabulary on outcomes such as patient satisfaction (231–236). The development of new evaluation strategies could help strengthen psychiatric interviewing approaches. In addition, it will be important to expand such research across different patient subgroups (e.g., according to age, gender, sexual orientation, race, ethnicity, cultural background), to individuals with psychiatric disorders, and to collaborative models of assessment and care. Measures of outcomes will also need to be expanded to include factors such as treatment adherence and the strength of the therapeutic alliance. Furthermore, studies will need to assess whether guideline-concordant approaches to assessment are associated with improved outcomes in community-based patient samples (237).

Research has also focused on the impact of technology on information gathering and the physician-patient encounter. For example, some studies have examined differences in the information elicited by face-to-face interviews as compared with computer-aided assessments or telephone interviews (238, 239). Other studies have assessed computerized documentation by physicians at the time of evaluation and its effect on patient perceptions (240–242). Patients and family members are increasingly learning about possible diagnoses and treatments through direct-to-consumer advertising and through Internet-based educational resources, which they sometimes bring to the evaluation. Systematic study of the influences of these information sources on the assessment and treatment planning processes would be useful. It also remains unclear whether use of template-based electronic health records as compared with narrative-based health records will influence the evaluation process, the physician-patient relationship, or communication with other members of the health care team. Thus, with the increasing use of technology in medicine, including computer-based interviews and telepsychiatry, the influence of such technologies is worthy of additional study in the full range of psychiatric settings.


B. Rating Scales

Although rating scales have been widely used in clinical research for assessment by the clinician and self-assessment, they are less often incorporated into psychiatric evaluations in clinical practice. To be most useful, rating scales need to be valid and reliable as well as demonstrate practical utility in typical clinical settings. Further study of clinical rating scales is required in clinical samples including patients with potentially confounding co-occurring disorders (243). Development and testing of rating scales also need to consider the different requirements for rating scales that are used in initial diagnostic assessments as compared with those used in monitoring of signs and symptoms over time or with treatment. The ability to use rating scales to detect prodromal or subsyndromal disorders as part of the psychiatric evaluation would be an important step in the design and testing of preventive approaches to psychiatric disorders. Ideally, research on rating scales could lead to the development of a limited set of formal systematic measures for screening and monitoring, with resulting benefits in identification and treatment of common psychiatric disorders, including substance use disorders.


C. Diagnosis and Formulation

An integral part of the psychiatric evaluation is the process by which the information gathered as part of the psychiatric evaluation is synthesized and integrated into the development of a multiaxial diagnosis and biopsychosocial formulation. In addition to research on the validity and reliability of specific diagnoses, further research is needed on variations in both clinical and community presentations across different patient subgroups (e.g., according to age, gender, sexual orientation, race, ethnicity, cultural background) and in the presence of co-occurring general medical and psychiatric conditions. It is anticipated that the development of DSM-V will stimulate such research across many diagnostic areas, guided by APA's systematic efforts to review existing data and provide agendas for new research (228). With the advent of electronic health records and the increasing availability of decision-support tools, computerized approaches that may permit development of differential diagnoses or formulations will need to be compared to clinician-generated assessments. Longitudinal research on the reliability and validity of approaches to the clinical formulation may aid in fine-tuning this aspect of assessment.


D. Diagnostic Testing

With regard to diagnostic testing, neurogenetics and structural and functional neuroimaging techniques are areas of active and promising research. A burgeoning body of literature has reported associations between genetic markers (e.g., apoplipoprotein E 4 allele, dopamine D4 allele, catechol-O-methyltransferase polymorphisms, promoter polymorphisms of the serotonin transporter gene) and the presence of psychiatric illnesses or symptoms (244–251). Neurogenetic approaches may ultimately be useful in distinguishing between genetic and environmental etiologies of psychiatric disorders as part of the psychiatric evaluation (252), thereby permitting greater specificity in treatment planning and outcome measurement. While some have speculated that characterization of the particular genotype of a patient will lead to "personalized medicine" by guiding treatment choices, significant support for such therapeutic guidance in psychiatric disorders is not yet substantiated by the literature. The potential for progress in this area merits continued vigilance for reports of its impact on the practice of psychiatry.

Neuroimaging techniques are currently used in identifying central nervous system processes such as infection, malformations, cerebrovascular events, and malignancy. Accumulating evidence also suggests other applications of neuroimaging in psychiatric evaluation. In cognitive disorders of late life, such as Alzheimer's disease, neuroimaging techniques have been evaluated for use as surrogate markers for the microscopic neuropathologies that characterize the illness (253–256). Functional neuroimaging with positron emission tomography or single-photon emission computed tomography has demonstrated an association between reduced regional activity (metabolism or perfusion) in temporoparietal regions and the presence and severity of Alzheimer's disease (257–264), whereas other dementing illnesses do not show this temporoparietal feature. The reproducibility of these findings has enhanced the differentiation between Alzheimer's disease and other dementing illnesses (265). Ongoing work aims to confirm the clinical utility of such information.

In patients with schizophrenia and mood and anxiety disorders, structural and functional neuroimaging studies have reported differences between patients and healthy control persons (266–288) as well as differences in some patient subgroups (289–292) and in responders and nonresponders to some treatments (293–302). Nevertheless, the clinical utility of neuroimaging techniques for planning of individualized treatment has not yet been shown. Further research is needed to demonstrate a clinical role for structural and functional neuroimaging in establishing psychiatric diagnoses, monitoring illness progression, and predicting prognoses.


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