Who this is for

A second opinion makes sense if any of these sound familiar:

• You were given a diagnosis after a short visit and it never felt quite right

• Your diagnosis has changed with each clinician you have seen

• You are newly pregnant or in the postpartum period and are not sure what medications are safe in pregnancy or in breastfeeding

• You have tried several medications and none has worked, or the side effects outweigh the benefits

• You are on multiple psychiatric medications and no one can explain why

• You are about to start a long-term medication, or about to stop one, and want to be sure

• You are a physician or other professional who wants a careful, confidential read from someone outside your own system

What the research says about second opinions

A Mayo Clinic study of 286 patients referred from primary care to a general internal medicine division found that the referral diagnosis matched the final diagnosis in only 12% of cases. In about two-thirds it was refined, and in about one in five it was distinctly different (Van Such et al., 2017). While that study was not about psychiatry specifically, we can infer that medicine, and psychiatry, can have the same problem and then some.

In psychiatry, brief 15 minute visits miss things. When researchers compared routine clinical diagnoses with structured research interviews, the routine diagnoses missed many co-occurring conditions, including anxiety disorders and PTSD (Zimmerman & Mattia, 1999). Bipolar disorder is frequently labeled as depression for years (Hirschfeld et al., 2003). And when treatment fails, it is worth asking whether the diagnosis was right, whether the medication trials were adequate in dose and duration, and whether the plan has grown more complicated than it needs to be. Even in the largest real-world depression study, each additional treatment step helped fewer people (Rush et al., 2006), which is why a fresh look at the plan, and not just another medication, can be valuable.

What a second opinion includes

1. A records review. Prior evaluations, testing, discharge summaries, and a printout from your pharmacy if you can get one.

2. A long diagnostic interview. Your history from childhood forward, what symptoms look like day to day, family history, sleep, substance use, medical conditions, and trauma.

3. A medication history. For each drug: dose, how long you took it, what happened, and why it stopped. This is where a lot of the answers are, because many failed trials turn out to have been too short or too low, or to have targeted the wrong problem.

4. Standardized measures and medical review. Rating scales where they help, and suggestions for labs or tests if something medical might be contributing.

5. A written summary. My diagnostic impressions, what I would keep, what I would change, what I would leave alone, and what I would try next, in order.

If you want, I will speak with your current clinician so everyone is working from the same page.

What it is not

It is not a replacement for your treating psychiatrist unless you decide you want to transfer your care, and it is not a forensic, disability, or legal evaluation. I will also tell you when I agree with your doctor. A second opinion that confirms a good plan is a useful result.

How to prepare

• A list of every psychiatric medication you can remember, even without exact doses

• Prior evaluations or testing, including neuropsychological testing

• Names of past clinicians and roughly when you saw them

• Recent lab results

• Your questions, written down before the visit