When patients come to me from another practice, they often ask the same question in the first ten minutes. They say something like, "Are you going to put me on something else, or take me off something, or change my dose?" I never answer that question on the day they ask it. The plan comes later -- after I have asked them everything I am about to describe below.
This list is not exhaustive. It is the floor. The minimum I gather before I am willing to write a prescription for anyone.
What you have already tried, and what it did to you.
The single most useful piece of information I get from a new patient is their medication history. Not just the names. The dose. How long they were on it. What it did. What it stopped doing. What side effects it caused. Whether they stopped because the medication did not work or because the side effects made it unlivable.
The reason this matters: prior response is the most reliable predictor of future response. If you tried fluoxetine at 20mg for three weeks and felt nothing, that tells me one thing. If you tried fluoxetine at 60mg for six months and felt better but stopped because of weight gain, that tells me something completely different. Most patients have been asked "what have you tried?" but not "what dose, for how long, with what response?"
That distinction often changes the entire treatment plan.
Your medical history, not just your psychiatric history.
Psychiatric medications interact with the rest of your body. SSRIs can interact with NSAIDs and increase bleeding risk. Some mood stabilizers require kidney monitoring. Stimulants can affect cardiovascular function. Many antipsychotics affect metabolic markers in ways that matter if you carry any cardiac history, thyroid history, or diabetes risk.
If your previous provider did not ask about your full medical picture before prescribing, that is a gap. I ask about thyroid function, cardiovascular history, liver and kidney function, autoimmune conditions, gastrointestinal issues, sleep apnea, hormonal patterns, pregnancy or pregnancy planning, and current medications including over-the-counter and supplements. Not because every patient needs every test. Because the prescription that fits you specifically requires me to see the whole picture first.
What your family history is, on both psychiatric and medical sides.
Some of the most useful information about which psychiatric medication will work for you comes from which medications have worked for your blood relatives. The genetic component of psychiatric medication response is real and increasingly well-documented. If your mother responded to bupropion and tolerated it well, that is meaningful for you. If your sibling tried three SSRIs and ended up on a different class, that is meaningful too.
I ask about family psychiatric history with the same care I ask about your own. Not to pathologize your relatives. To use the information that your own DNA carries them and that information has clinical value.
Your lifestyle, your sleep, your relationships, your work.
Medication is one variable in your mental health. It is not the only one, and often it is not the most important one. A patient on the right medication who is also sleeping four hours a night, drinking heavily, isolating, or working in a job that is breaking them down will not get well. A patient who addresses the sleep, the alcohol, the isolation, and the work might find that they need less medication, or different medication, or no medication.
I ask about all of it. Not as judgment. As context. The treatment plan we build together has to fit the actual life you are trying to live, not an idealized version of it.
What you are hoping for, and what you are afraid of.
Some patients come to me hoping psychiatric care will eliminate their symptoms. Some come hoping it will help them tolerate symptoms they have decided will be with them for life. Some come scared of being on medication at all. Some come scared of stopping medication they have been on for years. The answer shapes the conversation we have, and the conversation we have shapes the plan.
I have not met a patient who did not have something they were specifically afraid of. Asking about it is part of the work. It is also how I avoid prescribing something that, even if clinically appropriate, the patient will not actually take.
Why the careful work matters.
Most psychiatric medications do not work for most patients on the first try. The statistic varies by class and by condition, but the rough number for antidepressants is around forty percent first-try response. For stimulants in ADHD, higher. For mood stabilizers, lower. For antipsychotics, lower still.
What changes that statistic in your favor is information. The more I know about you specifically -- your prior response, your medical context, your family history, your lifestyle, your goals -- the better I can prescribe. The number is not random. It is predictable when the inputs are good.
This is the answer to the patient who asked me "are you going to put me on something else?" The answer is: maybe. But not until I have asked everything above. And once I have, the prescription will be the most considered one I can write for who you actually are.
That is what slow psychiatry means in practice. Not a marketing claim. The actual work.
— Nkemdilim Nwofor, PMHNP-BC