In most psychiatric practices, the first appointment is fifteen minutes long. I know that because I have been on the patient side of that fifteen minutes, and I have watched what it does to the people who walk into mine after.
The model has reasons. Insurance reimburses short appointments at a rate that favors high volume. Provider panels are full. Wait lists are long. Cutting visits short is how a practice keeps its panels open. Those reasons are real. None of them are about the patient sitting across from the provider.
My first appointment is sixty minutes. Not because I think I am better than the providers who run on fifteen. Because what I am trying to do in that first appointment cannot be done in fifteen.
What I am actually doing in those sixty minutes.
I am trying to understand the symptoms you are describing in the context of your specific history. That means I am asking about what your symptoms looked like when they first appeared, how they have changed, what made them better or worse, who else in your family has lived with something similar, what other medical conditions you carry, what medications you are taking and how they have made you feel.
I am asking what you have already tried. Therapy you found helpful or unhelpful. Medications you have been on that worked, did not work, or caused side effects so persistent that you stopped them. I am asking what you have read, what you have feared, what you have decided about your own diagnosis before you walked in.
I am asking what you want from psychiatric care — not abstractly, but specifically. Some patients come to me because they want to stop crying every morning. Some come because they want to sleep through the night without waking with their heart in their throat. Some come because their primary care doctor sent them and they are not sure what they want yet. The answer matters. It shapes the treatment plan.
What I cannot do in fifteen minutes.
I cannot tell the difference between bipolar depression and unipolar depression in fifteen minutes. I cannot tell the difference between ADHD and untreated anxiety presenting as inattention in fifteen minutes. I cannot tell whether the SSRI you took five years ago that "did nothing" was actually dosed too low, given too briefly, or stopped because of a side effect you did not realize was the medication.
I cannot tell whether the medication I am about to prescribe will interact dangerously with the supplement you started taking on the recommendation of your sister-in-law. I cannot tell whether the diagnosis you arrived with is the diagnosis you actually have, or the closest thing the last provider could fit you into during their fifteen-minute appointment.
In fifteen minutes, I can write a prescription. I cannot make sure it is the right one.
What the extra time is for.
The extra time is for two things, and both of them belong to you.
The first is the chance to be heard before being prescribed to. Most psychiatric patients I see have spent years being asked yes-or-no questions about their symptoms. Have you been feeling sad? Yes. Have you been sleeping badly? Yes. Here is a prescription. The first time someone asks them what their life looks like — their actual life, the texture of it — they often start crying, because no one in a clinical setting has asked before.
The second is the chance to make the medication decision well, the first time. Trial and error prescribing is what happens when there is no time to do anything else. Personalized prescribing is what happens when there is time to look at your specific genetics, your specific history, your specific lifestyle, the specific medications you have tried, and make a choice that has a better-than-random chance of working.
Sixty minutes is not a marketing claim. It is the floor of what the work requires. The actual time it takes to do it well, in my experience, is often longer.
Follow-up appointments are thirty or sixty.
After the first visit, follow-ups are thirty or sixty minutes, depending on what we are doing. A medication check-in three weeks into a new prescription is usually thirty. A re-evaluation after a major life event — a job loss, a death, a child diagnosis, a relapse — is usually sixty.
The pattern is the same. The visit lasts as long as the work requires. Not the billing template.
This is not for every practice.
I want to be honest about the trade-off. Practices that run on fifteen-minute appointments can see four patients an hour. I can see one. That math is real. It means my practice is smaller. It means my wait lists are sometimes longer. It means I am not trying to be the highest-volume PMHNP in Las Vegas, and I will not be.
What I am trying to do, instead, is the work that brought me to psychiatric care in the first place. The work that — when it is done well — means a patient walks out with a treatment plan that fits, a provider who heard them, and a chance at actually getting better.
Sixty minutes is what that takes.
— Nkemdilim Nwofor, PMHNP-BC