Psychiatric IME Records: Reviewing Mental Health Documentation

The Psychiatric IME Challenge

Psychiatric IMEs are different. The records are different. The examination is different. The opinions are different.

The records:

• Mental health progress notes (often brief, focused on symptoms and medications)
• Psychological testing reports (MMPI, personality inventories, cognitive testing)
• Therapy notes (often protected or redacted)
• Psychiatric hospitalization records
• Substance use treatment records

The examination:

• Mental status examination
• Psychometric testing (if performed)
• Collateral information (family, employers, records)

The opinions:

• Diagnosis (DSM-5 criteria)
• Causation (is the condition related to the claimed event?)
• Prognosis (will the condition improve?)
• Functional impairment (how does the condition affect daily life and work?)

This post shows you how to review psychiatric IME records — what to look for, what to question, and how to render a defensible opinion.

The Framework for Reviewing Psychiatric Records

Phase 1: Establish the Timeline of Mental Health Treatment

Goal: Understand when mental health symptoms started and how they evolved.

What to document:

• Date of first mental health treatment
• Date of first diagnosis
• Timeline of symptoms
• Timeline of treatment (medications, therapy, hospitalizations)

Questions to ask:

• Did symptoms start before or after the claimed event?
• Was there a prior history of mental health treatment?
• Were there prior diagnoses?
• Have symptoms improved, worsened, or stayed the same?

Red flags:

• Mental health treatment started years before the claimed event
• Prior diagnoses that were not disclosed
• Gaps in treatment without explanation

Phase 2: Review Psychiatric Diagnoses

Goal: Determine whether the diagnosis is supported by the record.

What to look for:

• DSM-5 criteria for the diagnosed condition
• Documentation of symptoms in progress notes
• Results of structured diagnostic interviews (if performed)
• Consistency of diagnosis across providers

Questions to ask:

• Does the record document the symptoms required for the diagnosis?
• Is the diagnosis consistent across providers?
• Are there competing diagnoses?
• Is the diagnosis supported by psychological testing?

Example:

• Diagnosis: Major Depressive Disorder, Recurrent, Severe
• DSM-5 criteria: ≥5 symptoms for ≥2 weeks, including depressed mood or anhedonia
• Record review: Progress notes consistently document depressed mood, anhedonia, insomnia, fatigue, difficulty concentrating, and thoughts of death. Symptoms have been present for 6 months. Diagnosis is supported.

Red flags:

• Diagnosis not supported by documented symptoms
• Diagnosis changes frequently without explanation
• Diagnosis is based solely on self-report without objective assessment

Phase 3: Review Psychological Testing

Goal: Assess the validity and results of psychological testing.

Common tests in psychiatric IMEs:

• MMPI-2 or MMPI-3: Personality assessment, validity scales
• PAI (Personality Assessment Inventory): Personality, validity scales
• Beck Depression Inventory (BDI): Depression severity
• Beck Anxiety Inventory (BAI): Anxiety severity
• PTSD Checklist (PCL-5): PTSD symptoms
• SIRS-2 (Structured Interview of Reported Symptoms): Malingering assessment
• Cognitive testing (WAIS, neuropsychological battery): Cognitive function

What to look for:

• Validity scales (are the results valid?)
• Clinical scales (what do they show?)
• Consistency with self-report and clinical interview
• Evidence of symptom exaggeration or malingering

Example:

• MMPI-2 results: Validity scales show elevated F scale (infrequency), suggesting possible symptom exaggeration. Clinical scales show elevated scales 2 (depression) and 7 (anxiety). Results should be interpreted with caution due to validity concerns.

Red flags:

• Invalid test results (elevated validity scales)
• Evidence of symptom exaggeration or malingering
• Inconsistency between test results and clinical presentation

Phase 4: Assess Treatment Response

Goal: Determine what treatments have been tried and how the plaintiff responded.

What to review:

• Medications (antidepressants, anxiolytics, antipsychotics, mood stabilizers)
• Therapy (CBT, DBT, psychodynamic therapy, EMDR)
• Hospitalizations
• Other treatments (ECT, TMS)

Questions to ask:

• What medications have been tried? At what doses? For how long?
• What therapy has been provided? For how long?
• Has the plaintiff responded to treatment?
• Is the plaintiff compliant with treatment?

Red flags:

• Non-compliance with medications or therapy
• Multiple medication trials without improvement
• Treatment refusal
• Treatment seeking behavior (doctor shopping, requesting specific medications)

Phase 5: Assess Functional Impairment

Goal: Determine how the mental health condition affects daily life and work.

What to assess:

• Activities of daily living (self-care, household tasks)
• Social functioning (relationships, social activities)
• Occupational functioning (ability to work, concentration, attendance)
• Cognitive functioning (memory, attention, decision-making)

Sources of information:

• Progress notes (often document functional status)
• Plaintiff's self-report
• Collateral information (family, employers)
• Functional capacity evaluations (if available)
• Work records (attendance, performance)

Questions to ask:

• Can the plaintiff care for themselves?
• Can the plaintiff maintain relationships?
• Can the plaintiff work? If not, why?
• Are there cognitive limitations?

Red flags:

• Self-reported severe impairment but good social functioning
• Self-reported inability to work but evidence of other activities (e.g., social media showing travel, hobbies)
• Inconsistencies between self-report and collateral information

Phase 6: Assess Causation

Goal: Determine whether the mental health condition is causally related to the claimed event.

Types of causation questions in psychiatric IMEs:

• PTSD: Is the PTSD related to a specific traumatic event?
• Depression/Anxiety: Is the condition related to a work injury, harassment, or other event?
• Cognitive impairment: Is the impairment related to a brain injury, toxic exposure, or other event?

Causation framework:

1. Temporal relationship: Did symptoms start after the claimed event?
2. Mechanism: Is the claimed event capable of causing the condition?
3. Pre-existing conditions: Did the plaintiff have prior mental health issues?
4. Alternative explanations: Are there other causes (genetic, developmental, substance use)?

Example:

• Claimed event: Workplace harassment over 6 months
• Diagnosis: Major Depressive Disorder
• Temporal relationship: Symptoms started 2 months after harassment began
• Pre-existing conditions: Prior history of depression 5 years ago, treated successfully
• Alternative explanations: None identified
• Conclusion: The current depressive episode was likely triggered by the workplace harassment, but the plaintiff had a pre-existing vulnerability (prior depression). On a more probable than not basis, the workplace harassment was a substantial contributing factor to the current condition.

Red flags:

• Symptoms started before the claimed event
• Pre-existing condition that explains current symptoms
• Alternative explanations (substance use, relationship problems, financial stress)

Phase 7: Assess Malingering and Symptom Exaggeration

Goal: Determine whether the plaintiff is exaggerating or fabricating symptoms.

Indicators of malingering/symptom exaggeration:

• Invalid psychological testing (elevated validity scales)
• Inconsistencies between self-report and observed behavior
• Inconsistencies between self-report and collateral information
• Atypical symptom presentation
• Excessive disability relative to the condition
• Secondary gain (litigation, disability benefits, avoiding work)

Assessment tools:

• SIRS-2 (Structured Interview of Reported Symptoms)
• MMPI-2/MMPI-3 validity scales
• Clinical interview observations

What to document:

• Evidence suggesting malingering or symptom exaggeration
• Alternative explanations (e.g., genuine distress, personality factors)
• Conclusion (e.g., "Results suggest possible symptom exaggeration, but do not definitively indicate malingering. Clinical presentation is consistent with some genuine psychological distress.")

Important:

• Avoid accusing the plaintiff of malingering without strong evidence
• Use terms like "possible symptom exaggeration" or "inconsistent presentation"
• Document the basis for your conclusion

Common Pitfalls in Psychiatric IME Reviews

1. Not Reviewing Prior Mental Health Records

The mistake: You focus on records after the claimed event and miss prior mental health treatment.

The fix: Request all mental health records, including those before the claimed event.

2. Not Assessing Validity of Psychological Testing

The mistake: You report test results without checking validity scales.

The fix: Always assess validity. If tests are invalid, note it and interpret results with caution.

3. Not Assessing Functional Impairment

The mistake: You focus on diagnosis and symptoms but don't assess how the condition affects daily life and work.

The fix: Assess functional impairment. Document specific limitations.

4. Not Considering Pre-Existing Conditions

The mistake: You assume the claimed event caused the condition without considering prior history.

The fix: Review prior records. Assess pre-existing conditions. Determine whether the claimed event caused a new condition, aggravated a pre-existing condition, or is unrelated.

5. Not Assessing Malingering

The mistake: You accept self-reported symptoms without questioning validity.

The fix: Assess malingering and symptom exaggeration. Use validity scales and clinical observation.

Key Takeaways

1. Establish the timeline of mental health treatment. When did symptoms start?
2. Review psychiatric diagnoses. Are they supported by the record?
3. Review psychological testing. Are results valid? What do they show?
4. Assess treatment response. What has been tried? Has it helped?
5. Assess functional impairment. How does the condition affect daily life and work?
6. Assess causation. Is the condition related to the claimed event?
7. Assess malingering and symptom exaggeration. Are symptoms valid?

What's Next?

In our next post, we'll tackle "Life Care Planning: Building the Record Foundation" — the fifth in our case-type series.

This post is part of our series on medical record review for IME physicians. For more, see our 60 AI Prompts for IME Physicians Reviewing Medical Records.

Questions for Readers:

• What's the most challenging psychiatric IME you've reviewed?
• How do you assess malingering in psychiatric cases?
• What psychological tests do you find most useful?