New clinical examination is not always required

A new full psychiatric assessment and report is not required to be initiated for all claims for mental health conditions.  Commissions have agreed that where there has been a previous assessment and diagnosis by a psychiatrist, it can be sufficient to seek confirmation of the diagnosis, additional clarification and/or supporting information or existing notes from the psychiatrist in preference to requiring the veteran to undertake a new clinical examination for the purposes of obtaining a new psychiatric report, provided this information is sufficient to:

• confirm the diagnosis;
• confirm that DSM-V criteria are met; and
• to provide information on causation of the condition. 

This may be appropriate when the condition is currently being managed by a GP or clinical psychologist but prior diagnosis by a psychiatrist was obtained, or if a statement from the psychiatrist with the claim notes the diagnosis but provides no further information.

This approach is designed to reduce unnecessary additional psychiatric visits for veterans.  It can involve discussing and confirming the diagnosis with the psychiatrist and/or obtaining the psychiatrist’s clinical notes or a report from the psychiatrist.

Where the information provided through seeking clarification is not sufficient to allow the claim to proceed, then a new examination and clinical report may be sought if required.

Requesting a diagnosis

Along with the referral letter, suitably edited for the particular circumstances, the claims assessor should enclose a copy of Part 1 of these Guidelines and Attachments A and/or B as appropriate. Copies of relevant service medical records and any psychological records obtained in accordance with Departmental Instruction DI C20/2005 should also be included in cases where there is some evidence of psychiatric illness on service, especially in posthumous cases.