From Expectation to Experience: The Patient Expectation–Reality Gap in Psychiatric Consultations — A Narrative Review

Objective: To synthesize evidence on the gap between what patients expect from psychiatric consultations and what they experience, and on its origins, consequences and remedies.Methods: A narrative review, guided by the SANRA criteria, of conceptual frameworks, empirical studies, systematic reviews and meta-analyses from psychiatry, general medicine, psychotherapy and placebo research, identified through targeted searches of PubMed/MEDLINE, Scopus and Google Scholar and by citation chaining.Results: Patients most consistently expect to be listened to, to receive emotional support and explanation, and to be told what the consultation will involve, whereas consultations are typically assessment-driven, shorter than anticipated and more often end in prescription or referral than patients expect. Stigma, delayed help-seeking, illness beliefs and time-pressured services amplify the gap, and the therapeutic alliance moderates it. Unmet expectations predict dissatisfaction and non-adherence; optimistic outcome expectations are associated with better outcomes (r = 0.18 across 12,722 patients); and expectancy mediates placebo and nocebo responses to antidepressants. Eliciting expectations, preparatory information, shared decision-making, communication-skills training and expectancy-sensitive framing of benefits and risks show promise, although trial evidence from psychiatric settings remains limited.Conclusion: The expectation–reality gap is a modifiable determinant of patient experience and outcome in psychiatry that warrants precise measurement and targeted intervention.Practice implications: Clinicians should routinely elicit patients' predicted and desired expectations, explain what the consultation involves, negotiate plans that visibly address patients' requests, and frame treatment benefits and side effects to minimize nocebo responses; services should protect time for psychosocial discussion and embed communication and shared decision-making training.