What do Patients Wish Their Psychiatrist Had Asked—But Never Asked? A Narrative Review of the Unspoken Agenda in Psychiatric Consultations

Objective: To synthesise evidence on what patients wish their psychiatrist had asked but did not, why these questions go unasked, what follows from the silence, and which interventions close the gap. Methods: Narrative review, reported against the SANRA scale, of literature identified through PubMed/MEDLINE, Scopus, the Cochrane Library and Google Scholar to November 2025, integrating conversation-analytic and observational studies, service-user surveys and qualitative research, systematic reviews and meta-analyses, and randomised trials. Results: Evidence converged on eight domains: medication purpose and exit; sexual function; physical health and weight; suicidal thoughts; trauma; work, money and company; identity and stigma; and how information and decisions are handled. The gap is measurable. The patient's preferred approach to receiving information was rated at the lowest possible level in 80 of 80 recorded consultations; 34% of service users reported being offered a choice of medication, whereas 57% of clinicians believed they always or nearly always offered one; sexual dysfunction was detected in 58% of patients on direct questioning but 14% spontaneously; and 70% of patients concealing suicidal ideation feared practical consequences, chiefly hospitalisation. Five mechanisms suppress enquiry: disconfirming question design, divergent agendas, power and prior coercion, stigma, and time pressure that is largely perceived. Structured consultations, question prompt lists, decision aids, specific clinician training, trauma-informed enquiry and routine outcome monitoring have supporting evidence. Conclusion: The unasked question is a systematic, measurable and clinically consequential feature of psychiatric practice, linked to concealed risk, non-adherence, unmet need and disengagement. The deficit is one of implementation, not knowledge. Practice implications: Psychiatrists should replace disconfirming questions with open invitations, ask every patient how they want information and decisions handled, enquire routinely across the eight domains, make the consequences of disclosing suicidal thoughts transparent, and embed structured patient-agenda tools in routine care.