Training language models in simulation for psychiatric intake

arXiv:2610.40476v1 Announce Type: new Abstract: In psychiatric practice, the clinical intake interview remains a primary diagnostic instrument, requiring the clinician to establish rapport while disentangling complex, overlapping presentations. Here, we show that multi-turn reinforcement learning (RL) in simulation environments improves language model performance on structured text-based psychiatric intake, spanning history-taking, differential diagnosis, and initial management planning. In a randomized, double-blind crossover study ($N = 60$ matched scenario pairs, 120 encounters) comparing the RL-trained agent against its identically prompted base model, 32 board-certified psychiatrists role-played standardized patients while a separate panel of 15 independent, board-certified psychiatrists scored the de-identified transcripts. The trained agent outperformed the base model in 76.7% of matched scenario pairs ($p < 0.0001$), with gains on an adapted clinical-examination rubric ($d_z = 0.77$, $p < 0.0001$), patient-centered communication (82.0% vs. 65.2%, $p < 0.001$), and differential diagnosis appropriateness (68.3% vs. 33.3%, $p < 0.001$). Across 127 psychiatrist-validated simulated intake scenarios, the trained agent nearly doubled its base model's clinical rubric score (0.706 vs. 0.379; composite reward 0.564 vs. 0.294, $p < 0.0001$). To systematically probe conversational safety, we established two Delphi-consensus taxonomies, of clinical safety risks and relational competencies, from which 256 challenging adversarial presentations were derived; we find that training in simulation environments more than halved under-triage of acute safety risks (12.9% vs. 30.5%, $p < 0.0001$). Simulation environments thus provide a controlled testbed for training and stress-testing psychiatric conversational agents, with gains that transferred to psychiatrist-enacted encounters, though residual gaps require safeguards and clinician oversight.

arXiv:2610.40476 (cs)

Authors:Samuel Schmidgall, Tim Strother, Alex Bijamov, Min Woo Sun, Anil Palepu, Akshay Goel, Ulysse Marteau-Ferey, Théo Moutakanni, Yubin Kim, Joseph Breda, Christina Chen, Justin Chen, Paul Jhun, Andrew Marshall, Sarah Montgomery-Taylor, Eun Kyoung Hong, Shashank Ravi, Kameron C. Black, David J. H. Wu, Austin Schoeffler, John Lyon Havlik, Elizabeth C. Stade, Jared Moore, Johannes C. Eichstaedt, Logan Pierce, Jeff Jopling, Johannes Thrul, Thomas H. McCoy, Neguine Rezaii, Mark S. Chen, Ellen E. Fitzsimmons-Craft, Shirley Wang, Desmond C. Ong, Katharina Schultebraucks, Torrey Creed, Bhavna Daryani, Aleksandra Faust, S. Sara Mahdavi, Caroline Figueroa, Eric Lin, Kate H. Bentley, Ernest Lim, Zhihan Jiang, Xuhai "Orson" Xu, Daniel McDuff, John Torous, Yun Liu, Po-Hsuan Cameron Chen, Mike Schaekermann, Joelle Barral, Alvin Rajkomar, Tao Tu, Lin Yang, Isaac Galatzer-Levy, David Racz, Valentin Liévin

Abstract:In psychiatric practice, the clinical intake interview remains a primary diagnostic instrument, requiring the clinician to establish rapport while disentangling complex, overlapping presentations. Here, we show that multi-turn reinforcement learning (RL) in simulation environments improves language model performance on structured text-based psychiatric intake, spanning history-taking, differential diagnosis, and initial management planning. In a randomized, double-blind crossover study ($N = 60$ matched scenario pairs, 120 encounters) comparing the RL-trained agent against its identically prompted base model, 32 board-certified psychiatrists role-played standardized patients while a separate panel of 15 independent, board-certified psychiatrists scored the de-identified transcripts. The trained agent outperformed the base model in 76.7% of matched scenario pairs ($p < 0.0001$), with gains on an adapted clinical-examination rubric ($d_z = 0.77$, $p < 0.0001$), patient-centered communication (82.0% vs. 65.2%, $p < 0.001$), and differential diagnosis appropriateness (68.3% vs. 33.3%, $p < 0.001$). Across 127 psychiatrist-validated simulated intake scenarios, the trained agent nearly doubled its base model's clinical rubric score (0.706 vs. 0.379; composite reward 0.564 vs. 0.294, $p < 0.0001$). To systematically probe conversational safety, we established two Delphi-consensus taxonomies, of clinical safety risks and relational competencies, from which 256 challenging adversarial presentations were derived; we find that training in simulation environments more than halved under-triage of acute safety risks (12.9% vs. 30.5%, $p < 0.0001$). Simulation environments thus provide a controlled testbed for training and stress-testing psychiatric conversational agents, with gains that transferred to psychiatrist-enacted encounters, though residual gaps require safeguards and clinician oversight.

Artificial Intelligence (cs.AI); Computation and Language (cs.CL)

arXiv:2610.40476 [cs.AI]

(or arXiv:2610.40476v1 [cs.AI] for this version)

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Training language models in simulation for psychiatric intake

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