Performance of a domain-specific large language model in answering patient questions in psychiatry

Large language models (LLMs) are increasingly used for decision support in healthcare, but clinical evidence is often incomplete or evolving. When the available information is insufficient to support a reliable answer, models should request clarification or abstain rather than provide unsupported responses. Existing medical benchmarks, however, typically assume that complete information is available upfront. We introduce Safe-Psych, a sequential benchmark for evaluating how LLMs handle evolving diagnostic uncertainty in clinical psychiatry. Safe-Psych contains over 1,000 real-world psychiatric clinical notes segmented to simulate incremental evidence disclosure, with psychiatrist-derived action labels at each stage: DIAGNOSE, CLARIFY, or ABSTAIN. We evaluate multiple state-of-the-art LLMs in full-information and sequential settings. Our findings show that capability does not ensure calibration: even strong models struggle under incomplete clinical information, with under-abstention exceeding 60% for most models and safety-aware prompting reducing premature commitment only by shifting errors toward excessive abstention. In sequential evaluation, models frequently diagnose before sufficient evidence is available and rarely seek clarification unless explicitly prompted; these premature diagnoses are less accurate than on-time diagnoses. Overall, Safe-Psych reveals a limitation across the evaluated models: recognizing when clinical evidence is incomplete and additional information is needed. We release Safe-Psych to support research on improving LLM safety in healthcare.

Privacy and computational constraints limit the use of large language models in psychiatry, while adapting small language models (SLMs) often requires substantial data and expert annotation. We developed ClinMPO, an evidence-guided reinforcement-learning framework guided by the psychiatrist-defined Clinical Psychiatry Thinking Strategy (CPTS). ClinMPO uses ClinRM, a reward model trained on 18,569 question--answer pairs from 4,474 psychiatry articles. We evaluated four Qwen3 sizes on 1,737 model-screened questions. ClinMPO outperformed Base, supervised fine-tuning and standard group relative policy optimization across scales. From responses by 300 senior pre-licensure medical students, we established the human baseline, a medical-student reference. The 4B model approached this baseline, whereas the 8B model surpassed it and ranked first among 31 models and post-training variants. ClinMPO improved performance across two complementary schemes covering ICD-11 diagnostic categories and psychiatric practice competencies. Blinded assessment by three clinicians showed improved rationale quality across CPTS criteria. These findings highlight how existing clinical evidence and specialist knowledge can be incorporated into the development of medical AI systems through evidence-guided learning.

General-purpose Large Language Models (LLMs) are becoming widely adopted by people for mental health support. Yet emerging evidence suggests there are significant risks associated with high-frequency use, particularly for individuals suffering from psychosis, as LLMs may reinforce delusions and hallucinations. Existing evaluations of LLMs in mental health contexts are limited by a lack of clinical validation and scalability of assessment. To address these issues, this research focuses on psychosis as a critical condition for LLM safety evaluation by (1) developing and validating seven clinician-informed safety criteria, (2) constructing a human-consensus dataset, and (3) testing automated assessment using an LLM as an evaluator (LLM-as-a-Judge) or taking the majority vote of several LLM judges (LLM-as-a-Jury). Results indicate that LLM-as-a-Judge aligns closely with the human consensus (Cohen's $κ_{\text{human} \times \text{gemini}} = 0.75$, $κ_{\text{human} \times \text{qwen}} = 0.68$, $κ_{\text{human} \times \text{kimi}} = 0.56$) and that the best judge slightly outperforms LLM-as-a-Jury (Cohen's $κ_{\text{human} \times \text{jury}} = 0.74$). Overall, these findings have promising implications for clinically grounded, scalable methods in LLM safety evaluations for mental health contexts.