Communication Commentary: Time in a Bottle: The Psychopharmacologist-Patient Relationship in “Split-Treatment” Models of Care

The doctor-patient relationship has been and remains the keystone of all medical care. It is the medium by which symptom data are gathered, diagnoses made, the patient is engaged in the enterprise of formulating a treatment plan, the issues of motivation and adherence are addressed, and nonjudgmental support is provided to enhance the work of healing (1). Medical communications researchers Roter and Hall (2) remarked that “talk is the main ingredient in medical care and it is the fundamental instrument by which therapeutic goals are achieved” (p. 8). They noted that we in the psychiatry field are “participating in a dramatic transformation of the identity of our profession. Clinical practice is moving toward psychopharmacological evaluation and treatment monitoring as the principal role for psychiatrists in direct service provision” (p. 13).

Psychiatrists often work in teams with nonphysician therapists, case managers, and other specialists. This model can be very effective for individualizing care such that patients may receive appropriate multidisciplinary treatment from professionals with high levels of expertise in their areas of specialization. Access to psychiatric care is often limited. A collaborative care team or “split-treatment” model in which nonphysicians provide psychotherapy and/or other psychosocial interventions and physicians provide psychiatric assessment and psychopharmacological care allows greater psychiatric access for patients in need. In fact, Interian and colleagues have demonstrated improved engagement in treatment for depressed underserved racial-ethnic groups in the United States when a collaborative care model is utilized (3). However, the increasing pressures to control costs have often put a great deal of pressure on the psychiatrist to see patients in very short and specified periods of time. In addition, medical documentation is taking a larger chunk out of the time allotted (4–6). The frequent use of the term “med check” for the psychiatric encounter conveys to patients and physicians alike that this aspect of treatment is peripheral to the healing process.

Psychiatry as a discipline has, as its core, the primacy of the doctor-patient relationship as a crucial therapeutic ingredient of the healing process. “Psychiatrists have long recognized the importance of the psychiatrist-patient relationship in achieving optimal treatment adherence, as well as symptom reduction and improved functional outcomes” (5, p. 323). The time psychiatrists spend with each patient has been declining over the past decade. As managed care organizations attempt to provide evidence-based treatment interventions in a cost-effective manner, the current model of psychiatrists primarily providing psychopharmacological interventions and treatment monitoring to patients may have an adverse impact on the psychiatrist-patient relationship, with subsequent undesirable effects on service satisfaction, treatment outcomes, and cost-effectiveness of care. Patient satisfaction surveys have uniformly found that the patient-consumer is more satisfied when the physician takes the time to truly listen and communicate thoroughly (4, 7, 8). Defining psychiatrist-patient factors that are essential to the treatment process has been a complex endeavor, yet one that is ongoing. The impact of teleconferencing and telepsychiatry on therapeutic engagement is another area ripe for further investigation (9). Psychiatry, through an empirical validation of the importance of the therapeutic relationship, can maintain this core aspect of its identity in today’s mental health care system (4).

Research has identified six factors that contribute to the ideal conception of the physician-patient relationship. The six C’s are: choice, competence, communication, compassion, continuity, and (no) conflict of interest (5). Patient consumers want a choice of doctors and treatment options. They search for evidence of competence in the medical specialty, and value a doctor that communicates clearly and promptly and demonstrates a compassionate “bedside manner.” Patients want to be able to keep their doctor when they are satisfied with their care. They want reassurances that the doctor is not choosing a treatment based upon conflicts of imposed “rationing” by employers or because they receive secondary financial gains for advocating a specific plan of care. Patients want what we all want—a competent, compassionate physician who is dedicated to the best interest of the patient.

Clinical Vignette

“Hello, Ms. Jones,” Dr. Gonzales smiled, shaking her hand as she entered the office. “I understand your therapist, Ms. Thomas, has referred you to me to learn if medications may be helpful to your treatment. Is that correct?” Dr. Gonzales asked encouragingly after Ms. Jones sat down.

Ms. Jones appeared anxious and uncomfortable and looked up tentatively. “Yes, she has been encouraging this for a long time because she says I’m depressed. I know that I am, but I really didn’t want to take medication. She finally convinced me that this may be the best course.”

Dr. Gonzales smiled with understanding. “Perhaps I should explain a bit about how I work. I believe that I need to get to know you as a person as well as understand your symptoms and how they affect your life before I make recommendations. To do that, I will be asking questions about your history, the symptoms that are interfering with your life, and what you enjoy and are good at. If I do recommend medication, we will talk about pros and cons and you can decide for yourself. So, you’re the one in charge here. Okay?”

Ms. Jones smiled and nodded. Dr. Gonzales waited for a bit and when Ms. Jones did not begin to speak, she continued, “What I ask of you is that you tell your story as accurately and honestly as you can. I need to understand what you are experiencing in order to make appropriate recommendations and to be sure that you are safe. Is that fair?”

Ms. Jones nodded again, her body noticeably relaxed.

By the end of the session, Ms. Jones had described her symptoms of depression, some of the triggers for her depression, confided in Dr. Gonzales about her emerging suicidal thoughts, and given reassurances about her support structure and conviction not to act on these thoughts. She had completed a Beck Depression Inventory and psychotic and manic symptoms had been ruled out. Her family, developmental, and psychiatric history were reviewed.

“Well, Ms. Jones, you are suffering from a serious depression. And it does seem to be making your life miserable and keeping you from doing your best at your job. I suggest you come back in a week and we can discuss the pros and cons of medication, and make sure you feel comfortable with whatever decision you make. In the meantime, I want to be sure that you are safe with yourself. Let’s review your safety plan. I will talk with Ms. Thomas to be sure we are all on the same page. Are you comfortable with this plan?”

Ms. Jones looked directly at Dr. Gonzales. “It’s funny,” she mused. “I guess I never thought of psychiatrists as ‘people.’ You seem like a real person that I can trust. I’ll be back next week.”

Ms. Jones seemed to stand a little taller when she left the room.

Tips for Enhancing the Patient-Psychopharmacologist Relationship

It is incumbent upon psychiatrists to advocate with employers for the time required to effectively provide psychiatric assessment and treatment. It is also incumbent upon psychiatrists to optimize engagement skills such that the quality of the therapeutic relationship may be enhanced, even when time allotted for the appointment is not increased. Tasman, Riba, and Silk (10) have advocated that psychiatrists employ the following methods to convey their interest in each patient as an individual:

Although psychiatrists avoid self-disclosure in the interest of focusing on patient concerns, giving the patient a clear sense of your procedures, treatment philosophy, and methods, enhances engagement and reduces the anxiety that many patients experience when visiting a psychiatrist. As noted in the vignette, negative media portrayals or other preconceptions of what psychiatrists do may heighten patient anxiety and interfere with engagement. Most patients appreciate the time spent up front demystifying and clarifying what to expect, how you work, and expectations of them around treatment engagement. Psychoeducation—the explanation of what psychiatric disorders are, why you are diagnosing one, and what treatment options are available—is a core aspect of all psychiatric interventions. When medication is involved, patients require a greater degree of psychoeducation around what to expect and how to monitor for effectiveness and sideeffects. An ongoing open dialogue around symptom severity, treatment effectiveness, and therapeutic engagement is necessary for optimal collaboration in the healing process. Patients need to feel that they can tell you when things are going badly and when things are going well. They also need to feel in control and begin to take responsibility for the choices they make with regard to the aspects of treatment that are under their control (e.g., medication adherence, etc.). Some patients need continual reassurance that you want to know how they are feeling and what they are experiencing when they take the medication you have prescribed. This can be particularly reassuring for patients, such as the one portrayed in the vignette who resisted taking medication for a long time because of feeling like a failure, a fear of side-effects, or a conviction that a psychiatrist will put them on medication and “forget about” them as a person.

“Underlying each of these types of interactions are empathy on the part of the psychiatrist as well as patience in allowing the patient to speak and express how he feels or what he is trying to say. In other words, prescribing medications gives us the opportunity to emphasize our interest in how taking the medication impacts upon the patient’s life and how the patient deals with the positive effects as well as the side effects. It provides an arena where the patient will be encouraged to turn to the psychopharmacologist for more help along the way should it be necessary” (10, p. 5).