Meyer and Simon (1999) offered a model letter that a psychiatrist would send to a referring therapist that addresses the important elements each partner needs to know about the other: their qualifications, certification, liability coverage, experience, clinical orientation, who will provide what part of the treatment, how to contact each other after hours, vacation coverage (do not cover each other; get someone from your own discipline), how emergencies will be handled and confidentiality. The patient needs to know that all information will be shared between the collaborating partners and should sign appropriate releases at the outset.
Himle (2001) enumerated what each partner can expect from the other. It is expected that the psychiatrist will ask the therapist for a clinical report with a reason for referral and then interview the patient. If medications are recommended, the reasons and specific options will be discussed with the patient. Since patients have very personal reactions to medications, the specific medication is best chosen as a collaborative venture to improve adherence. How to take the medication, expected improvement and potential side effects are clearly described and perhaps even written down so that both the patient and therapist are aware of them. The schedule for follow-up appointments will be clearly spelled out. After the first or second appointment, the psychiatrist and therapist will communicate directly and agree on a treatment plan. Finally, the psychiatrist will support the psychosocial treatment plan, but not discuss psychotherapeutic issues with the patient.
The therapist is expected to provide a written clinical summary with a reason for the referral, preferably followed by a brief phone call to the psychiatrist. The therapist will set the stage appropriately with the patient about the referral for medication consultation by describing the symptoms to be targeted and summarizing the research data that suggest medications are likely to be helpful. With psychotic patients, I emphasize medications as critical; with personality-disordered patients I present medications as a potentially useful adjunct to the more important work of psychotherapy; and with other patients, I present medications as an equal and often synergistic partner with ongoing psychotherapy. Patients need to be told explicitly that the consultation may or may not result in medication being prescribed. It is also important that the referral be for an open-ended consultation and not for a specific medication.
An important expectation of therapists is that they will promptly convey to the collaborating psychiatrist any clinical deterioration, suspected side effects or medical problems. This is critical, since the therapist will generally see the patient more frequently than the psychiatrist and is usually the best-informed member of the treatment team. It is important that therapists educate themselves as to the most common side effects of the frequently prescribed medications.
Finally, therapists are expected to fully support the medication regimen and are an important ally in improving adherence. If the therapist disagrees with or wants to change the medications, this discussion should take place directly with the physician and not through the patient. Similarly, specific questions from the patient about medications should be referred back to the prescribing physician.
The prevailing primary care model and the traditional biopsychosocial model allow psychiatrists to provide seamless, integrated combined treatment. In addition, for many conditions such as depression, integrated care is more cost-effective than split treatment. However, since split treatment continues to be widely practiced, it is important to pay particular attention to several aspects in order to make it work. The meaning of medications for both the patient and the therapist must be taken into account. Successful split treatment requires clarity of roles, respect for the many strengths that each profession brings to the enterprise and an appreciation of the powerful psychological dynamics of each. A thoughtful and sometimes energetic engagement is required by all partners in order to avoid potential pitfalls and benefit from the rich promise of medications and collaborative care.