24 Sep Attunement to Subtle Cues of the Need for Psychiatric Intervention: A Model of Psychotherapist-Psychiatrist Collaboration

Posted at 3:09 pm in Individual Therapy by jlbworks

By Philip Chanin, Ed.D., ABPP, CGP
Board Certified Clinical Psychologist
Assistant Clinical Professor, Department of Psychiatry
Vanderbilt University Medical Center

“Surely, all mental health providers need to grasp the full range of mental illnesses. Psychiatry is an essential, foundational discipline for all of us.” (Volney P. Gay, Ph.D, personal correspondence, June 8, 2019)

Some recent statements from new patients: 1) A 28-year-old female patient states, “I have dealt with anxiety forever. I have very serious fears of people leaving me—I didn’t grow up in a secure family.” 2) Another 28-year-old female patient says, “I don’t really get excited about much. I don’t know how to be happy.” 3) A 32-year-old male patient states, “Meditation isn’t soothing the anxiety. Nothing is soothing the anxiety—today my heart is racing.” 4) A 41-year- old female patient says, “It’s hard to feel anything. I don’t feel. I’m always afraid of failing.”
5) A 72-year old patient states, “I am awake for 2-3 hours each night thinking about all this—wears me out!”

What do all these patients have in common? None of them came into psychotherapy thinking about medication. Yet all have benefited greatly from psychiatric intervention, in addition to their psychotherapy. Prior to returning to Nashville 28 years ago, I worked closely with psychiatrists in my private practices in Philadelphia and then in New Hampshire. I grew to value their diagnostic expertise and acumen when we shared patients.

Beginning my private practice in Nashville in 1991, I sought out psychiatrists to whom I could refer my patients. One of my early experiences here involved a young psychiatrist to whom I referred several patients who needed psychiatric help. One of these patients was hospitalized at Parthenon Pavilion, and was managed there by this psychiatrist. We had a family meeting at the Pavilion, including the patient, the psychiatrist, myself, and another psychotherapist who was working with the family. Evidently, during this meeting, the psychiatrist felt that I was challenging her authority over this patient’s care. The following week she abruptly terminated her relationships with all the patients I had referred to her, which was quite disturbing to me and disruptive of their care. I vowed to try harder to find psychiatrists who were more open to working with psychotherapists in the community and value what we offer to our patients.

Fortunately, since that time, I have been able to develop mutually beneficial relationships with a number of Nashville psychiatrists. Currently 43 of my patients (almost 50 per cent of all my patients) have had (or are scheduled to have) evaluations with psychiatrists who only schedule 90-minute initial evaluations and 45-minute follow-up sessions which combine psychotherapy and medication management. Having also paid for weekly psychotherapy supervision for the past 30 years, I have enormous appreciation for the perspectives that another seasoned
psychotherapist or psychiatrist offers to me in understanding and treating my patients.

In recent years, I have grown in my knowledge of which patients would benefit from psychiatric intervention. This is particularly true as a result of my relationship with the psychiatrist who has evaluated (or will be evaluating) 43 of my patients, including 11 over an 8-week period this spring and early summer. When I make a referral to him, with my patient’s permission, I send him a long email summarizing my clinical impressions from my work with the patient. The psychiatrist then sends me an appointment time for the patient, which I then email to the patient and copy the psychiatrist on the email, so that the patient can confirm with the psychiatrist whether this appointment time works for her/him. Following the evaluation, the psychiatrist sends me a long and thorough email, summarizing his diagnosis, clinical impressions and recommendations. And whenever relevant issues arise during my ongoing psychotherapy with the patient, I email the psychiatrist so that he can address these concerns when he meets in 45-minute follow-ups with the patient.

An experience this week is illustrative of my working relationship with this psychiatrist. On Friday, 3 days ago, I met with a 28-year-old patient with a long history of depression. When I had first met this patient six weeks earlier, he had scored a 7 (mild depression) on the PHQ-9, a paper and pencil questionnaire that I find extremely helpful in evaluating depressive symptoms. On Friday, when I re-administered the PHQ-9, his score was 17 (moderately severe depression), with passive suicidal ideation. The following morning (Saturday), I sent the psychiatrist a long email, with my clinical impressions. Within a few hours I got a return email from him, saying that he had had a cancellation in his schedule in 4 days, and would this appointment time work for the patient? I immediately texted the patient, who greatly appreciated getting such a timely appointment!

Not only do my patients get additional skilled psychotherapy from this psychiatrist, but they also get medical and scientific expertise that has been invaluable in furthering their overall progress in psychotherapy and in their lives. He sends all his patients for lab work to check for vitamin levels and genetic mutations, which most of our patients have, and which can be a major contributing factor in their depression and anxiety. Recently, after getting lab work back on one of my patients, who has struggled with depression off and on throughout the 15 years I have seen her, the psychiatrist sent her the following message:

“1) Your vitamin B12 level is in the low normal range. 2) Your vitamin D3 level is very low. D3 is important for dopamine production and thus low levels are a causal factor in depression. 3) Inside your body, folate is converted into L-methyl-folate, which then forms neurotransmitters important for mental functioning. The rate limiting step in this process is controlled by the MTHFR enzyme, which has its DNA blueprint on chromosome #1 at the 677th and 1298th set of alleles. You have two mutations at the 1298th position. It is possible that you are having some trouble making needed neurotransmitters. 4) Homocysteine is an inflammatory amino acid that at high levels can be associated with depression and possibly dementia. Your homocysteine is mildly elevated. 4) The solution to #2, 3, & 4 above is for you to take a vitamin complex by the name of Enlyte-D. It has L-methyl-folate and methyl-B12 and can lower homocysteine levels. Also, it has 5,000 IU of vitamin D3.”

As almost half of my patients are (or will be) working with this psychiatrist, I have great confidence that their anxiety, panic attacks, dysthymia, depression, obsessive-compulsive disorder, or insomnia are being adequately treated from a psychiatric and medical point of view. Sometimes when I suggest to a patient that they have a psychiatric evaluation, they respond with “I don’t want to be on medication.” I usually then say that “nobody is going to force you to take medication, but I believe you would benefit from a psychiatric perspective on your situation.”

Some patients who have seen this psychiatrist have greatly benefited from having their vitamin deficiencies and genetic mutations addressed and treated, even when they did not take medication. I hear back from my patients frequently about the benefits they are getting from their psychiatric treatment and from the psychiatrist’s perspectives on their lives. Because he is not just a medication provider—he is also a psychotherapist. As another psychiatrist, who clearly values psychotherapy, stated in a New York Times article, “Medication is important, but it’s the relationship that gets people better.” (“Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy,” by Gardiner Harris, NYT, March 5, 2011)

I have written this article in the hope that more NPI psychotherapist will seek out psychiatrists who have not submitted to insurance reimbursement pressure to only offer 15-minute medication management follow-ups, but instead take a deep and genuine personal interest in providing skilled scientific expertise as well as psychotherapy to their patients. Certainly, we do have patients who cannot afford the cost of seeing psychiatrists who do not accept insurance. In those cases, we can endeavor to find “psychotherapy friendly” in network psychiatrists (unlike the psychiatrist I profile in the 3rd paragraph above!) who value and support our work.