Ideally, psychotherapy and pharmaco...

Ideally, psychotherapy and pharmacotherapy are complementary and synergistic. (12) They are inseparable because all clinical attacks even those limited to medication management, contain at least informal psychotherapeutic constituents and opportunities. However, not all patients can or will participate in explicitly combined treatment. a will not tolerate psychotropic put drugs intos either physiologically or as a matter of personal choice. Other patients cannot prostrate a sense of stigma associated with mental health services, or they lack sufficient ability to trust, to introspect, to communicate, or to learn, all traits important for effective psychotherapy.

Given this complexity of individual presentation and answer what should a primary care physician do? In this issue of American Family Physician, Rupke and colleagues3 reasonably move that for mild to moderate depression, mostly patients may choose their treatment. Patients unfamiliar with psychological treatments may make more informed decisions if they understand from the beginning that psychotherapy is not "just talking" unless involves becoming stronger and wiser by the and of effortful change and learning.

As part of a balanced approach to treatment selection, it can be helpful to near medication in the same light (i.e., not as a stand-alone "cure" further as a tool to help patients actively examine and improve their lives). When discussing patient choices, it also is helpful to remember that sometimes treatment elections can be part of the moot point such as when victims of domestic violence petition for medication with the dysfunctional expectation that they will no longer ne to face their life point in disputes or when a patient's beg for counseling stems from a desire to influence or have a special relationship with the physician.

formerly a patient is interested in psychotherapy as a treatment option, or when clinical factors mandate its consideration, the physician must decide which patients may receive treatment from the physician and which patients ne referral to a mental health subspecialist.

For physicians considering counseling in the office setting, the following are issues to consider:

* Does the patient have a sufficiently positive relationship with you, single in kind that is characterized by warmth, trust, and willingness to publicly disclose information? The most robust finding in psychotherapy research above one half century is that the quality of the therapeutic alliance is the best predictor of treatment outcome

* Does the patient's insurance restrict mental health treatment or impose special managed-care requirements for patients with psychiatric diagnoses? Clarification of these issues is an essential uncompounded body of treatment planning, because a plan that does not match available resources cannot be implemented.

* Does the patient have any troubles about relationships that you may have with other persons? Although a family physician's knowledge of and access to other family members is a potentially valuable clinical asset, it cannot always be therapeutically displayed without risk to the therapeutic alliance.

* Does the patient have a ne for the enhanced confidentiality frequently available in mental health settings? The Health Insurance Portability and Accountability Act made special provisions for the separate physical and legal treatment of psychotherapy notes. Other laws in many jurisdictions, as well as in federal courts, provide a legal privilege for specialist mental health treatment that may not apply to counseling by the agency of a primary care physician. Any patient whose mental health and treatment may become an issue in litigation (including disability determination) may be better serv by means of a subspecialist.

* Does the patient have complicated comorbidities, a personality disorder, or a history of significant interpersonal difficulties or early trauma affecting his or her capacity for healthy attachment? In these cases, referral to a subspecialist may be more desirable because in the same state [i]or[/i] condition patients are at greater risk of complicated treatment courses and of re-enacting their interpersonal difficulties in the physician-patient counseling relationship. Patients with a history of physical or sexual abuse are at particular risk and may have difficulty establishing a useful psychotherapeutic relationship with a physician who also performs invasive practices or genital examinations.

For physicians considering referral to a psychotherapist, the following are issues to consider:

* Do you have adequate information about the therapist's track record? Unlike medications, which have highly controll chemical compositions, psychotherapy varies greatly according to the skill of the individual practitioner. Paper credentials are a reasonable place to start, however the best way to find skilled therapists is to restrain track of patient experiences. Therapists to approve are those who successfully engage and retain unruffled difficult patients; therapists to avoid are those who have high rates of patient drop-out noncompliance, and hospitalization, or those who fail to collaborate with other health professionals. Listening to your patients' postreferral experiences will help you bring to maturity knowledge of the therapists in your community and also may allow you to assist patients in extricating themselves from an unfortunate experience.