When psychiatrists must terminate a patient’s treatment, they should provide the patient with as much information as possible about his or her diagnosis, treatment plan, and referral options, according to a risk management expert.

If psychiatrists fail to do so, which could impair continuity of treatment especially for those patients who are severely mentally ill, a psychiatrist can be charged with abandoning the patient, said Jackie Melonas, assistant vice president for risk management at Professional Risk Management Services (PRMS), the administrator of APA’s liability insurance program.

In the past, termination of treatment was usually due to retirement or relocation, but today an all-too-common reason is the ending of managed care contracts.

Melonas recommended giving patients at least 30 days’ notice that treatment will end and reviewing the patient’s diagnosis, treatment plan, and recommendations for follow-up. A brief letter summarizing the treatment recommendations should be sent to the patient.

The verbal notification of termination and recommendations should be documented and kept in the patient’s chart for future reference, said Melonas.

The implications of discontinuing therapy and/or prescribed medications should also be discussed with the patient, said Melonas. "We have recommended this for some time, but the Liptzin case highlights the importance of covering this topic."

In that 1998 case, Williamson v. Liptzin, a jury in North Carolina decided that Myron Liptzin, M.D., the treating psychiatrist, was guilty of medical malpractice. The plaintiff’s lawyer argued that Wendell Williamson, a law student at the University of North Carolina at Chapel Hill, stopped taking his medication approximately a year after treatment and killed two people because, the lawyer maintained, Liptzin had not adequately discussed the perils of stopping the antipsychotic medication he prescribed for Williamson’s paranoid delusional disorder. Liptzin also had given Williamson a 30-day supply of medication on his last visit and recommended that he seek further treatment either in his rural hometown or at the student health center in the fall if he returned.

Melonas commented, "Many psychiatrists don’t realize that they can be held liable for adverse reactions to medication they prescribed after they stop seeing the patient."

The jury verdict created outrage among psychiatrists nationwide. The University of North Carolina is appealing the case, and the North Carolina Psychiatric Association has filed a brief calling for the verdict to be reversed.

When further treatment is recommended, patients should be given specific referral information including the names and telephone numbers of psychiatrists they can contact for appointments, said Melonas.

"However, when a patient has a severe mental illness that would make it difficult for him or her to make an appointment, the psychiatrist should go ahead and schedule one," said Melonas.

If psychiatrists want or need to continue treating patients after a managed care contract ends, they should check their contract for any clause prohibiting their treatment of managed care patients on a private fee-for-service basis, said Melonas.

Participants in the APA-sponsored Professional Liability Insurance Program can call PRMS for additional information about terminating physician-patient relationships. A sample patient termination letter and information on terminating patient relationships are included in APA’s Practice Management for Early Career Psychiatrists released last year. Ordering information is available by calling APA’s Managed Care Help Line at (800) 343-4671.