An essential component of PEARLS is psychiatric supervision and consultation, or an equivalent level of supervision and consultation from a psychologist paired with a medical doctor. The psychiatrist provides recommendations about psychiatric medications (mostly antidepressants) and is available as a consultant to discern when medical issues, drug side effects, or other organic issues are contributing to depression or other medical or mental health symptoms. The supervisor reviews all cases in the course of PEARLS counseling during weekly or biweekly case supervision meetings with the PEARLS counselor. In addition, the psychiatrist is available to contact the client’s physician and medical team to recommend initiating or adjusting antidepressant medications, or to assess for potential medical and substance abuse etiologies for depression.
Approximately 40%-50% of clients receiving PEARLS will be on antidepressant medications at the start of PEARLS counseling, and will require higher dosages or augmentation with a second antidepressant agent. This process of tailoring treatment to a patient’s level of disease severity is consistent with evidence-based chronic care models using stepped care, targeted communication between specialist and primary care physician or between specialist and patient – especially for cases with unremitting symptoms. The psychiatrist will also review any new or changed medical problems and medications for all clients at each supervision session, occasionally clarifying details about diagnosis or medication regimens by contacting a client’s physician. The psychiatrist may call clients, after discussion at supervision sessions, to clarify clinical issues (e.g., suicidal ideation or diagnostic uncertainty) that arise in case review. The availability of such relatively infrequent telephone contacts with providers or participants optimizes patient safety and increases the comprehensiveness of the PEARLS intervention.