Can A Split-Treatment Model Work?

There is no question that psychotherapy and psychopharmacology can be successfully integrated. Indeed, there are still many psychiatrists left in this country who talk to patients and families, provide both psychotherapy and psychopharmacology, and care for patients in a biopsychosocial context.

The real issues that vex our field concern the practice of split treatment. Can psychotherapy and psychopharmacology really be integrated when provided in our current health care model, which emphasizes split treatment? What are the implicit and explicit problems and opportunities? This discussion will provide some of the background regarding the forces that have fueled split treatment and suggestions that could promote more integration of services within a split-treatment model.

Background

Freida Fromm-Reichmann, M.D., (1947) was one of the first to describe what has now come to be called "split treatment," wherein a therapist provides the psychotherapy and a physician provides the medical care. Over the last 50 years, there have been a number of terms used in the literature to describe and extend the definition of this practice (e.g., divided treatment, integrated treatment, combined treatment, split treatment). Many of these terms seem contrary to one another, leading to confusing terminology, to say the least. The confusion lies, to some extent, in the integrated treatment. There are those who view split treatment as integrated, in that the patient is receiving both pharmacotherapy and psychotherapy, albeit from more than one clinician. The issue is not how many clinicians are providing these treatments, but that the patient is receiving several modalities of treatment. Since the field has not universally adopted standard definitions, we will use integrated treatment to describe the practice wherein the psychiatrist provides both the psychotherapy and pharmacotherapy (Kay, 2001) and split treatment when the therapy and pharmacotherapy are provided by separate practitioners.

While there has been increasing evidence that a combination of psychotherapy and pharmacotherapy is best for patients with certain disorders (e.g., major depression), the controversies have revolved around whether care should be provided in split or integrated treatment, and how the pharmacotherapy and psychotherapy should be sequenced in both of these practice patterns (Roose, 2001). Further, are patients with certain types of disorders, such as borderline personality disorder, best treated in integrated or split treatment (Silk, 1999)? What are the economic advantages/disadvantages for split versus integrated treatment?

There have been multiple political, administrative, educational and economic factors that have led more psychiatrists to provide care in a split treatment modality (Dewan, 1999) (Table 1). Duffy et al. (2001) have presented data from the American Psychiatric Association's Psychiatric Research Network (PRN) demonstrating that outpatients with mood disorders (especially those with bipolar disorder) who are seen by younger, board-certified psychiatrists practicing under utilization management in clinic/hospital-based practices are more likely to be seen in split treatment arrangements.

One of the few studies that looked at the economics of integrated versus split treatment was completed by Goldman et al. (1998). This study showed that, in fact, it might be less expensive for psychiatrists to provide integrated care than split treatment, mostly because patients are seen fewer times in integrated care and achieve the same endpoint.

Pros and Cons

Balon (2001) has described the various arguments for and against split treatment. Positive aspects include: the use of special talents of therapists and psychiatrists; cost-effective use of all available resources; increased time and resources available for patients; an increased amount of clinical information; more opportunity for patients to select a therapist with an ethnic background similar to theirs; enhanced patient compliance; and professional and emotional support for both therapists and psychiatrists. Negative aspects include: inappropriate prescribing decision without knowledge of the content of therapy; potentially discrepant information given by a patient to each of the treating parties; splitting of the treating parties; unclear confidentiality; clouded legal and clinical responsibility; therapist, psychiatrist and patient misperceptions; and no reimbursement for collaboration.

Unfortunately, many of these aspects are not actually determined ahead of time for patients. In other words, when a patient calls a residency training clinic, a community mental health center or managed behavioral health care triage number requesting mental health services, there are often systems issues that cause a patient to see a psychiatrist first, rather than a non-physician clinician. Very often, it has to do simply with which clinician has the next available slot (most likely, a non-physician) or whether the patient is having acute symptoms (more likely, a physician slot). If a patient first sees a non-physician clinician, then that person will decide whether the patient will be further evaluated for medications. If the patient is first seen by a physician, then it will be up to the physician to decide if they will also provide psychotherapy or will refer the patient to another clinician for psychotherapy.

If this sounds complicated, it is. A case in point:

Ms. J is a 44-year-old divorced woman with no previous psychiatric or medical history. Her youngest child is moving back home and is causing Ms. J to have to adjust to a new schedule and new issues. She becomes depressed and irritable. Ms. J's friend suggests that she get help. Should Ms. J see her primary care physician? Should she call her health benefits coordinator and see the first available clinician? With her history, which type of clinician will be assigned--a social worker, psychologist or psychiatrist?

One of the problems for patients is deciding who is in charge. Who should they see for which problems? What is occurring within the doctor-patient relationship? Complaints that seem like side effects of medications may be physical side effects or possibly resistance to taking medications. Patients often do not know who to call in emergencies; who to call when one clinician is on vacation; and what to do if there are transferential difficulties arising in the different relationships with clinicians.

Similarly, clinicians often do not work out communication patterns that lead to successful split treatment arrangements or articulate the implicit and explicit responsibilities of the clinicians (e.g., as in a contract for services) (Appelbaum, 1991). At the beginning of split treatment, clinicians often do not discuss how to manage various issues (e.g., talking with the family; use of mental health insurance benefits; treatment planning; and coverage) and often find themselves in legal and ethical quagmires (Lazarus, 2001; Macbeth, 2001).

Successful Split Treatment

It is critical that clinicians and patients understand the pitfalls and problems inherent in a split treatment arrangement. Unless the clinicians are working in a contained, well-organized setting (e.g., an outpatient resident clinic) where the clinicians see one another regularly and have computer-based charts available to all clinicians, much planning and thought must go into providing effective and safe split treatment. As with any treatment planning, clinicians--along with the patient--must think about the care with a beginning, middle and end. Table 2 lists some suggested guideposts of issues that must be discussed between clinicians and patients when in split treatment arrangements (Rand, 1999; Tasman and Riba, 2000).

Providing split treatment actually requires better psychotherapy skills than integrated treatment. It is actually more complex to manage the care that two clinicians are providing than if you are doing it yourself. The doctor-patient relationship is disrupted in a split treatment arrangement (Tasman et al., 2000). As Smith (1989) said, "In contemporary treatment situations that include a patient, a therapist, a pharmacotherapist, and a pill, the transference issues can become more complex than the landing patterns of airplanes at an overcrowded airport."

References:

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2.Balon R (2001), Positive and negative aspects of split treatment. Psychiatric Annals 31(10):598-603.
3.Dewan M (1999), Are psychiatrists cost-effective? An analysis of integrated versus split treatment. Am J Psychiatry 156(2):324-326 [see comments].
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