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.
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.
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