Therapists also have strong biases and reactions toward the use of medications. Sometimes therapists do not refer for medication evaluation because they erroneously believe that relief from medications will undermine psychotherapy or that medications are not needed because there is a psychological explanation for the symptoms. Some therapists oppose the use of benzodiazepines, believing them to be addicting. Thus, patients are deprived even when such medications could be enormously helpful and prescribed safely. The therapist's unrecognized feelings, be it fear, hate or sexual attraction toward a particular patient, may unfairly dictate the addition of medication as a way of distancing, controlling or even punishing the patient (Dewan, 1992).
Over the past decade, medicine in general and managed care organizations (MCOs) in particular have moved toward the primary care model. The aim is to provide primary, holistic care in which one doctor takes care of all the patient's needs. However, the only mental health care practitioner capable of providing comprehensive biopsychosocial care--the psychiatrist--is being replaced by a supposedly less costly but fragmented split treatment model.
Using a theoretical model, I first challenged the widely held assumption that split treatment was less expensive than integrated treatment (Dewan, 1997). In a more elaborate study, I collected the 1998 payment schedule from seven large MCOs with a combined market share of 54% and 67.8 million covered lives (Dewan, 1999). Medicare, covering 36.9 million people, was also added. As can be seen in the Table, (Due to copyright restraints, we are not able to publish this table on the Internet. Please see our print publication.) there are both substantial cost and time savings with integrated treatment. Furthermore, "When time away from work or child care plus the expense of traveling are factored in, the cost benefit analysis favors integrated care from a psychiatrist even more." Even when a social worker was substituted for the psychologist, the cost for integrated treatment was only $16 higher (Dewan, 1999).
In an elegant study, Goldman et al. (1998) used an MCO's database to retrospectively evaluate 1,517 depressed patients followed for 18 months. It is revealing that, despite this MCO's stated aim of trying to "directly refer to psychiatrists for both psychotherapy and pharmacotherapy," only 191 patients (13%) were in integrated treatment. Patients in split treatment needed more psychotherapy sessions (21.2 versus 10.4), more medication visits (6.3 versus four), and more total outpatient care (26.2 versus 14.7 visits). Instead of split treatment leading to savings, it cost $518 more per patient ($1,854 versus $1,336). For all 1,326 patients in split treatment, the MCO paid an extra $686,868! The authors concluded:
Splitting psychotherapy and pharmacotherapy is a practice and point of view that has in effect been legislated without evidence...This study contradicts the pervasively held belief that split treatment is more cost-effective.
In fact, these data indicate that integrated treatment provided by a psychiatrist is the preferred theoretical (biopsychosocial) and economic model. However, there are no studies comparing the therapeutic outcomes of integrated versus split treatment. There is an urgent need for studies in this area.
In 1980, the American Psychiatric Association attempted to clarify split treatment relationships and described three models. In the consultative model, the psychiatrist provides a limited consultation but no care. In the private practice collaborative model, responsibility is shared equally. However, in fact the psychiatrist carries the greater liability risk because they are deemed the head of the team by the legal system and have deeper pockets. In the supervisory model, most often seen in clinics, the psychiatrist is responsible for the initial diagnosis, formulation of the treatment plan, and for supervising, directing and monitoring all aspects of the therapist's work.
Collaboration between disciplines has many advantages for the patient and the collaborators. The patient receives greater amounts of time and expertise, which may lead to better adherence to medications. Collaboration provides an invaluable opportunity for professional and emotional support of each other on an ongoing basis, especially in times when the patient is in crisis or when treatment has a disastrous outcome such as a suicide.
Unfortunately, therapists and psychiatrists often do not take the additional time to interact regularly and instead work on parallel tracks. Further, interdisciplinary competition, whether conscious or not, allows for the undermining of each other's work or working at cross purposes and lends itself to splitting by the patient. To avoid failure, the therapist and the psychiatrist need to build a mutually trusting and respectful relationship, one that clearly recognizes the special and differing skills that each partner brings to the collaboration.