This issue of Psychiatric Annals, guest edited by Richard Balon, MD, and Michelle B. Riba, MD, MS, is entitled, "Improving the Practice of Split Treatment." Reading these articles reminded me of the advantage of the format of Psychiatric Annals for the practicing clinician in that an entire issue addresses a specific topic of current clinical importance. The topic of "split treatment," "medication backup," "triangulated treatment," or "dual treatment" has become a major one in mental health care. This issue evaluates the realities sustaining this practice, its potential pitfalls for the patient and the psychiatrist, and its potential benefits.
There is no question that split treatment may be advantageous to patiente in some situations. Several psychotherapeutic approaches with documented efficacy have been developed, such as the cognitive-behavioral treatment of depression and the behavioral treatment Of obsessive-compulsive disorder, panic disorder, and phobias. Many of us who are practicing general psychiatry have not had specific training in these therapies and can aid some patients by referring them for psychotherapeutic treatment, although psychiatric treatment and medication management may also be required. Although split treatment did not begin with the appearance of managed care, it seems clear that managed care and community psychiatry multiplied the practice because of its presumed economic efficiencies.
There are also substantial potential disadvantages to split treatment. As pointed out in this issue, it is incumbent on us to maintain communication and therapeutic synergy with a cotherapist depending on the clinical needs of the patient when we engage in split treatment or medication backup. This must be done despite the difficulty and inconvenience of getting in touch, sometimes at a time of crisis, and the added time required and complexity involved. In the event of a disaster, we should know that we will be scrutinized and that liability may be daimed on the basis of the way we kept in touch with the patient's therapist and coordinated and documented our treatment (regardless of whether we were paid for it or it was appreciated). This clearly a demanding situation - and peril lies in not meeting the demand.
Everyone seems to see split treatment or medication backup as persisting. We need to pay more attention to the way we conduct it and the way we document our efforts. Perhaps protocols need to be developed that might even include some type of agreement or contract among the therapist, the psychiatrist, and the patient. I think most of us have gradually been led into this situation, as if it happened to us.
We all must be aware of the expectations and ramifications of agreeing to split treatment. It seems that a whole new treatment paradigm has materialized from several sources over the years. This paradigm has been driven by economic forces that are powerful, and it is something that we must deal with. Do we need American Psychiatric Association guidelines for split treatment or medication backup?