The practice of psychiatry has been changing. Fifty years ago, psychiatrists mostly practiced psychotherapy and rarely prescribed medication, as there was almost no psychotropic medication available and psychoanalysis dominated the field of psychiatry. Thirty years ago, some psychiatrists were practicing psychotherapy exclusively, whereas other psychiatrists were combining psychotherapy and pharmacotherapy, providing both modalities themselves. EHiring the past two decades, most psychiatrists gradually relegated the practice of psychotherapy to nonphysidan clinicians, or therapists. Currently, most psychiatrists (at least two-thirds according to some surveys1'2), primary care physicians, and even some psychoanalysts3-4 practice either combined pharmacotherapy and psychotherapy or, more frequently, split treatment.
Split treatment, which is also called collaborative, combined, consultative, divided, or fragmented treatment or medication backup, involves the prescription of psychoactive medication by a psychiatrist or other physician with the remainder of the therapy conducted by a therapist who is usually not a physician.5
The alleged reasons for the expansion of this practice have been mostly economic ones and the so-called industrialization of American psychiatry.6 Presumably, a medication review conducted by a psychiatrist combined with a psychotherapy session conducted by a therapist is less expensive than the integrated treatment in which one psychiatrist provides both pharmacotherapy and psychotherapy. However, the difference in the costs of these treatment practices has not been well studied. Recently, two articles7-8 challenged the assumption that split treatment is less expensive than integrated treatment. Thus, the economic advantage of split treatment remains unclear. In addition, the theoretical reasons may support using the integrated treatment.8 However, split treatment is deeply rooted and widely practiced in American psychiatry, especially in places such as community mental health centers.
Psychiatrists and organized psychiatry have been ambivalent about this frequently ambiguous practice for a long time.9 The American Psychiatric Association (APA) has issued guidelines regarding the relationship between the psychiatrist and the therapist10 and regarding psychiatrists' signatures.11 However, these guidelines have not been revised for some time. The APA has also indirectly reaffirmed its support of integrated treatment by issuing the position statement on medical psychotherapy.12 The practice of split treatment remains fairly unregulated, with ambiguous responsibilities, understudied, and unappreciated.13 Also, split treatment has, at times, been resented by psychiatrists, therapists, or both. It has been misconstrued, misrepresented, and misunderstood and, as a result, poorly practiced. There are only a few comprehensive texts that focus on this practice.14,35
Nevertheless, the necessity of integrating pharmacotherapy and psychotherapy for various mental disorders is becoming more obvious.16"18 As Michels4 pointed out:
The central question is not whether a treatment is psychological or biological; it is whether it helps. Similarly, a combined therapy, whether it be two drugs or two interpretations or one of each, is neither inherently better nor worse, although careful study may show it to be either. Patients are well advised to seek out therapists who worship neither the mind nor the brain, but rather the most effective intervention available.
The increasing pressure to integrate pharmacotherapy and psychotherapy in the form of split treatment comes mainly from managed care organizations and third-party payers. For this reason, split treatment will probably remain a dominant practice of providing combined pharmacotherapy and psychotherapy to patients.
The five articles in this issue of Psychiatric Annals review the most pertinent issues of split treatment. The first article, by Richard Balon, MD, reviews the positive and negative aspects of split treatment and, overall, provides a useful introduction to the topic.
The second article, by JoAnn E. Macbeth, JD, summarizes the most troublesome and, for the psychiatrist, disquieting issue - the legal aspects of split treatment. The article also provides guidance for auditing and managing one's risks when practicing split treatment. She suggests that psychiatrists should familiarize themselves with the operations, routines, and personnel of all practice settings and that considerations should be given to weeding out the most problematic practice sites (and collaborators). Also, a careful coordination with therapists who have greater access to patients is critical to guide the conduct of everyone involved in the practice of split treatment.
The third article, by Jeremy A. Lazarus, MD, discusses the ethics of split treatment. Dr. Lazarus outlines the American Medical Association's and the APA's ethical principles and discusses potential ethical conflicts of split treatment. Examples of such conflicts are related to state licensing laws, competency questions, being used as a figurehead, delegation of medical judgment, and financial arrangements.
The fourth article, by Kenneth R. Silk, MD, provides an excellent summary of and guide to split treatment for patients with personality disorders. This is probably the most challenging population of patients with a special propensity to turn split treatment into "really split treatment." Anyone who is prescribing medication for patients with personality disorders (and not only for them) who are involved in psychotherapy with a therapist should incorporate the seven "understandings" suggested by Dr. Silk: (1) understanding the relationship between the therapist and the prescriber; (2) understanding the meaning of the medication to the therapist and the prescriber; (3) understanding the meaning of the medication to the patient; (4) understanding and conveying to both the therapist and the patient the limitation of the effectiveness of the medication; (5) understanding at the outset of the prescribing process the role of the medication in the overall treatment and the treatment plan for the patient; (6) understanding and conveying to the therapist and the patient the potential lethality of the medication; and (7) understanding the relationship of interpersonal crises and affective storms to the timing of medication initiation or dosage change.
Finally, Joseph A. Himle, PhD, provides the nonphysician clinician's perspective of split treatment. This interesting and refreshing article informs psychiatrists about what motivates therapists to seek split treatment, what therapists expect from them, what they should expect from therapists, and what the shared problems and rewards are of split treatment.
It is our hope that these five articles will help psychiatrists and therapists navigate a bit easier through the rough waters of split treatment. Our ultimate goal is to improve the split treatment for the benefit of our patients.
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