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"Split treatment," the practice of providing psychotherapy through a psychologist or social worker and medication through a psychiatrist, is regarded by many nonpsychiatrists as more cost-effective than integrated care from a psychiatrist alone. But a recent study by United Behavioral Health (UBH) in San Francisco published in the April 1998 issue of Psychiatric Services suggests that the opposite may be true.
Researchers from UBH as well as APA and Duke University Medical Center examined nationwide claims data on service use and costs from a large managed behavioral health care company for 1,326 patients in split treatment and 191 patients in integrated treatment for 18 months in 1996 and 1997.
They discovered that patients in integrated treatment used significantly fewer outpatient sessions and had lower costs for care than patients in split treatment-$1,300 versus $1,850, a fact that APA has long argued with lawmakers and employers.
"We've always believed, from the patient's point of view, that it is easier to work with one person rather than two for treatment," said psychiatrist William Goldman, M.D., UBH's director of research.
Goldman said UBH decided to analyze data from its own databases to find out whether the common assumption about lower cost for split treatment was accurate. Deborah Zarin, M.D., an APA deputy medical director, and Ana Suarez, both of whom are in the APA Office of Research, and Barbara Burns, Ph.D., from the Duke University Medical Center in Durham, N.C., helped analyze the data.
Results of the study indicate that patients seeing psychiatrists used therapy in an episodic way, attending several sessions and then having a break of 90 days or more, whereas those in split treatment attended more sessions and had fewer breaks. Psychiatrists providing integrated treatment may initiate medication earlier in treatment and rely on its growing effect in the psychotherapy.
At present, said Goldman, split treatment is "the rule" in the private sector, and it dominates care in all other organized care systems. "We hope this study will re-engage the field in looking at this practice," said Goldman. "We need to look at what is easier and better for patients."
In addition, he said, he hopes this study and others in the future will challenge the perception in this country that psychotherapy is not a critical part of a psychiatrists' work. Advances in pharmacotherapy and increased clinical research on the effectiveness of psychotropic medication in treating a growing number of mental disorders have reinforced the psychiatrist's role as pharmacotherapist.
"What is psychiatry?," Goldman asked. "It's not just writing prescriptions."
The first study of its kind, its results raise doubt about current practices and call for further investigation, said Goldman. He emphasized that these results must be validated and that qualitative research must be done. UBH is already designing studies to look at outcomes, he said.