Dr. Richard Gottlieb has experienced the worst of times and the best of times in collaborative practice.
Also known as the “split care model” or, less formally, “doing the meds,” the approach encompasses a range of formal or informal arrangements in which a psychiatrist takes responsibility for the medication management of a patient while another health care professional conducts psychotherapy.
The worst, without question, was when he was moonlighting as a psychiatric resident at a public mental health agency and was handed a stack of pre-written scripts for medications and asked to sign his name.
When he explained that it would be inappropriate for him to order or renew medications for patients he had never evaluated, “it created an uproar,” he recalled in an interview.
“We're just trying to save you time,” he was told.
“I was expected to be a pill dispenser, really, literally signing a stamp of approval on someone else's judgment,” he said in an interview.
Fast forward to 2010.
Dr. Gottlieb is founder, owner, and clinic manager of PsycHealth, a cooperative independent practice association (IPA) in Phoenix, where he conducts diagnostic interviews with patients that draw on his training both as a psychiatrist and a psychoanalysis-trained psychologist.
Although he sees some patients on an ongoing basis for psychoanalysis, he directs most to colleagues with counseling skills best suited for each patient's needs, whether that might be a child psychiatrist, neuropsychologist, or a master's level counselor adept in cognitive-behavioral therapy (CBT).
He maintains responsibility for the patients' medications and overall progress, but otherwise acts as a “casting director,” matching patients to the “right people with the right personalities and the right skill sets”–predominantly within the IPA.
The group shares leased office space and secretarial services, but each professional operates an independent solo practice–with no strings attached.
If he feels that a patient would be best served by a clinician with a psychotherapeutic orientation not found within the IPA, Dr. Gottlieb said he has no qualms about referring outside the group.
The IPA designed by Dr. Gottlieb “tries to pull together the benefits” of other models, bridging a voluntary integration of skills and resources with the autonomy intrinsic to a fulfilling psychiatric practice, he said.
Controversial to its core, collaborative practice between psychiatrists and other mental health professionals appears to be on the rise, driven by economic pressures of managed care.
A recent study tracked psychiatric patient office visits between 1996 and 2005, documenting a 35% reduction in psychotherapy-dominant appointments, from 44.4% to 28.9% (Arch. Gen. Psychiatry 2008;65:952–70).
The number of psychiatrists who said they provided at least 30 minutes of psychotherapy during all patient visits declined to 10.8% in 2004–2005, from 19.1% in 1996.
(Psychotherapeutic visits were statistically more common among self-pay patients, white patients, older patients, and patients in the Northeast region of the United States.)
The numbers represented a sharper decline in psychotherapeutic visits to psychiatrists than was seen during the late 1980s and early 1990s, and likely reflect basic arithmetic in a managed care world, said several clinicians who were interviewed for this story. A 50-minute visit for psychotherapy cannot match the reimbursement for four medication management visits during the same hour.
From their point of view, managed care systems would rather pay the lower reimbursement rates charged by non-MD mental health professionals for ongoing psychotherapy visits, reserving payments to psychiatrists for brief medication management visits that other therapists cannot provide.
In another development, psychiatry's rich history of psychoanalytic therapy seems to be giving way in academic training to “evidence-based” psychopharmacology and CBT, approaches that are easier to assess in randomized trials than the slow unfolding of the unconscious through talk therapy.
Other forms of psychotherapy, including CBT, supportive or solution-focused therapy, or family therapy, are practiced by many mental health professionals, from psychologists and master's-level social workers and marriage and family therapists.
The APA Commission on Psychotherapy by Psychiatrists has voiced concern that in residency programs, fewer senior psychiatrists and mentors model and emphasize psychotherapy, and a newly released study appears to back up that belief.
Among 249 psychiatric residents from 15 training programs in the United States, 28% felt that not enough time and resources were devoted to psychotherapy, and a third did not believe psychotherapy training was fully supported by “key” leaders in their departments (Acad. Psychiatry 2010;34:13–20).
“Changes in practice patterns are affected by socioeconomic forces, the insurance industry, and pharmaceutical companies, all of which conspire to create specialization,” Dr. Gottlieb said.
Although he pursued doctoral-level psychoanalytic training, which he feels helps him understand the epistemology of belief systems that influence his patients' illnesses, “it's very hard to see that level of investment is going to pay off in the long-run in today's climate,” he said.