Dr. Dewan Replies

To the Editor: The comments by Drs. Zarin and West provide an opportunity for clarifying the background and assumptions of my article. It is clear that the mental health model practiced by managed care organizations has at least two major assumptions: compared to integrated treatment provided by a psychiatrist, split treatment is at least equally effective and less expensive for treating all conditions. This is obvious from managed care’s preferential use of nonpsychiatric psychotherapists for evaluation and treatment at the initial diagnosis. As Drs. Zarin and West correctly point out, there are no data comparing outcomes under these different treatment conditions for any specific disorder. Given this lack of outcome data and assuming equivalent outcomes for split versus integrated treatment, I attempted to evaluate only the presumption that split treatment is less expensive. I first presented data in 1997 (1) showing that this is not necessarily correct and suggested that the “preference for split treatment should be reconsidered.” Goldman et al. subsequently provided utilization data in 1998 from one specific managed care organization that showed that only 12.5% of the patients received integrated treatment. The other 87.5% who received split treatment needed more sessions than the patients who received integrated treatment (26 versus 15, respectively) and had total payments of $1,854 versus $1,336. The authors did not present data on treatment outcomes but concluded that “for all its limitations, this study contradicts the pervasively held belief that split treatment is more cost-effective” (Goldman et al., 1998, p. 482, italics added). It is therefore surprising that my use of the term “cost-effective” in the title under the same limitations is labeled as “misleading” by Drs. Zarin and West. Given the consistent and continuing assumption of treatment outcomes being equal, and the many caveats enumerated in my article, the article’s title and the summary statement given are both justified.

The dangers of drawing firm conclusions regarding cost-effectiveness in the absence of outcome data, as emphasized by Drs. Zarin and West, should serve to temper the praise by Dr. Markowitz and colleagues. Although much appreciated, their praise should await the author-to-be of the more comprehensive study that all of us recognize is critically needed, one that objectively assesses a variety of treatment outcomes and cost measures.