To The Editor: Amid the rapid changes in health care, some trends are nonetheless discernible. There is movement toward primary, holistic care in which one doctor addresses all the patient's needs rather than several specialists providing care in a fragmented fashion. There is also a greater attempt toward integration of psychosocial factors in the practice of medicine. In contrast, the only mental health practice capable of providing comprehensive, holistic psychiatric care, that is, that offered by a broadly trained psychiatrist, is being dismantled and replaced by fragmented care (therapist-psychopharmacologist split) because it is putatively less expensive (+1). However, by using managed care and Medicare rates to compare the cost of integrated care provided by a psychiatrist (medication and psychotherapy) vs. split treatment (psychopharmacologist plus non-MD psychotherapist), one study found that 10 combined sessions with a psychiatrist cost $1,007, whereas split treatment (10 psychotherapy sessions/5 medication) cost $1,177 with a psychologist and $1,004 with a social worker. Similarly, 5 combined sessions cost $513 vs. split treatment (5 psychotherapy/3 medication) costs of $656 with a psychologist and $568 with a social worker (+2). One managed care company has since confirmed that combined care costs less than split treatment (+1).

There is continuing concern that psychiatrists are not learning or providing psychotherapy (+3); however, the data show that they are providing psychotherapy, either alone or as part of combined treatment (+4). To remain competitive, we felt a need to add competence in short-term therapies to psychiatrists' traditional strength in long-term therapy. Therefore, our Department of Psychiatry at the State University of New York at Syracuse developed a combined short-term psychotherapy—psychopharmacology fellowship that promotes psychiatry's unique capacity to provide integrated biopsychosocial treatment in a cost-effective and competent manner.

The Combined Short-Term Psychotherapy—Psychopharmacology Fellowship is a 1-year program with an optional second year that focuses on research. The first year includes an academic curriculum that augments an intensively supervised clinical experience (10 hours a week of brief therapy and 10 hours a week of psychopharmacology) designed to model the typical outpatient practice of the late 1990s and beyond. Sensitive to contemporary issues involving managed care, the provision of psychiatric services to the medically ill, the paucity of mental health services for the indigent and the elderly, the need for the judicious combination of the two therapies, and the medicolegal issues arising from the split-provider model, the fellowship is divided into and described as two tracks that run parallel to each other throughout the year, although a number of patients need combined treatment. The principal goal is to have the fellow attain mastery in the practice and combination of the two modalities.

The Brief Psychotherapy Track is comprised of didactic, supervisory, and clinical portions. The fellow meets for an hour each week with an instructor to discuss the didactic syllabus, which addresses in detail 1) an overview of the contemporary practice trends, 2) issues central to time-limited psychotherapy, 3) brief dynamic therapy, 4) cognitive—behavioral therapy, and 5) solution-focused therapy (+5). These particular therapies are chosen because they are commonly used, have research support for their effectiveness, and we have faculty who could teach them. Interpersonal therapy is another specific brief therapy that warrants inclusion, but we do not have the capacity to teach it well at present. For the about 10 hours of brief psychotherapy done each week, 2 hours of supervision is provided throughout the year. Supervision is focused on clinical issues, review of tapes, and occasionally direct participation in sessions. The core curriculum is enriched with special topics such as grief and loss, brief marital therapy, and brief family therapy; these have both a didactic and clinical component to them.

Additional brief therapy-related activities include team-teaching a brief therapy seminar for residents and psychology interns, observation of brief therapy sessions conducted by skilled faculty, and attendance of an off-site national conference on brief therapy.

The Psychopharmacotherapy Track also provides an equivalent didactic, supervisory, and clinical experience. In the didactic series (which is an exhaustive reading of the primary literature aimed at enunciating "evidence-based" clinical recommendations for complex patients with severe, treatment refractory disorders), the major topics covered are neuropsychiatric disorders (8 weeks), anxiety disorders (6 weeks), mood disorders (10 weeks), substance abuse disorders and pain syndromes (4 weeks), personality disorders (4 weeks), schizophrenic disorders (4 weeks), disorders in the medically ill (4 weeks), childhood disorders (4 weeks), and research methodology (2 weeks).

Besides an individual hour per week for didactic instruction, the fellow receives 1 to 2 hours of clinical supervision for the 10—15 hours per week of psychopharmacology patients. The fellow also attends an off-site psychopharmacology conference.

It must be reiterated that although the two modalities are being described separately, a great deal of effort is expended on the challenge of choosing the best treatment option (based on the literature and clinical experience) and on integrating modalities, when appropriate. Integration is emphasized even when "only" medication is being prescribed. For instance, compliance can be influenced by transference issues and by the symbolic meaning of the medication to the patient (+6); also, a psychotherapeutic intervention can often be made during a short medication follow-up visit.

The fellow is funded by converting a postgraduate year (PGY)-4 slot to a PGY-5 position. This position is supplemented by moonlighting, which is allowed for a maximum of 6 hours per week. The department allots $2,000 for conferences and $1,000 as a book stipend.

The fellow sees a wide range of patients through referrals (which are plentiful) from community therapists, primary care providers, the university hospital's inpatient unit, the three colleges in the area, and from the faculty. The fellow treats about five patients with each of the psychotherapeutic modalities and 30 patients with medications. About 75% of patients require combined treatment with medication and brief therapy. By the end of the fellowship, the fellow can provide and teach a number of specific brief psychotherapies as well as psychopharmacotherapy, singly or in combination as appropriate.

The fellow is rigorously evaluated. All therapy sessions are either audiotaped or videotaped; in select cases the supervisor sits in on sessions, for example, as a co-therapist in brief marital therapy. Besides weekly informal feedback to the fellow, a formal written report is sent to the training director every 4 months by each of the supervisors. Similarly, the program and each supervisor are evaluated by the fellow.

Current health care models emphasize primary, holistic care and cost effectiveness. For moderate-to-severe psychiatric disorders that require combined treatment with both medication and psychotherapy, the only (and therefore preferred) mental health practitioner who can provide cost-effective, holistic care is the psychiatrist (+1). Our fellowship promotes this combined expertise and was launched to make an important statement about the biopsychosocial model that the department at Syracuse believes in, and to generate excitement with a "cutting-edge" program. The Combined Short-Term Psychotherapy—Psychopharmacology Fellowship provides an elegant heuristic yet pragmatic model, a model that captures its strength from our roots in Hippocratic medicine (+7) and prepares us for the psychiatry of the future.