Integrated Treatment Approaches

To the Editor: Drs. Szigethy et al. presented an interesting clinical case conference of an adolescent girl who, after a neck injury, developed neck dystonia (torticollis), pain, and depression. She was treated for 6 weeks as an orthopedic inpatient with an integrated longitudinal medical-surgical and psychiatric approach. After discharge, she had psychiatric follow-up. Treatment was successful. The authors presented this case as an example of what psychiatry consultation services can offer, indicating that current managed care systems often carve out psychiatric services, not allowing the type of psychiatric approach used in this case.

I would like to present another pole of the managed care issue using this case. It is clear from this case report, although not presented as such, that this patient had chronic neck pain and was a chronic pain patient. Multidisciplinary pain facilities have been shown in a number of meta-analyses to be effective in treatment for a number of outcome variables, such as less pain, greater function, and return to work (1–3). These meta-analyses have even been critically reviewed and found to be of good quality (4). It is interesting that referral to a multidisciplinary pain facility, however, was not considered, in spite of the fact that nonintegrated treatment of this patient had previously failed. The kind of treatments (physical therapy, counseling, psychiatry, rehabilitation, etc.) provided to this patient are usually available to patients at multidisciplinary facilities in an integrated fashion. One could then argue that a referral should have been considered.

There are two possible reasons why pain facility treatment was not considered. First, the orthopedic attending physician either did not know or did not believe that treatment in a multidisciplinary pain facility could have been of value. In this case, consultation-liaison psychiatry should have made such a recommendation. Second, the patient’s insurance may not have covered such treatment. Such a situation would have then forced the orthopedic attending physician to proceed with alternative treatment. This second scenario again would speak to the issue of managed care and the consequences of such a system.