Efforts to increase the cost-effectiveness of public mental health
systems are hindered by inadequate information about the determinants of
use and cost. This paper reviews empirical research and theory suggesting
that costs in the public health system are affected more by the disruptive
behavior of persons with severe mental illness than by their age, sex,
race, and diagnosis, which have been the focus of most economic studies.
The author proposes modifications of traditional theories of health service
use to explicitly account for the role of disruptive behavior in
determining public mental health system costs. He describes a help-seeking
pathway in the public mental health system in which the decision to seek
treatment is initiated not by the mentally ill person but by others
affected by the person's disruptive behavior. This "other-determined"
pathway into treatment is contrasted with the self-determined pathway in
which an individual with distressing symptoms makes a rational choice to
seek help. Empirical research consistent with the other-determined
perspective will help target clinical interventions and system reforms to
the factors responsible for high-cost mental health care and will improve
the ability to predict resource use from observable clinical
characteristics of consumers.