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Book Review   |    
David L. Cutler
Psychiatric Services 2007; doi: 10.1176/appi.ps.58.7.1015
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edited by R. Paul Olson; Springfield, Illinois, Charles C Thomas Publisher, 2006, 381 pages, $89.95

Dr. Cutler is medical director of the Mental Health and Addictions Services Division, Multnomah County Department of Human Services, Portland, Oregon.

This ambitious work covers a topic that has been neglected but that sorely needs attention in the field of mental health. How are we to know if we are on the right track for sorting out the complexities of issues related to mental health systems and mental illness service provision? Without some comparative studies on ideal international models it will be difficult to shed some light on the best ways to care for populations of persons who have or who are at risk of having mental illnesses. Certainly for the most severe mental illnesses in developed countries the morbidity and mortality are similar, and the loss to society is obvious.

Yet the authors note that there are significant treatment gaps among the selected developed countries, and they identify three systems factors underlying these differences. They are a lack of policy on mental health and neurological health, the failure of professionals in the fields of mental health and neurology to engage in the economic aspects of the health and social policy, and the lack of preparation and training for leadership in policy development and dialogue.

The authors also correctly point out the lack of comparative literature regarding international systems. To remedy this lack of a comparison condition they chose four countries to write about. They set out to describe each within a consistent framework, then finish with two chapters discussing the similarities and differences among them, look at unmet needs in the various countries, and finally make recommendations for reforming the American system.

All of this is exemplary given the reluctance of these various counties to compare themselves to one another for fear of not looking good.

Many failures in this volume keep the editors from accomplishing what they have set out to do. To begin with, the complexity of the task without real comparative data is enormous. It would be nice if there were some international quality standards to use as a measuring device to overlay on each system. The editors don't even attempt such a thing. Second, the descriptions of the countries often do not follow the consistent format they seem to have adopted, so the reader is left wondering what is actually being compared. The editors start with giving a three-part structure to the chapters, but each author seems to decide independently whether to use the categories. Part 1 is supposed to be description, Part 2 is evaluation, and Part 3 is recommendations. Only two of the chapters adhere to this format.

Also why did the editors choose to focus on these particular countries? They are all in northern Europe or North America, and, except for Norway, whenever the authors make comparisons to the United States, they usually use Canada and the United Kingdom. Unfortunately, pat arguments already discount these systems, which may not be accurate but are widely accepted as justification to avoid socialized medicine. Norway is a lovely country, but it is not on the minds of Americans. Why not pick Italy, Germany, and France, for example, which are all in Europe, all quite different from the United States, and none of which are commonly compared to the United States? Or the editors could have looked at other Western-style countries such as Japan or Australia. Perhaps the mental health community would be more likely to pay attention.

In all four countries the book considers, most people who need services for a mental illness don't get them. That amounts to 60%—75% of those thought to suffer from some sort of psychological distress. This finding is consistent despite the enormous differences among the four in health care system financing. In fact here the United States looks pretty good at 60% versus 75% for Norway. However, what this really means is unclear, because the figures used are based on different methods of estimating prevalence in the various countries. It leaves one wondering if there is much use in even bothering to make the comparisons.

I did appreciate the section in chapter 6 comparing fair financing mechanisms in the four countries. The authors' rankings put Britain and Norway at the top of the list, then Canada. (The United States is way down the list.) All have single-payer systems—paid for by payroll taxes in Norway and Canada and general taxation in the United Kingdom. The United States has a hodgepodge of revenue schemes, predominantly private sector but also public and private copays and deductibles that place a significant burden on the individual. The World Health Organization ranked 53 countries, which include nearly the entire developed world, higher than the United States in fairness. This is a sad commentary on the state of heath care financing in America.

At the turn of the last century, Upton Sinclair wrote The Jungle, which is about the meatpacking industry in Chicago, and it changed the course of history. Perhaps this volume will influence someone in high places to remedy the situation in mental health care financing and systems organization in this country or others. But I doubt if we have another The Jungle here, unless one considers having to navigate through one of these "jungle-like systems" that contain more barriers than pathways on the quest for some treatment. The authors do deserve much credit for taking on such a task.

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