For several decades, the search for alternatives to inpatient care has claimed the attention of mental health researchers and policy makers. The cost of care in a high-tech, 21st century hospital and the reluctance of payers to underwrite treatment that may not be necessary or effective have resulted in the "logic" of the briefest possible hospital stay, even for medical-surgical patients. In the Open Forum in this issue, Ira D. Glick, M.D., and colleagues argue that ultrashort stays for psychiatric inpatients may do more harm than good by diminishing opportunities for a sustained recovery and eroding the therapeutic alliance with patients and families. In the absence of an evidence base on the outcomes of ultrashort stays—and as the nation implements health care reform—clinicians have an ethical obligation to promote what they consider to be best practice, the authors note. They outline a three-phase model of inpatient care, with specific principles to guide length-of-stay decisions and requirements for staffing. "Our model is not new or revolutionary. … However, it is our effort to address a problem that is vexing and enduring" (page 206). In Taking Issue, Howard H. Goldman, M.D., Ph.D., highlights the problem's enduring nature, the troubling role that confinement continues to play in inpatient care, and the lack of evidence to guide policy and practice in offering alternatives to hospital care (page 117). Provision of a range of community-based services to avert the need for inpatient care is a much-desired alternative. In an analysis of Medicaid claims over three years for adults with a mental disorder, Tanya Nicole Wancheck, Ph.D., J.D., and colleagues found that greater use of community-based services, but not a greater variety of available services, was associated with fewer inpatient days (page 194). The closure of a large tertiary psychiatric hospital in Vancouver provided James D. Livingston, Ph.D., and colleagues with an opportunity to examine whether careful policy implementation could prevent discharged long-term patients from ending up in other institutional sectors, such as correctional facilities, general hospitals, and mental health boarding homes (page 200).

Federal Employee Health Benefit (FEHB) plans are important data sources for researchers who wish to predict the effects of the Federal Mental Health Parity Act of 2008. Beginning in 2001, FEHB plans were mandated to provide parity coverage to federal workers in need of mental health and substance abuse treatment. Previous research on use of mental health care in FEHB plans has generally allayed fears of rising costs. In this issue Vanessa Azzone, Ph.D., and colleagues report their study of whether the same holds true for substance abuse treatment. The authors compared spending and utilization data for two-year periods pre- and postparity for continuously enrolled FEHB beneficiaries and beneficiaries in a matched set of nonparity plans. They found that for FEHB beneficiaries who used substance abuse treatment, out-of-pocket spending declined significantly compared with nonparity plans, whereas changes in total spending per user did not differ significantly between plans. The authors conclude that mandated parity coverage improved insurance protection for those who needed substance abuse treatment, but it had little impact on utilization, costs for plans, or quality of care (page 129).

ESEMeD (European Study of the Epidemiology of Mental Disorders) was a general population survey (2001—2003) of noninstitutionalized adults in six European countries: Belgium, France, Germany, Italy, the Netherlands, and Spain. Differences between countries in prevalence rates and service use, as well as key variations in mental health systems and policies, have permitted researchers to examine a range of hypotheses. Two studies in this issue looked at factors associated with receipt of care—whether from psychiatrists or nonpsychiatrists or in primary or specialized settings. Anne Dezetter, M.Sc., and colleagues found that although the characteristics of a country's mental health system and culture, such as gatekeeping and reimbursement policies and interest in particular forms of therapy, played a role in choice of psychiatrist or nonpsychiatrist provider, the data suggested no simple model of associations (page 143). Andrea Gabilondo, M.D., and a research group in Spain found that among respondents in that country who had severe past-year depression, 31% used no services. For a third of those with depression, treatment was provided in primary care. Only a third of respondents who used any services received adequate depression treatment (page 152).