The past two decades have seen a shift in the predominant model by which public mental health services are funded, organized, and delivered. Medicaid now funds more than half of public mental health services administered by the states, and the proportion is expected to reach two-thirds by 2017. In this issue of Psychiatric Services, Jeffrey A. Buck, Ph.D., describes how the community model, in which planning and administration of services is centered in a state mental health authority, is being displaced by a model associated with state Medicaid programs. In the newer model, the approach to the organization and delivery of services is similar to that of a private-sector health plan. Dr. Buck discusses the changes that are likely to occur as administrators, policy makers, and interest groups increasingly understand the implications of the health plan model of state-based public mental health services. He warns that efforts to preserve organizational structures and practices that are more in line with the community model may result in a system in which major policy decisions are made by government agencies that have limited expertise in mental health issues and services (see page 969).

Since its enactment in 1974, the Employee Retirement Income Security Act (ERISA) has virtually prevented successful litigation against administrators of health plans that fall within its mandate. The act has preempted state laws that conflicted with ERISA, making it difficult for patients and their families to recover damages associated with utilization review decisions of managed care companies. However, a recent decision by the U.S. Court of Appeals for the Second Circuit—Cicio v. Does—may bring about a means of redress in such situations. In this month's Law & Psychiatry column, John Petrila, J.D., LL.M., discusses the decision and its implications. As Dr. Petrila explains, Cicio is one of the first decisions to hold explicitly that prospective utilization review decisions may be characterized as medical rather than administrative, making it possible for them to proceed as malpractice claims in state courts. The decision constitutes one of the most significant legal challenges to third-party reviews of medical necessity since the beginning of the managed care era (see page 945).

The use of seclusion and restraint in psychiatric facilities, particularly among children and adolescents, has recently been the subject of heightened legislative and media attention. In this issue, medical student Abigail Donovan, B.S., and her coauthors present the results of a study of seclusion and restraint among 442 psychiatrically hospitalized youths at a children's hospital in Connecticut (page 987). These authors identified characteristics of the use of seclusion and restraint in the sample and analyzed trends in use since the implementation of relevant federal regulations in 1999 as well as an institutional performance improvement program, which the same authors describe separately in this month's Child & Adolescent Psychiatry column (page 958). Over the two-year study period, the total number of episodes of seclusion and restraint at the hospital decreased by 26 percent, and the cumulative duration of episodes decreased by 38 percent. The authors highlight the need to identify effective staff training programs to help individual institutions meet their goals of reducing the use of seclusion and restraint.

Although telepsychiatry has been in existence for more than 40 years, little research has focused specifically on its cost-effectiveness. In this issue Steven E. Hyler, M.D., and Dinu P. Gangure, M.D., review 12 studies published since 1995 on the costs of telepsychiatry projects implemented in the United States and other countries and describe a variety of methods that have been used to calculate the costs of telepsychiatry. The authors conclude that seven of the 12 studies showed that telepsychiatry is financially viable in selected settings. However, future research that attempts to determine whether telepsychiatry costs more or less than in-person psychiatry must take many factors and perspectives into account (see page 976).

A study in Washington State found that high service users expressed substantial interest in creating psychiatric advanced directives, especially when case managers supported the idea (see page 981).

Long-term use of benzodiazepines among nearly 2,500 Medicaid patients did not lead to notable dose escalation (see page 1006).

The book review section highlights three books by clients writing about the role of psychiatry in healing and recovery (see page 1044).