Taking Issue: Blaming the Wrong Villain

All the complaining about mental health managed care misses the point. I agree with Jeffrey Geller and his colleagues, in their reprinted 1998 article (page 1385), that the introduction of managed care in state mental health systems usually brings disruption and not a few unintended consequences. It's clear that pushing on the system of care at one point—say, admission to state hospitals—will result in a bulge of badly served people at another point.

James Sabin is absolutely correct in his commentary (page 1392) that managed care itself is not the villain many in our field think. In fact, one of its useful products is the aggregation of data about people with mental illnesses and the treatment they receive, which displays the gaps and failures in our treatment system. Managed care makes rationing of care obvious.

But psychiatry's focus on the inequities of managed care obscures the more fundamental issue. Our mental health system is not working for the people who most need help. More than 300,000 persons with mental illnesses are in our nation's jails and prisons—four times more than are served in state mental institutions. Ten to 15 percent of patients with depressive or psychotic disorders commit suicide. Little more than half the patients being treated for schizophrenia receive one of the newer antipsychotics. Even worse, only about half of those with schizophrenia are receiving any psychiatric services at all. Eighty-five percent of citizens with severe mental illnesses are unemployed. And the picture is no better for children and adolescents with mental illness.

Yes, we need accountability for managed care companies, especially those serving patients in the public sector. But the larger problem remains: we need basic system reform. Our mental health system was built on discrimination and perpetuates stigma. Our federal and state policies and programs do not support recovery. What consumers and families want and need is not provided. How can we ignore the magnitude of the gap between what science tells us is effective and what our system offers?

We support this dysfunctional system with billions of dollars each year. Why aren't more people with severe mental illness getting better? What will it take for us to truly prioritize the most vulnerable patients and align our systems and services with their needs? A new administration and a new Congress should take a bold look at the complex and unworkable federally supported programs that undermine recovery. True reform in our mental health system will begin by recognizing that our old structures don't fit today's realities.