Steven S. Sharfstein

Neuropsychiatric Aspects of Acquired Immune Deficiency Syndrome

Acquired Immune Deficiency Syndrome is a newly described, highly virulent, idiopathic syndrome characterized by lymphocyte dysfunction, multiple opportunistic infections and lymphoma, which primarily affects previously healthy, promiscuous homosexual males. Dementia and delirium due to infection and/or disseminated lymphoma may frequently occur in these patients, especially as the illness progresses. Consulting and liaison psychiatrists must be particularly alert to the possibility of organicity in these patients, in addition to the psychological distress caused by the AIDS syndrome itself.

Will community mental health survive in the 1980s

There are now 675 funded community mental health centers (CMHCs), covering almost half the country. Many of these programs were funded in the social optimism of the 1960s and now face a crisis of purpose and funding. Additional requirements imposed by the 1975 amendments to the CMHC act are not matched by additional fiscal resources. Programs are graduating from the federal grant to find that other sources of funds, especially third-party insurance funds, are not replacing the lost federal dollars. There is evidence that CMHCs are changing from clinical/medical programs to social programs; the numbers of persons seeking care who have diagnosable mental illness and of psychiatrists and nurses relative to other staff are decreasing. The issue is whether CMHCs as a national program are headed for extinction or whether there will be new vitality for this program into the 1980s.

Reductions in insurance for mental disorders: adverse selection, moral hazard, and consumer demand.

Coverage for mental illness has been sharply reduced in the Federal Employees Health Benefits Program (FEHBP), especially in the largest of the participating plans, the Blue Cross and Blue Shield plan. The authors examine the role of adverse selection (accumulation of high-risk consumers within a given plan), moral hazard (demand for services for illness depending in part on the price of the services), and lack of overt consumer demand in the current trend. They point out the critical need for psychiatry to develop more effective approaches to public education on the nature of mental illness and its treatment. If the recent major cutbacks in the FEHBP prevail, this kind of restriction is likely to become the prevailing mode of mental illness coverage under private health insurance.

Hospital Psychiatry For The Twenty-First Century

Economic policies have shaped the provision of hospital psychiatric care. The main theme of the past fifty years has been the shift from long-stay public hospitals to acute care provided in private settings. States have reduced their costs by shifting their financial burden to federal dollars and commercial insurers through managed care practices. The net result has been a reduction in, and shortage of, psychiatric beds. Positive developments include better services in the continuum of care, the subspecialization of hospital psychiatry practice, and an increasing emphasis on patient choice and recovery.

Insuring intensive psychotherapy.

Many private insurance programs that currently cover mental disorders eliminate intensive psychotherapies, including psychoanalysis, from the range of treatment options by placing restrictions on the number of visits covered. The authors examine the economics of intensive psychotherapy coverage and present data indicating that relatively few people in an insurance program with comprehensive mental health benefits use high cost forms of psychotherapy. They conclude that insurance coverage of intensive psychotherapy is feasible but suggest that further study of the goals of intensive treatment, potential demand for it, and the supply of qualified practitioners is needed.

The aftermaths of deinstitutionalization: Problems and solutions

Thousands of mentally handicapped patients released from mental hospitals are now living in a variety of community settings. Services to help them remain in community are often fragmented, uncoordinated and limited. Research and experience have highlighted the services they need. Numerous demonstrations have shown that patients can be successfully maintained in community settings. Coordinated services and fixed responsibility for each individual placed are essential.

Psychiatric consultations at the NIH

The history of the consultation-liaison psychiatry movement in America is briefly reviewed. Evaluation of a consultation-liaison program in a research hospital setting at NIH is described in the context of the historical paradigm.

Fraud and abuse in psychiatric practice

A consensus has not yet been reached on definitions of fraud and abuse, particularly the latter. Further, the terms tend to be linked routinely by federal agencies, although abuse is generally understood to relate to inappropriate and fraud to illegal practices. These definitional problems make it difficult to determine what constitutes fraudulent or abusive practice in psychiatry. The authors provide hypothetical examples relevant to psychiatry, noting that in many cases it is still impossible to determine at what point a practice becomes inappropriate or illegal. Criteria must be developed by claims review systems, ethics committees, and PSROs; all those in the mental health field should devote serious attention to these issues.

Community mental health centers: Returning to basics

Community mental health centers (CMHCs) have made a significant contribution to making mental health services available to many Americans; in 1977 they served almost two million people. External fiscal constraints and internal service and accountability requirements now test the viability of CMHCs, but the most recent extension of the law allows increased flexibility on implementation, and the Presidents Commission on Mental Health has reinforced the original purpose of CMHCs by calling for an initiative to give special attention to the needs of children and youth, the elderly, minorities, the chronically mentally ill, and other underserved populations and areas.

The Planning and Evaluation of Mental Health Services in the United States

Mental health services in the United States are delivered in a variety of settings by a variety of medical and nonmedical professionals to a wide range of patient groups. These settings have multiple funding sources, both public and private, and mental health care is delivered through the general medical system, specialty services and a range of nonmedical systems in an unplanned and uncoordinated manner.