MENTAL

HEALTH

Mental BY

DELIVERY:

Health

BORIS

M.

Am J Psychiatry

DISCUSSION

Care

ASTRACHAN,

Delivery

Systems:

PAPERS by Lebensohn, 0km, Sharfstein, and Morrill taken together present an overview of the treatment systems in which the work ofour profession is performed. Much has been made of claims of fragmented on nonexistent delivery systems, but these papens demonstrate that within a number ofdiffenent sectons, patients are receiving concerned clinical care. In all of the papers, the medical roots of psychiatry are evident and the goals of practice are emphasized: to prevent disease and disability when the knowledge base is adequate; to treat or to consult as to treatment in the face of disease or disorder; to cure when possible, to care always; and to identify disability and through the use of psychosocial interventions to restone functioning. Psychiatry is represented as a bridging discipline, with important concerns about physical as well as mental health, and with required interaction with segments of the human services and social welfare systems. The four treatment systems cleanly differ in the extent to which they encompass and/on interact with social welfare systems. To some extent, this reflects the nature of the patient population with whom each

The about significant

is most

concerned.

private mental health cane system the efforts of the individual practitioner. extent,

changes

in insurance

practices

revolves To

a

have

democratized access to private cane. Currently services in this sector are available and used by members of the working class as well as the more affluent. An organized treatment system that integrates inpatient and outpatient activities is not required; as Lebensohn notes, the individual practitioner can provide for continuity of care. In this sector the greatest proportion of the practitioner’s time is spent in providing direct clinical service. The great strength of this system is paradoxically its most serious weakness. The usual form of practice is that of the isolated individual clinician responsible for and to his patients. Individuals with complex medicalpsychiatric-social problems demand much time and assistance just to provide them with adequate entry into cane. This is particularly true for those who are both fiscally deprived and psychologically disabled. These individuals are not well represented among patients in the private sector. 0km speaks clearly for the needs of the destitute

Dr. Astrachan is Professor, Department sity School of Medicine, 34 Park St., 1366

November

/978

Discussion

M.D.

THE

system

135:1/,

of Psychiatry, Yale UniverNew Haven, Conn. 06519.

0002-953X/78/OOl

l-1366$0.35

©

1978

severely those

mentally receiving

ill.

The

services

state

from

hospital

it have

system

often

been

and deval-

ued by society and their requirements neglected. 0km clearly points to our responsibility to provide for the chronically mentally disabled. He identifies not only the importance of medical and rehabilitative forms of care but also the social welfare needs of this patient population. Within community mental health centers, clinical and social welfare goals have at times become confused. Sharfstein articulates the differing goals and processes in human services and in clinical settings and raises questions about the direction in which the CMHC movement will progress. At one point it had been hoped that combining clinical and social welfare services would in fact provide for more comprehensive care for individuals in greatest need. As Sharfstein notes, this usually has not happened within cornmunity mental health centers and too frequently the chronically ill have not been served. Mornill identifies an important role for psychiatry in multidisciplinary group practices or in HMOs. The psychiatrist consults to other practitioners (particularly to generalists) and to other health professionals, assisting them in the management of relatively routine emotional

problems

complications also available cases directly. which

and

with

some

of

the

emotional

of physical illness. The practitioner is to deal with the more difficult clinical The health center serves as a locus in

medical

care

is emphasized

but

in

which

con-

nections are directly available to mental health, rehabihitative, and social welfare systems. In speaking to the future of health delivery systems, all of the authors identify the importance of fiscal considerations in defining organizational structures. As 0km notes, our patients have been discriminated against in provisions of Medicare and Medicaid and if such discrimination persists and is reified in whatever form of national health insurance is enacted, our patients will suffer and our treatment systems will be incompetent

We tems

to

do any

not

make

up

anticipate

single

for

that

monolithic

that

out one

suffering.

of these will

be

differing formed.

sysHow-

ever, legislated regulatory forces probably will increasingly insist upon better coordination of governmentally funded services. In particular, voluntary hospital, state hospital, and community mental health center services can be expected to be required to complement rather than compete with one another. To some extent, we already see general hospital services interacting with government-sponsored ones, either American

Psychiatric

Association

Am J Psychiatry

directly ferred with

/35:1/,

November

as part of CMHCs setting for the initial insurance

/978

or, increasingly, hospital treatment

BORIS

as a preof those

coverage.

Currently, each of the described treatment systems has its own unique advantages and limitations. Each performs some aspects of patient cane most efficiently. The problem for psychiatry as well as for the rest of medicine is how to stimulate organizational systems to provide excellent care for individual patients without

doing

injury

to

the

necessary

plunalism

M.

ASTRACHAN

in

our

care-

giving treatment system. A major dilemma that is still only poorly addressed, even in theory, is how best to coordinate multiple service needs for emotionally, financially, and educationally disadvantaged patients. The failures of total institutions are well known. They are, however, matched by our inability to assist the severely disabled with medical, rehabilitative, housing, and financial resources.

1367

Mental health care delivery systems: discussion.

MENTAL HEALTH Mental BY DELIVERY: Health BORIS M. Am J Psychiatry DISCUSSION Care ASTRACHAN, Delivery Systems: PAPERS by Lebensohn, 0km,...
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