Book Review

Privatization and Mental Health Care: A Fragile Balance

N Engl J Med 1994; 330:580-581February 24, 1994

Article

Privatization and Mental Health Care: A Fragile Balance
By Robert A. Dorwart and Sherrie S. Epstein. 184 pp. Westport, Conn., Auburn House, 1993. $45. ISBN: 0-86569-002-2

In this monograph, two policy analysts from the John F. Kennedy School of Government at Harvard University examine the role of the private sector in the provision of mental health care in the United States, from the earliest private asylums to today's managed-care systems. The book has three sections. The first presents the history and evolution of mental health services. The second summarizes the results of three national surveys carried out in 1988 and 1989, which collected data on populations served and services offered from administrators of psychiatric hospitals, psychiatrists, and directors of community mental health centers. The third provides a detailed description of the development of the Cambridge-Somerville Mental Health Center, followed by a discussion of future directions in mental health policy.

The meat of the book is in its organizing concepts and the relatively recent survey data it presents. The authors observe that mental illnesses can be viewed in several ways: as medical conditions requiring treatment; as disabilities calling for protection, assistance, rehabilitation, or social support; and sometimes as the cause of behavior requiring social control or legal sanctions. Thus, mental health care cannot be planned independently but must be responsive to changes in general health care policy, social-service systems, and the law. Moreover, the systematic integration of acute and long-term care, physical and mental health care, and medical and social services is necessary to avoid gaps and inefficiency in the provision of care. Privatization has winners and losers; for example, the presence of several competing private hospitals in a region facilitates access to care and the provision of a wide range of special services for insured patients but decreases access for the uninsured. Public institutions, although less likely to develop new services, may be more likely to innovate for the sake of economic efficiency or better management of severe and chronic illness.

There are a few weaknesses worth mentioning. Regression models based on survey data are central to the authors' arguments but are not actually displayed in the book. The uniqueness of the circumstances and people involved in the story of the Cambridge-Somerville Mental Health Center is insufficiently emphasized. The systemic problems associated with coexisting medical conditions and organic mental disorders are scarcely mentioned, which is somewhat surprising given the controversy in Massachusetts over the mental health system's role in the care of patients with dementia and the widespread practice of rigidly separating medical and mental health budgets in managed-care plans.

Although tradition has kept mental health care out of the mainstream of medicine, many policy issues in the care of the mentally ill are broadly relevant to the care of populations with other chronic disorders that involve mental or behavioral disabilities. Dementia, AIDS, brain injuries, and developmental disabilities all require flexible and integrated systems of care. Those contemplating the options for health care reform may find this book worthwhile reading.

Barry S. Fogel, M.D.
Brown University, Providence, RI 02912