The industrialization of American psychiatry

Physician surpluses and escalating medical care costs have fostered an alliance among government, corporate America, and health insurers that has inspired medicine's industrialization. These same forces will transform psychiatry into an industry where prospective payment, automation, salaried employment, and central control of clinical activities threaten to become the dominant form of medical practice. Emerging trends suggest that both patients and health professionals will gravitate to various forms of alternative provider organizations in an effort to shield themselves from the economic uncertainties of seeking and providing care. The chronically mentally ill and others requiring extensive treatment risk exclusion from this new system, where cost consciousness may supplant compassion.     

Twentieth-century developments in American psychiatry

This article traces the development of psychiatric services from their institutional base at the turn of the century to the enactment of the Community Mental Health Center Act of 1963. Many perceived this legislation, which brought about community based but federally funded psychiatric care, as a radical departure from existing trends; indeed, President John F. Kennedy introduced it as a bold new approach. In fact, it represented the culmination of a slow, gradual evolutionary development. This article identifies the concepts underlying community psychiatric services and their programmatic elements and specifies their time of origin. The author concludes that while the current federal initiative in community psychiatric care (e.g., CHHCs) may be in jeopardy, its evolutionary nature ensures its continuance in one manner or another.     

Peer review and PSRO in American psychiatry

The past 5 years have provided major pressures for and development in the varied areas of peer review of medical services. Organized psychiatry's activities on the national and local levels have been vigorous and responsive. The author traces the development of the mandated, professional and third party payer forms of peer review and the mechanisms and requirements within these programs. The specific programs and projects within the American Psychiatric Association and it's district affilates are also reviewed.This paper was presented at the Ninth Biennial Divisional Meeting, Area-II Council, American Psychiatric Association, New York, Nov. 7, 1976.     

Big pharma and health care: unsolvable conflict of interests between private enterprise and public health

A landmark paper on Game Theory showed that individual maximization of profit necessarily endangers the public good, and since the problem has no technical solution, "it requires a fundamental extension in morality" (1). We propose here that public health, as a public good, now emerges as a grave example of this problem. Recent events and reports increasingly suggest misalignment between the interests of the pharmaceutical industry and those of public health. Johnson & Johnson illegally and effectively promoted Propulsid off-label for children despite internal company documents raising safety concerns. Death in drug trial has been described as a "trade secret." On Vioxx, Topol wrote: "Sadly, it is clear that Merck's commercial interest exceeded its concern about the drug's toxicity" (2). More and more concerns are raised by scholars and major journal editors about the type and the quality of published evidence, often biased towards efficacy of new products. The industry, funding over 80% of trials, sets up a research agenda guided more by marketing than by clinical considerations. Smart statistical and epidemiological tactics help obtain the desired results. Budget for marketing is by far greater than for research. Massive advertising to physicians and to the public gets increasingly sophisticated: ghost writing, professional guidelines, targeting of consumer groups and manipulating media for disease mongering. Pervasive lobbying and political ties limit the independence of regulatory bodies. Obligation to shareholders overriding public health considerations is not unique to the pharmaceutical industry. The chemical, tobacco and food industries share similar tactics: proclaiming doubts about safety issues, buying researchers, infiltrating universities, boards, media and legislative agencies. By contrast, powerful and cheap health promoting activities, poorly supported by industry because they are too cheap and not patented, are markedly underutilized: technologies for changing behavior (e.g., cardiac rehabilitation), palliative care and use of old, effective and safe drugs - all could benefit from industry's tools of marketing and quality. As those most affected are the sick, the poor and the least educated, free market successes appear to pose unsolvable challenges to social justice in public health.     

Turning points in twentieth-century American psychiatry

The author examines four major turning points in twentieth-century American psychiatry, emphasizing the movement during the post-World War II period toward a psychotherapeutic/psychoanalytic approach and the emergence of biological psychiatry, neuroscience, and logical positivism during the 1970s and 1980s. He discusses the impact of Adolf Meyer during the mid-twentieth century and his ongoing influence. The final turning point involves a prediction of a late twentieth-century change, including new directions in nosology, emphasis on combined pharmacotherapeutic/psychotherapeutic treatments, efforts to create alternatives to full inpatient care, better outcome data for psychiatric treatments, and beginning resolution of major boundary problems of current practice.