Is empathy cost efficient?

In an attempt to constrain rising health-care costs, third-party payers are currently encouraging psychiatrists and other physicians to focus on the financial aspects of their treatment approaches. This paper has attempted to address the impact of this cost-efficient attitude on our empathy and by tracking the evolution of our health-care-delivery system since the turn of the century. I have described three overlapping phases: the humanist, the scientific, and the current corporate phase, and emphasized the importance or trivialization of an empathic practice-style associated with each stage. I have warned how the corporate delivery system, with its focus on cost constraints, may inhibit our capacity to be empathic by stimulating self-serving concerns about the corporation's monetary welfare and our own financial well-being. This unempathic stance may result in treatment being driven by financial factors that override clinically driven needs of the patient. At its extreme, this approach may render psychiatrists vulnerable for viewing patients as bad objects that deprive financially, and for countertransferentially retaliating against them through "warehousing" and abandonment.     

Mental Health in the Oregon Health Plan: Fragmentation or Integration?

The Oregon Health Plan was implemented in 1994 with a 50% expansion of Medicaid enrollment to include some of the working poor. Over 75% of Oregon Medicaid clients are now enrolled in health maintenance organizations (HMOs). Outpatient chemical dependency services have been capitated since May 1995. Capitated mental health services have been provided for the 25% of eligibles who live in demonstration counties since January 1995. Expansion and capitation appear to have been achieved without major trauma. More challenging has been the attempted integration of public sector behavioral health services with private sector health plans. Stakeholders interviewed for this study were especially concerned about the long-term impact on Medicaid clients with chronic mental illness. Strong leadership and clear policies regarding the mixture of public, private nonprofit, and private for profit entities are necessary if the state is to achieve its aim of integration without fragmenting a system of care for people with severe mental illness.     

Are the triptans for migraine therapy worth the cost?

The triptans represent a major advance in migraine therapy but their cost per dose greatly exceeds that of many older treatments. There is evidence that for a significant proportion of migraine patients these new drugs can show a positive cost benefit and also improve quality of life. Cost benefit would be expected to be greatest in patients with more severe migraine attacks.     

Modernizing Mental Health Services: Mission Impossible?

Managing complex change initiatives can be a risky and controversial task. Hargrove and Glidew's (1990) model of impossible jobs defines typical obstacles: constituency conflict, perceptions of client legitimacy, respect for professional authority, and the strength of the agency myth. The author uses this model to describe his experiences while implementing major changes within British Columbia's community mental health system and provincial psychiatric hospital. Coping strategies include coalition building, public education, meaningful stakeholder participation, systemic feedback, mutual aid, and staff development.     

Review: Autophagy and neurodegeneration: survival at a cost?

S. J. Cherra III, R. K. Dagda and C. T. Chu (2010) Neuropathology and Applied Neurobiology 36, 125–132
Autophagy and neurodegeneration: survival at a cost? Protein aggregation, mitochondrial impairment and oxidative stress are common to multiple neurodegenerative diseases. Homeostasis is regulated by a balanced set of anabolic and catabolic responses, which govern removal and repair of damaged proteins and organelles. Macroautophagy is an evolutionarily conserved pathway for the degradation of long‐lived proteins, effete organelles and protein aggregates. Aberrations in macroautophagy have been observed in Alzheimer, Huntington, Parkinson, motor neuron and prion diseases. In this review, we will discuss the divergent roles of macroautophagy in neurodegenerative diseases and suggest a potential regulatory mechanism that could determine cell death or survival outcomes. We also highlight emerging data on neurite morphology and synaptic remodelling that indicate the possibility of detrimental functional trade‐offs in the face of neuronal cell survival, particularly if the need for elevated macroautophagy is sustained.     

Health care: for patients or for profits?

The author contends that the medical-industrial complex has come to dominate a substantial and growing segment of the health care "market." This complex is characterized by its ability to charge and collect for services, pass through its capital costs, and skim off profitable patients--and, at the same time, to shun its proportionate responsibility for the medically indigent, for the costs of medical education and research, and for meeting community needs. He concludes that physicians have an ethical imperative to join in a broad public coalition to protect equity and quality in medical care.     

Why Is Better Mental Health Care So Elusive?

PURPOSE. There are numerous barriers to improving healthcare delivery. This article summarizes contemporary theories and research evidence to focus on ways to motivate change within the hospital system to provide better health care. CONCLUSIONS. Understanding multidisciplinary team processes, recognizing hospitals as systems, and ascertaining the unit culture is a prerequisite for leaders and policy makers to improve mental health practices. PRACTICE IMPLICATIONS. Finding ways to deliver better health care to people with a mental illness is a high priority, and nurses have a central role to play in this pursuit of excellence.     

Does the radiologically isolated syndrome exist? A dual-task cost pilot study

Simultaneous performance of motor and cognitive tasks may compete for common brain network resources in aging or patients with some neurological diseases, suggesting the occurrence of a cognitive-motor interference. While this phenomenon has been well described for multiple sclerosis (MS) patients, it never has been tested on asymptomatic subject with magnetic resonance imaging (MRI) findings suggestive of demyelinating disease (i.e., radiologically isolated syndrome: RIS). In this pilot study, 10 RIS subjects and 10 sex/age-matched healthy controls were tested by means of static posturography under eyes opened (single-task trial) and while performing two different cognitive tasks (semantic modified word list generation for first dual-task trial and phonemic semantic modified word list generation for second dual-task trial), to estimate the dual-task cost (DTC) of standing balance. In our sample, under cognitive interference (without any substantial differences between semantic and phonemic modified word list generation), the RIS group showed significance differences in CoP (center of pressure) total sway area, ellipse eccentricity, CoP sway path length, CoP median sway velocity along the AP (anteroposterior) axis and along the ML (mediolateral) axis, reflecting a higher negative DTC respect to healthy subjects (which have simply shown a statistical trend, failing to reach a significance, in some trials). The phenomenon of cognitive-motor interference might be unmasked by a dual-task posturography in RIS subjects, too. We hypothesize that this approach could be useful to early reveal the presence of a demyelinating disease and to reach a MS diagnosis in subjects otherwise classified as RIS.     

Does the Sunset of Mental Health Parity Really Matter?

The 1996 Mental Health Parity Act (MHPA), which became effective in January 1998, is scheduled to expire in September 2001. This article provides an overview of what the MHPA intended to do and what it actually has accomplished. We summarize state legislature actions through the end of 2000 and report on their effects on employer-sponsored mental health coverage using a national survey fielded in 1999–2000. We then discuss possible amendments to the MHPA and reforms beyond full parity that might be considered.     

Health anxiety – An indicator of higher interoceptive sensitivity?

Background and objectivesAccording to cognitive-behavioral models, health anxiety arises from the misattribution of normal bodily sensations as signs of a severe illness. Consequently, higher levels of interoceptive accuracy might be critically involved in the development of health anxiety.MethodsTo test this central assumption of cognitive behavioral models of health anxiety, we assessed interoceptive accuracy in a sample of college students (N = 100). Two interoceptive tasks (detection of one's own heartbeat using the Schandry paradigm and detection of nonspecific skin conductance fluctuations, NSCFs) were used.ResultsWe found no indication for a positive association between facets of health anxiety and a higher interoceptive accuracy in the two tasks. In fact, worse heartbeat perception was associated with higher health anxiety as measured by two questionnaires whereas perception of NSCFs was not significantly related to any facet of health anxiety. In addition, we found a bias to overestimate NSCFs in people with heightened health anxiety.LimitationsBecause a sample of college students served as participants, the generalization of the findings is limited and further studies in patients with the diagnosis of hypochondriasis are necessary.ConclusionsThe findings of both interoceptive paradigms suggest that health anxiety is not associated with better but rather with less accurate and biased interoceptive sensitivity. Probably, not a heightened interoceptive sensitivity but rather the bias in overestimating harmless somatic cues is more relevant for the maintenance of health anxiety. Our results are in line with recent research in other somatoform disorders.