Cognitive Dissonance in the Pages of Psychiatric Services

In Reply: Congratulations to Dr. Masland. He is certainly paying attention. In his letter, Dr. Masland highlights the disconnect between the harsh reality of decreased funding for behavioral health services and our ability to provide treatment that is demonstrably more effective. His conclusion, which I suspect was delivered more tongue in cheek than a true critique of the journal's editorial practice, is to stop publishing papers about studies that might require us to spend more money on health care.

A good friend of mine, when presented with a question that appears to demand a choice between two alternatives, often answers "yes and yes." We are now at a "yes and yes" point in time. Yes, we have experienced a significant decrease in funding for behavioral health services. And yes, we should continue to evaluate the impact of our interventions to identify best practices, even if these practices cost more.

The Hay Group reported that between 1988 and 1998 funding for behavioral health services decreased by 54 percent, compared with a 7 percent decrease for all other areas of health care (1). And yes, we should expect more of the same. This restriction challenges psychiatrists to allocate their limited resources wisely.

Dr. Hser and colleagues (2) provide data to support the hypothesis that increasing service intensity enhances patient satisfaction, which increases retention and leads to improved clinical outcome. But interestingly, length of stay and outcome were nearly identical for patients in residential programs and for those in outpatient drug-free programs. In fact, although length of stay tended to be longer in the more expensive residential programs than in outpatient care, outpatients in the study reported greater treatment success than those in residential treatment. It is possible that those treated as inpatients were more severely impaired. Nevertheless, the data support preferential use of less costly outpatient substance abuse treatment in the absence of contraindications. Their study provides clinical outcomes data to inform clinical decision making and case manager intervention and stimulates clinical services redesign. This finding makes it possible for us to "make do with less."

But yes, we should also continue to support the kind of research into the kinds of questions Dr. Hser and his group raised. We are at a point in time when the payers are calling the shots. These payer decisions are highly driven by data. Fortune 100 companies are routinely self-insured. Because they pay the bills, they can track health care costs at a level of sophistication that would amaze most psychiatrists. And they are remarkably attentive to return on investment. As employers discover that they are receiving a positive return on their investment in behavioral health services (through increased attendance, enhanced performance, decreased medical and disability costs, and diminished retraining costs), they increased their investment in behavioral health care.

Work like the investigation conducted by Dr. Hser is a valuable contribution to the emerging database in behavioral health. Many believe that evaluations that compare the efficacy of treatment alternatives and identify best practices will be crucial to our convincing payers that their money is being well spent.