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Ten years can make a lot of difference in the way a patient with severe mental illness is treated - especially if those years are marked by extraordinary changes in the way mental health services are paid for.
This was dramatically illustrated in a report by Miles Quaytman, M.D., and Steven S. Sharfstein, M.D., titled "Treatment for Severe Borderline Personality Disorder in 1987 and 1997" in the August American Journal of Psychiatry.
Quaytman and Sharfstein describe the treatment in 1987 of a woman with severe borderline personality disorder prone to burning herself with a cigarette and compare that treatment with a hypothetical treatment scenario today.
In the 1987 case, the woman received 15 months of inpatient treatment including dynamically oriented psychotherapy, three times a week, focusing on the patient’s intense conflicts surrounding dependency, and on integration of painful and angry feelings she had difficulty avowing as her own.
In the 1997 hypothetical scenario the woman would receive brief inpatient and day hospitalization. A "flexible" benefit structure would allow her to move from the hospital to residency in a "quarterway house" - a house on the hospital grounds, but away from the hospital, utilizing behavioral and dynamic principles with a rehabilitative approach—and back to the hospital again as needed.
She would also receive once-a-week psychotherapy and would participate in Alcoholics Anonymous.
The total cost of care for the 1987 approach was approximately $220,000 (in 1997 dollars adjusted for inflation). The total cost of care for the 1997 approach is approximately $62,650.
"Are the outcomes of care in 1987 and in 1997 comparable?" the authors ask. "Research into the resources needed for good, positive long-term outcomes is an urgent task. If outcomes are better in the second scenario, ‘less is more’ can have real meaning. Managing the costs of care has become a day-to-day imperative for hospitals and psychiatrists in the new medical marketplace.
". . . .Economic factors are the driving force behind the development of the continuum of care," continue Quaytman and Sharfstein. "Effective, less restrictive, and less expensive alternatives are the byproduct of the managed care revolution. We still need good programs with excellent staffs in order to treat these severely ill patients, and that costs money. . . . ‘Less is more’ can have real meaning with these patients, but ‘something from nothing’ remains out of reach."