Depression constitutes a considerable mental health problem. Depression is too often unrecognized or unproperly treated, which causes distress, social impairment, and increased risk of mortality for the individual, and large costs for society. However, several efficient treatment modalities and strategies exist. Different somatic antidepressant treatments for short- and long-term therapy and their respective quality-of-life and economic aspects will be presented and discussed.

Schizophrenia typically affects individuals in early life and leads to long-term suffering at high cost to both the individual and the community. Structural, functional, and biochemical factors may play a role in the pathogenesis, and perhaps the course, of schizophrenia. Although early research into the treatment of schizophrenia was not fruitful, the results of recent research, particularly the use of narcoleptics combined with new clinical appreciation of psychosocial factors in chronic psychotic disorders, give reason for hope and optimism.

In the process of involuntary commitment,1 the state makes available its coercive power for use as a psychiatric technology. This application of the state's power is based on the idea that mental illness can make a person not only sick but also unaware of the illness, and dangerous or unable to care for his/her basic needs; thus, coercion may have to be used to secure the mentally ill person's and/or the public's safety, and to give treatment until the illness abates.

Technology for psychiatric prevention is poorly developed, and knowledge about the causes of mental Illness is difficult to apply to practical preventive work. As it would take many years before the effects of primary preventive efforts would be visible, secondary and tertiary prevention are essential to reducing the prevalence of mental illness. Recent studies on reducing the negative health consequences of acute stress seem to justify some optimism that psychosocially-oriented prevention is possible. Experience with the preventive benefits of social support at times of crisis suggests that active social support can prevent social disintegration at the community level and mental health problems for individuals.

This paper presents a discussion of the historical development of deinstitutionalization in the United States, including the political, ideological, and social origins of that policy. The outcomes of deinstitutionalization are considered, including the impact of the policy on the quality of life of people with severe mental disorders. The authors also provide a brief review of the literature on the efficacy and cost-effectiveness of hospitalization versus outpatient (community) care. Recent developments in the use of involuntary hospitalization are discussed, along with a number of important trends in the delivery and financing of services for persons with severe mental disorders.

The Basaglia movement in Italian psychiatry is described and analyzed in several contexts: the historical, the cultural, and the “practical” in terms of outcomes. Those who began the movement of democratic psychiatry grasped interesting elements of “critical theory”: the definitions of madness, power structures, and medical discourse itself. A backward look at the sea change, however, reveals states and rates of dysfunction that disappoint and indicate that political ideology divorced from cultural awareness can often harden the opposition.

Consumerism is a growing phenomenon in U.S. health care, yet its exercise is still inhibited by powerful forces within the medical community. Despite the neuroscientific framework that stresses the commonalities between mental and physical illness, consumerism is even more problematic and difficult in mental health care than in other areas of health care. People with severe mental illness and their advocates must contend with limited public understanding of neurobiological disorders, poor definitions of effective treatment, and a paucity of outcome data, especially from prospective randomized and long-term studies. The only clear way for consumerism to grow in mental health care is for its advocates to align themselves with the neuroscientific revolution and to demand that effective and equitable treatment programs be created based on the documented evidence of the physical nature of neurobiological disorders.

The use of electroconvulsive therapy (ECT), controversial since its inception, offers an instructive case study on the challenge of addressing patients' perspectives in the evaluation of health care technology. Despite widespread professional acceptance of ECT, groups of former psychiatric patients have worked through the U.S. legal system to restrict and even ban ECT in the treatment of mental illness. This unusual lay participation in the regulation of health care illustrates how differing conceptions of evidence can affect the evaluation of technology. ECT provides a powerful example of the value of a more complex definition of the significant outcomes of treatment and the growing practice of outcomes assessment, especially as such research is used to shape health policy.

Mental health services depend both on efficacious drug and interpersonal interventions and strategies for financing, organizing, and delivering these services. In recent years, much attention has been devoted to approaches that seek to coordinate needed care and to provide it in the most cost-effective ways. Cost constraints encourage the substitution of alternative community treatments for expensive inpatient care and the identification of appropriate ways to link effectively the varying care components. The mechanism most commonly advocated is case management, but the concept is applied in diverse ways and has little agreed upon meaning and disparate outcomes. This paper discusses and evaluates concepts of case management and a variety of other systems interventions designed to reduce fragmentation. It also reviews approaches to managed care, including mental health capitation and utilization management. New organizational technologies are likely to change dramatically professional practices and standards and the future provision of mental health care.

Clnical trial randomization schemes to control patient characteristics that can influence clinical response are not sufficient to control for their effects on operational efficiency and cost within the provider institution. This variation can result in biased economic findings when patients are allowed to select a provider themselves.

We present the prospective economic evaluation that served as a secondary endpoint for the FIRST study, a randomized international multicenter trial of patients with severe congestive heart failure. Although the clinical results of this study were disappointing, we demonstrated the feasibility of incorporating prospective economic evaluation in phase III clinical trials.

The ability to extract information on resource use from randomized controlled trials can provide the groundwork for systematically compiling health economic reviews of health interventions. A review of the brief smoking interventions in general practice demonstrates that not all the necessary information can be extrapolated from these trials, and cost data will have to be supplemented from other sources.

We reviewed the Canadian literature on cost-effectiveness from 1980–1995 with regard to costing methodologies. We abstracted each study using a list of data elements that describe costing methodology, and evaluated costing methodologies in the light of biases in costing methods, site, and case-mix selection.

We studied the role of economic incentives for private providers in explaining Spain's disproportionately large number of extracorporeal shock wave lithotripters (ESWLs) and low number of linear accelerators (linacs) per million population (pmp) in comparison to other countries of the Organization for Economic Cooperation and Development (OECD). We found that the reimbursement policy for 1990 allowed an average profit per private ESWL of $732,000, but no profit for linacs. Regional per-capita income was positively correlated with ESWLs pmp in Spain (R2 = 0.49; p =.001), but not with linacs. Sixty-nine percent of ESWLs were privately held versus only 16% of linacs. To avoid these types of distortions, financial incentives should be based on a reasonable relationship between cost and charges and should be associated with the appropriateness of medical care.

This article analyzes the use of antibiotics in Danish general practice. We observed considerable variation in the prescription of antibiotics among general practitioners (GPs). Internationally, Denmark has a low consumption of antibiotics. The use of antibiotics was closely associated with GPs' use of drugs, other than antibiotics, and to some extent with use of microbiological diagnostic tests. These findings provide evidence for the assumption that the consumption of antibiotics can be decreased further, which stresses the need for a restrictive policy concerning antibiotics.

This study investigates recent changes related to the import and export of medical technology and their results in Turkey. Between 1980 and 1993 the number of medical technology imports in Turkey rose, and there was a parallel rise in its ratio to total imports and health expenditures. In contrast the ratio of medical technology exports to total exports decreased significantly in the same period. The liberalization of foreign trade and the changes of health services toward free market policy has caused growing import of medical technology in Turkey.