Managed Care, Mental Health, and the Marketplace

To the Editor.  —Several articles appearing recently in professional journals are critical of managed mental health care and deplore the loss of quality and professional autonomy.^1,2 These articles contain descriptions of hospital and managed care businesses that are unnecessarily pejorative and typically flawed by damning overgeneralizations without substantiation ("... but direct clinical work was typically performed by undertrained, poorly paid 'counselors'"²).Contrary to Drs Jellinek and Nurcombe,¹ we maintain that psychiatry is neither the first specialty to be affected by managed care nor has it been singled out for special treatment. Much of its difficulty is due to psychiatry's lack of objective treatment criteria or other guidelines and the associated extreme range in variance utilization. If profit motive is to be implicated here, one must question whose.We know several things about psychiatry that help explain its market behavior. Demand for psychiatric services is highly sensitive to benefit