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Book Forum: Health Services   |    
Unmet Need in Psychiatry: Problems, Resources, Responses
RICHARD BALON, M.D.
Am J Psychiatry 2001;158:1345-a-1346. doi:10.1176/appi.ajp.158.8.1345-a
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Edited by Gavin Andrews and Scott Henderson. Cambridge, U.K., Cambridge University Press, 2000, 444 pp., $90.00.

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As Ronald C. Kessler states in his contribution to this book,

The key premise of the symposium [in Sydney, Australia, in late 1997] on which this volume is based is that no society can afford to intervene to meet the needs of all the people found in psychiatric epidemiological surveys to have a clinically significant psychiatric disorder. Therefore, some triage rules are required to rationalize the allocation of limited resources.

Thus, it seems that services should be rationed according to economic rationalism, i.e., the burden of a disease and the cost effectiveness of it. Again, according to Kessler, "An intervention should be considered appropriate if, and only if, its expected benefits clearly exceed the sum of its direct costs and expected risks."

The editors of this book ask in the preface more specific questions related to whether the available skills and services in the community could be organized to reach all in need. These questions include the following: If not everyone with a diagnosis needs treatment, how do we decide who does? What should be used as a criterion to deploy health services—diagnosis, disability, or the likelihood of treatment success? Do we have sufficiently reliable estimates of prevalence, comorbidity, disablement, etc., to do this? Finally, if we have these data, would it be ethical to triage people this way? They gathered an international team of 64 primarily psychiatric epidemiologists who attempt to answer all these questions in 30 chapters.

The book is divided into five parts: 1) Unmet Need: Defining the Problem, 2) Unmet Need: General Problems and Solutions, 3) Unmet Need: People With Specific Disorders, 4) Unmet Need: Specific Issues, and 5) Unmet Need: Conclusion. In part 1, Norman Sartorius poses relevant questions such as whose needs are more relevant (the patient’s?, the family’s?); whether demands are linked to disease, illness, or sickness; and what is an effective intervention. He suggests that effective interventions are those which have a predictable and significant positive effect on the problem and are acceptable to the individuals who have the problem and those who care for them. Harvey Whiteford in his chapter reminds us that there has been a little public debate on how much should be spend on health versus other areas, such as education and defense. In a provocative manner, Gavin Andrews states that, sadly for doctors and fortunately for sufferers, the doctor-patient relationship is not essential if one has effective and proven treatments. He also reminds us that one-fourth to one-half of all professional services are being delivered to people who do not meet criteria for a current mental disorder.

Part 2 attempts in nine chapters to further discuss the problems and provide some solutions. For instance, Darrel Regier and colleagues question the equation of diagnosis with need for treatment. The most provocative and best written chapter here is the one by Kessler on resource allocation decisions. Interestingly, he also questions whether primary preventive interventions for psychiatric disorders are feasible. A few other chapters in this section are also interesting and well written (e.g., the one comparing data on service use between countries, according to which the United States does not fare very well). The last chapter in this section attempts to answer the question of whether complementary medicine fills any needs that could be met by orthodox medicine instead of focusing on which patient needs are being fulfilled by complementary medicine.

Parts 3 and 4 focus on unmet need in specific disorders and populations or age groups. The 16 chapters in these two sections are uneven, with some chapters presenting results, some presenting reviews of topics, and some basically consisting of essays. A clear winner is the chapter by Hans-Ulrich Wittchen presenting the results of a long-term study from Munich, according to which about 40% of young people required an intervention specifically for anxiety and that intervention was not provided, even when the widest possible definition of service was used. In part 5, two chapters summarize the book’s premises, findings, and further possible directions.

As John Copeland states in his chapter, "This is a book on epidemiology." It is written by epidemiologists, and it understandably poses more questions than answers. It skillfully argues for getting more reliable and immaculate data to convince society to increase funding for mental disease intervention. However, the book does not appropriately deal with some important issues, such as the difference between the definition of mental illness according to epidemiological surveys or criteria versus the clinician’s criteria. It focuses mostly on the unmet need of those whose care is paid for by the society and does not discuss (again, probably understandably) the unmet need of the very small minority able and willing to pay for services. It does not guide the reader on how to convince the suffering person that his or her unmet needs are superseded by the needs of the society and whether it is the physician’s role to convince the patient about this. The book is also poorly conceptualized by the editors (the mentioned "data" chapters versus "review" and "essay" chapters) and unevenly written. Finally, it is not cheap. Nevertheless, it is a useful, thoughtful, provocative book, which should be read by the leaders in the field of mental health, as well as by academicians, health planners, administrators, and policy makers.

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