The three studies raise a number of frightening specters our profession must address if patients suffering from one of the worst illnesses are to get the high-quality, compassionate care they require. Although the value of gatekeepers has been questioned within the managed care industry, they remain predominant in managed care systems (R15570112). Mental health carve-outs may have a vested economic interest in gatekeeper systems that underdiagnose major depression (Koenig and Kuchibhatla, Druss et al.). A further concern, with the growing awareness that individuals with major depression have high rates of medical service utilization (Koenig and Kuchibhatla, Druss et al., Rost et al.) is that HMOs will assume that high utilizers are depressed and dump them. Or, rather than dump depressed individuals directly, the HMO may give them partial but inadequate care while "informing" the patients that they are getting optimal care, abandoning them to years of unnecessary disability and pain.