The Cost Of Mental Care
Coser, Rose Laub
"A Society that can afford atomic bombs can afford some good psychiatry," say the authors in their conclusions to this book,* after documenting in impressive detail that at present...
...In private hospitals, approximately 93 per cent of the class I patients receive analytic psychotherapy, but only 19 per cent of class IV's...
...Thus, in places where the fees are low, lower-class patients are not given as much opportunity as upper-class patients to profit from the recent advance in psychoanalytic or analytically oriented therapy, due to their soWhich Paragraph Do You Read...
...It is, of course, hardly news that because of prohibitive costs lower-class patients do not receive the same amount and quality of medical care as upper-class patients...
...From two consecutive paragraphs in "On the Nature of Marxism" by Paul A. Baran in the Monthly Review, November 1958...
...Only nine patients were carried free by private practitioners, and no psychiatrist carried more than one free patient...
...But what is more important is that even where lower-class patients do spend the same amount of money, they receive less care, and a different type of care, than the upper-class patients...
...ATTENTION HAS already been called to the fact that psychotherapy is much more costly than organic types of treatment...
...cial status...
...A psychiatrist can treat only about 12 patients at a time over a given period of time, seeing each of them several times a week...
...Class V patients are not to be found in private mental hospitals...
...But the more it changes, the more it remains the same...
...But electro-convulsive therapy, the authors point out, is a controversial form of therapy to be used only for a narrow range of illness...
...A large number of them go to large state hospitals where they are kept in custody rather than treated, while upper-class patients are more likely to enjoy the services of private practitioners and private, wellstaffed clinics...
...Thus arises the paradox that clinics, though they are especially set up for help to the indigent, spend more money on upper-class than on lower-class patients: the clinics' net mean estimated expenditure on class II patients is almost twice as large as it is for class III patients...
...These free patients were given only periodic treatment and for short periods...
...They conclude, "The contrast between who is prescribed which therapy, both from the perspective of class position and the costs to the hospital, are too great to be ignored...
...None of Marx's conclusions has been vitiated, let alone refuted, by subsequent events...
...c) Do lower-class patients receive a different type of treatment regardless of their ability to pay...
...The problems raised by this study are: (a) Is there greater susceptibility to mental illness in the lower class...
...Thus, in dollars and cents, it means that the mean payment per day is $23.76 for class I patients, $29.66 for class II, $29.88 for class III and as high as $31.11 for class IV patients...
...Thus, 30 per cent of the upperclass bills are discounted, and the percentage decreases with the decrease in class position, with only 2 per cent of the class IV bills being discounted...
...Class III patients there are treated by fully trained staff psychiatrists...
...Paradoxical as it may seem, however, the contrary is true...
...Not a single psychoanalyst or analytically oriented private practitioner is treating a Patient free, although a few patients are treated at slightly reduced fees...
...emphasis ours...
...A high proportion of lower-class patients simply rot...
...Bad as its condition has been, it was able to rise above the 'inescapable, unvarnishable, imperative misery' which was observed by Marx, and which he expected would be accentuated with the passage of time...
...resident trainees select class III and IV patients...
...But what is more surprising still is the fact that lower-class patients are given a different type of treatment regardless of their ability to pay...
...tients are likely to be kept in mental hospitals more continuously while upperclass schizophrenics go in and out of treatment more frequently...
...Hollingshead and Redlich write: "The folklore of medical practice foster the belief that a considerable portion of patients are carried free by practitioners...
...Related to this, and more important, is the fact that lower-class patients get a different type of psychiatric treatment...
...Perhaps the most shocking finding of this book is that the higher the class position of a patient, the more likely it is that he will receive a discount from the hospital bill...
...Highly competent in its scientific method, it is both brilliant and courageous in the analysis of data...
...In a large clinic in a community hospital the class status of the patients determined the professional level of the therapist who treated him...
...Seventy-one per cent of class II patients are given analytic psychotherapy, as compared with 33.3 per cent, 17 per cent and 6 per cent respectively in classes III, IV and V. No patients of the upper class are given shock therapy or sedation...
...IT MAY BE SAID that the type of care a patient is prescribed in a private hospital is related to his ability to pay...
...The psychiatrists involved reported that they 'gave the patient a little free time' when he dropped into the office 'from time to time.' These free patients are carried by directive-organic psychiatrists who give them supportive therapy...
...Moreover, class I patients begin to receive discounts after the first week and often from the hour of their admission, because many class I patients are not charged for the examination at admission (often for reasons of professional courtesy, etc...
...This is shown by the treatment accorded them in private hospitals, where they pay for this treatment, as well as in clinics, where both upper- and lowerclass patients pay only nominal fees...
...Fifty-seven per cent of class I patients receive discounts in private mental hospitals, as against 25 per cent of class II patients, 21 per cent of class III patients and only 7 per cent of the class IV patients...
...as one descends the class scale, shock therapy is given to 4.2 per cent of class III patients, 7.3 of lass IV and as many as 31.2 of class V patients...
...In other words, the differential rates might indicate a higher incidence of illness among the poor, or they might suggest that the latter are being kept in care for many years, thus allowing an increase in number over the years for lack of remission of symptoms...
...How can this be accounted for...
...the proletariat in the advanced capitalist countries has not developed in the way anticipated by Marx...
...ON xUE BASIS of a division of the New Haven population into 5 classes —according to criteria of residence, occupation and education—it was found that, while the rate of mental illness for classes I and II, i.e., for the two upper classes, is 556 per 100,000 of the population, it is 642 in class IV and as high as 1,659 in class V. the lowest class...
...In spite of the equality of cost in all clinics in the city in which the study was made, the class position of the patients is related in significant ways to the types of therapy they are given...
...Yet...
...The relatively high rate of readmissions of upper-class patients is due in part to the fact that lower-class pa...
...When they say next time that ours is an equalitarian and classless society, ask if there is a psychiatrist in the house...
...The authors report on the relation between mental illness and class position on the basis of a large-scale research on the social * Social Class and Mental Illness, by August B. Hollingshead & Fredrick C. Red lich...
...and class V patients are treated by undergraduate medical students or social workers...
...A Society that can afford atomic bombs can afford some good psychiatry," say the authors in their conclusions to this book,* after documenting in impressive detail that at present American society provides scandalously poor psychiatric care to the majority of lower-class patients...
...This significant class difference in the prevalence of mental illness leaves one to wonder whether low-class patients fall ill (or are defined, by their relatives and ther community, as being mentally ill) in significantly greater number than upper-class patients, or whether they are kept ill for longer periods of time...
...The lower the class a patient belongs to the less time he spends in a private hospital...
...while lower ranking patients are charged routinely for admission procedures...
...While the net treatment cost per class II patient is $390, the cost is only $204 per class III patient, and goes down to as little as $93 per class IV and $48 per class V patient...
...New York, John Wiley & Sons, 1958, 442 pp., $7.50...
...Needless to say, upper-class patients can enjoy the privileges of private hospitalization much longer than lower-class patients...
...This belief may be true in the general practice of medicine, but it needs to be modified before it fits the facts of private psychiatric practice...
...The class IV patients are treated predominantly by electro-convulsive therapy...
...structure of a community, the psychiatric patients of this community, the institutions where they are cared for and the psychiatrists treating them...
...Since the prescribed treatment in clinics is not connected with economic factors as it is in private practice, the authors infer that the type of therapy given to a clinic patient is related more to social factors than to economic costs...
...This is especially significant in view of the fact that clinic patients do not pay for treatment, or merely pay a nominal fee...
...The class II and III patients do not begin to receive discounts until their families are sorely pinched by the financial cost of the illness...
...The rate of first admissions as well as the rate for readmissions, it turns out, shows some, but not a high or consistent correlation with class positions...
...In addition to the differential selection of psychiatrists by rank according to a patient's class position, there is also a difference in the type of treatment given...
...This question can best be answered after comparing the proportion of patients in each class who are admitted to hospitals with the proportion of patients who reside in them...
...whereas electro-convulsive therapy is rapid and inexpensive: one psychiatrist may treat 40 to 50 patients...
...b) Are patients in different classes given different types of treatment...
...However, there is a significantly larger proportion of lower-class patients hospitalized than one would expect on the basis of admissions and readmissions from that class...
...The class IV patient who receives a discount does not have it applied to his bill until his family has insisted upon it...
...History never stands still, and capitalism has obviously undergone a number of important changes...
...It appears that, while many private hospitals are oriented toward class 1 patients so far as physical set-up and staffing is concerned, they are maintained, in good part, by the highpaying, low-cost class III and class IV patients...
...Analytic psychotherapy is a slow, time-consuming form of treatment, but it is believed to be effective in cases where the therapist is well trained and where it is applicable and acceptable to the patient...
...The authors say: "Private hospitals are designed for the `carriage trade' but they are supported by the `shock box.'" IF sucx is the situation in private hospitals, how about clinics which are especially designed to provide psychiatric treatment for those who cannot afford private practice or private hospitals...
...On the other hand, their economic status prevents them from seeking this type of therapy with private practitioners...
...This collaborative work by a sociologist and a psychiatrist is of great import for students of mental illness as well as for students of society...
Vol. 6 • January 1959 • No. 1
