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Public Psychiatry in the United States: What is it?

The Public Psychiatry Fellowship of New York State Psychiatric Institute was initiated in 1981 as a public- academic liaison between New York State Office of Mental Health and Columbia University.

The title "Public" Psychiatry distinguished this program from earlier programs more typically called "Social" or "Community" Psychiatry during the 1960s and 70s. Social Psychiatry had taken over a largely academic meaning, as a conceptual framework for the practice of Community Psychiatry, which in itself had generally come to mean "grassroots" work. "Public" Psychiatry refers to the use of clinical techniques, management skills and evaluation strategies within established institutions serving populations with social as well as psychiatric needs: patients with severe mental illness and other major social psychiatric problems such as substance abuse, homelessness and AIDS, as well as members of poor urban and suburban minorities. These groups cannot or do not purchase services of their own choosing, and must rely on public funding and services.

The United States has a cherished tradition of attempting to keep government out of people's affairs as much as possible. As a result, the "public" system functions largely out of sight, with government money funding myriad services in countless voluntary (not-for-profit) and even private (profit-making) institutions. In fact, 73% of the approximately $23 billion spent by all mental health organizations in the US in 1988 came from public funds. A relatively small percentage (35%) of the services funded by this public money takes place in what most people think of as public institutions: state, municipal, and federal hospitals and clinics. For the most part, public funding is funneled to both voluntary and private institutions which in turn provide public services even though neither patients nor providers may think of them as "public". As an example, US general hospitals (mostly not-for-profit institutions) received 59% of their funding from public sources in 1988, and private psychiatric hospitals (in which 62% of funding came from client fees, including private insurance) constituted the only category of mental health provider for which public funding constituted less than 50% of all funding.

In fact, the public sector is appropriately defined as constituting those agencies, programs and services financed primarily by public funds with mandates to serve the poor and other patients with severe mental illness. By this definition, many programs provided by "private" not- for-profit hospitals and agencies can be meanginfully called public sector programs. Public money inevitably comes with strings attached (e.g. contracts for specific services to mandated target populations, certification and accreditation standards, and mechanisms of fiscal accountability). Professionals running and working in these agencies and programs need to know what kinds of services will best fulfill the mandates that justify these public expenditures, how to create and maintain organizations to deliver these services, and how to deal with the myriad requirements encumbent upon functioning with public funds.

The Public Psychiatry Fellowship was created to prepare young psychiatrists to meet this challenge.

Comments would be appreciated. Contact Jules Ranz, M.D.
e-mail: jmr1@columbia.edu

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