Tardive dyskinesia is a serious, well publicized adverse effect resulting from long-term neuroleptic drug use. However, little progress has been made during the last two decades in ensuring that these drugs are prescribed with necessary caution. Incentives and constraints operating on the major participants in the decision-making process leading to the prescription of neuroleptics increase the likelihood that the benefits of drugs will be exaggerated and their adverse effects minimized. When combined with imbalances of power, these factors ensure that persons (...) having little power and information to make the decision to prescribe will bear most costs of that decision. This points to the operation of an ineffective system which can be expected to yield sub-optimal results. We suggest ways to make the decision process more efficient by more closely aligning responsibility with cost. If those who hold power in the decision process are held accountable for the unwanted risks they impose upon others, both the use of neuroleptics and its inevitable iatrogenesis would probably be reduced. (shrink)

Most writers now recognize that mental health policy and the mental health system are extremely resistant to real changes that reflect genuine biopsychosocial paradigms of mental disorder. Writers bemoaning the intransigence of the mental health system tend to focus on a small analytical level, only to find themselves mired in the rationalities of the existing system. Problems are acknowledged to be system-wide, yet few writers have used a method of analysis appropriate for systemic problems. Drawing upon the General System Theory (...) (GST) analytical perspective, this article advances a systematic approach to understand the mental health system and to facilitate the development of reform strategies that recognize the system's complexity and changing nature. The article first discusses the failure of major reform efforts in the mental health system and the limitations of mainstream analysis of mental health politics and policies with respect to the objectives of analysis and reform. This article describes how systems thinking has thus far influenced the study of the mental health policy and politics system, and argues that a systemic perspective is profitable for reconceiving the mental health system, enabling a fresh basis for the development of reform strategies. The mental health system should be seen as a social system influenced by larger political and economic dimensions, not just as a 'delivery system' scientifically constructed by neutral experts. Furthermore, the policy planning process should be viewed as part and parcel of a mental health system modeled as complex and dynamic. The systemic perspective outlined here should help both to clarify the value-based objectives that we hold for the system and, consequently, to plan for the strategic reforms that have so far eluded us. (shrink)

This article reevaluates the recent tendency to attribute economic causes C cost and fiscal factors C to deinstitutionalization and its subsequent "treatment in the community" mental health system. Economic determinist explanations are shown to be inadequate; instead, the primary impetus behind deinstitutionalization is seen to be the conception of a more humanistic "community care" alternative. How deinstitutionalization was transformed into a mere shadow of that model is explained by analyzing the mediation of social institutions. It is proposed that disillusionment and (...) policy paralysis be replaced with a teleological approach to planning: a long-term strategic plan based on goals and emphasizing the policy environment. (shrink)