It is 12:30 A.M. in a comfortably lit, carpeted hallway of a behavioral health facility in a local hospital. A psychiatric nurse walks arm in arm with a tearful patient who is suffering from depression and cannot sleep.

The patient is in the hospital for two weeks during which medication changes and talk therapy will be provided by a team of nurses and a doctor working together to help her recover.

That was in the days before managed care. Today a nineteen-year-old young woman sits with her knees drawn up, not looking at anyone in the room where patients sit to watch TV. She was hospitalized last week for the maximum of five days allowed by her HMO under managed care. Two days ago, she was readmitted. Her wrists have fresh stitches over self-inflicted cuts. Tears stream down her young face from swollen, bloodshot eyes. What is wrong with this picture? According to many physicians, nurses and patients: just about everything.

The only good thing to be said for managed care is that in the best of all possible worlds therapeutic decisions made by one doctor would be scrutinized by other physicians. The reality, far from the best of worlds, is simply this: the bottom line of managed care is profit, not patient care. We live in a make-money nation that has its greedy talons so deeply entrenched in our health care system that it now takes an act of congress to allow new mothers to stay in the hospital more than one night when they deliver.

Length of stay in the hospital is a function of the policy the individual buys and it is pretty much cast in stone. It has little to do with treatment decisions and treatment may be denied because the managed care company decides the patient no longer needs to be in the hospital. This is one of the things that make people very angry.

Andrew Solomon, in his recent article in the New Yorker, writes that most managed care companies are keen on medication, which is relatively cheap, and not very keen on talking therapies and hospitalization. He goes on to quote Sylvia Simpson, a physician at Johns Hopkins: "I spend more and more time on the phone with managed care companies trying to justify patients' need to stay in the hospital. Frequently, when a patient is still very, very ill and unable to function-if he's not acutely suicidal that day, authorization for coverage of further in-patient stay is denied." Furthermore, the HMO may have an approved list of medications that attempt to dictate to the physician which medicines may be prescribed. Again, an appeal must be made. So the doctor starts writing more letters. Physicians also fill out forms to apply for more out-patient sessions because the number of sessions permitted by the HMO is unrealistic. "I get furious about the decision and process being taken out of the physicians' hands, I get so pissed," says one psychiatrist. "It's a totally new way of practicing. It's very discouraging." Seasoned, experienced doctors find the new way of practicing IS forcing them to reconsider when they'll retire. The absurd degree of bureaucratic hassle is pushing them toward it quicker rather than later. But this isn't the only loss in the mental health field. The number of people going into psychiatric residency is down 45%. Among these, many will study psychopharmacology because psychotherapy both in and out of the hospital is being handled by social workers and masters level people. The days of receiving psychotherapy, medications, and hospital care from the same physician are quickly dwindling. Overall, from the physician's point of view, patients are receiving a poorer and more limited amount of care under managed care.

And what about the psychiatric nurses? "It's tragic what's happening to the nurses," says one psychiatrist. "They came into the field to help people and now they're filling out forms." As with doctors, nurses find the length of stay to be one of the most noteworthy changes in the recent years of managed care. Patients used to stay two to five weeks and now they're cycling in and out of the hospital in four to five days. At some hospitalsit takes two hours to do an intake and nurses may come back the next day to find the patient discharged. Patients in crisis often don't like or can't handle the sometimes-hostile environment of the hospital, Intake and discharge paperwork done by the nurses is greatly increased by the shorter five-day hospital stay mandated by most HMO's. In former days, nurses had a lot of one-to-one interaction with the patient, now they are discouraged from doing so. The time a primary care nurse spends with the patient may be limited to ten minutes standing in a hallway. His or her duties include checking that all the blood work is done. Again, more paperwork and less patient contact.

Another change that affects the amount of paperwork done by psychiatric nurses is the new emphasis on achieving direct and explicit outcomes. Some nurses feel this push is not always helpful to the patient. They have a suspicion that there are people in offices somewhere looking at forms and lists that don't have much to do with the human beings on the unit. An atmosphere of "Us vs. Them" is often true, admitted one nurse. What used to be a rewarding job has turned into a plethora of paperwork and patient interaction is limited to keeping patients quiet and not causing trouble. When confronted with the number of patients being blamed and yelled at while in the hospital, she replied that staff are human beings too. Even in the past, they might have been short with patients, and some are short all the time because they have the "Us versus Them" attitude. But being short with patients is exacerbated since managed care because nurses don't have the time to work with patients.

Like doctors, many nurses are upset that for-profit organizations are making decisions about the human beings who they want to help to lead healthier, more productive lives. And, as with doctors, the attrition rate is growing. "There is much less satisfaction for people in the field," says Ernestine Spoon who retired from nursing less than a year ago. "They [psychiatric nurses] are overloaded. They're just pushing pills and doing paperwork while hospitals are cutting down on staffing." Ms. Spoon says she is seeing some very good people getting out of the field because they're not satisfied with the job.

Where does all this leave the patient who is in crisis and in need of compassionate support while in the hospital? I wanted to write this article because I was hospitalized many times between 1970 and 1993. Then I went into the hospital, once in '97 and once in '98. The change was crushing, enraging, and I felt a sense of feeble failure at getting help. In the '97 and '98 hospitalizations, I was told that I could not go to the hospital where my doctor practiced, and even if I could, I would have another doctor because of my HMO. So I pulled whichever doctor happened to be on call when I came in. The first, a young woman, had not had a weekend off in four months. Since I came in on a Friday, I saw a different doctor on Saturday for about five minutes, and no one on Sunday, By Monday I was angry and ready to leave. I had spent three days measured by meals and hourly cigarettes, I was not getting any therapeutic help.

Where were the nurses? My keen observation, even in crisis, told me they were all in the nurse's station flipping through binders, writing, and preparing medications. I expressed some of my frustration to my doctor who got angry with me and walked out of the room in a huff. Not a very therapeutic response. I left the hospital feeling defeated. Within a week I attempted suicide by carbon monoxide poisoning, The '98 experience was more like those reported by others. There was one "Nurse Ratchet" who made the hours feel like incarceration rather than hospitalization. When she found cigarettes in my room, she punished me by forbidding me to smoke for 24 hours. Her manner was surly, angry, and full of blame. This is hardly the kind of treatment we patients need when we seek a safe place where we can be as vulnerable as we really are when we are in crisis.

"With one arm in a blood pressure cuff and a thermometer in my mouth, a nurse screamed at me from down the hall to get my Bible off the table," says Patricia Reynolds, a recent patient who has worked both sides of the mental health fence. "Ten years ago instead of being put in a safety belt and left to urinate all over myself, a nurse sat with me and held my hand until I fell asleep. Managed care means that even though I'm refractory, I have to stay out of the hospital in order to survive or to die, whichever the case may be," she added.

Indeed, according to a recent article from the Associated Press, 36-year-old executive and publisher J. Timothy Hogan did kill himself and left a four-page suicide note indicting the health care system. His HMO had no listings for psychiatrists, psychologists or mental health counselors. Is this what it will take for the revolutionary changes needed now in order to include mental health providers in future directories? How many successful suicides will it take before psychiatric units in hospitals revert to the "safe" places, the compassionate havens, patients so desperately need when in crisis. Instead of moving forward toward more successful treatment and patient care, we seem to be moving backward. When good doctors and nurses are so frustrated with the system that they are getting out of the field, it is the patient who suffers. And that's the bottom line. Our health care system is for profit, not for patient care.

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