Problems with managed psychiatric care without a psychiatrist-manager

Seven critical cases in which patients at major psychiatric risk received less than adequate managed care are presented. Five patients committed suicide, one patient progressed to psychosis, and one became permanently physically disabled. In all seven cases, the patient's care was managed by a nonpsychiatrist - by a bachelor's-level therapist or case manager in three cases and a family physician, a cardiologist, a nurse, and a master's-level social worker in the other four cases. In the cases in which psychiatric consultation was sought, psychiatrists, either in the managed care setting or outside it, were used mainly as psychopharmacological consultants. In three cases, their recommendations were not followed or were poorly implemented. In six cases, mismanagement of psychotropic medications was a factor in the fatal or serious outcome.