The catastrophic case. A special problem for general hospital psychiatry in the era of managed care.

In the quest for cost containment, case-managed care can harm some patients who are catastrophically ill and treatment resistant. One such case is presented and the "catch-22" situation described where the case manager determined that the chronicity and severity of the case deemed the patient "custodial" and discharge planning was ordered despite the fact that the patient had excellent continued inpatient benefits. The consequences of premature discharge or transfer to a state facility should be studied carefully as we move to more case-managed care. The process of managed care, which has become increasingly costly and time consuming, should also be scrutinized.