As a psychiatrist who cares for the elderly and for people with mental illness, I awaited Gov. John Baldacci's State of the State speech with trepidation, knowing that budget cuts were on the horizon. I applaud him for stating that he "will not pull the safety net out from under our most vulnerable citizens."

The governor said, "The choices we make in the coming days will help us define who we are as a State, and what we hope to become." I fervently hope that Maine will decline to define itself as a place that balances its budget on the backs of the poor.

We need to become a place that spends its social service dollars in an informed manner. We actually may be able to do more with less if we work smarter.

It is critical that we make the effort. The people who will be hurt by increasing economic woes are not strangers. They are us, our family members, neighbors, co-workers.

In hard times, substance abuse increases, as does domestic violence, elder abuse, child abuse and neglect and homelessness; retired or disabled people may have to choose between food and heat.

Hunger is already a problem. If you think the jails and emergency rooms are overcrowded now, just wait -- the safety net will be stretched dangerously thin at a time when need is likely to be greatest.

Morality, economics and common sense dictate that we do whatever we can to avoid creating an expensive cycle of increasing need.

Every penny needs to be spent in the best possible way. Unfortunately, there may be little hard data on which to base these decisions.

Brenda Harvey, commissioner of the Department of Health and Human Services (DHHS), speaking at the Bar Harbor Rural Geriatrics Conference in June, said DHHS has no method to assess the successes or failures of programs that DHHS funds (which is ironic considering the staggering amount of reporting that health care providers must send to the state).

We should be paying for programs that work, not for paperwork and guesswork. If we are going to spend taxpayer money on services, doesn't it make sense to know what we are getting for our money?

DHHS programs need to be evaluated by an independent examiner knowledgeable in both medicine and statistics. An epidemiologist based in either the state's Public Health offices or in the Office of Program Evaluation & Government Accountability could perform that function.

In Maine, most people with psychiatric disorders and dementia are treated by primary-care physicians. It makes economic and medical sense for psychiatry to support primary care. By using psychiatrists as expert consultants on only the most complex cases, rather than for day-to-day care of stable patients, access and patient outcomes should improve and costs decline.

We have models in place for this. The Maine Association of Family Physicians and the Maine Association of Psychiatric Physicians (MAPP) jointly developed The Consultation Project, in which primary-care physicians are paired with volunteer psychiatrists for patient care support.

MAPP is building on these relationships with a new educational program on post-partum depression funded by a grant from the American Psychiatric Association. These volunteer programs provide a framework that could be of use as DHHS looks to make changes.

The bureaucratic walls inside DHHS need to be more transparent if we are going to be able to judge what works. It would be extraordinarily useful to know if changes to the MaineCare formulary (the list of preferred, commonly prescribed prescription drugs) or the money spent on home services resulted in fewer emergency room visits or hospitalizations. Information about treatments that work could be disseminated more widely. Interventions that don't work could be improved or dropped.

There are many "ifs" in these suggestions, and much inertia in government agencies to overcome. Still, out of crisis comes opportunity.

Here is an opportunity to re-design DHHS to be more transparent and more effective, to reduce the administrative burden on health care and to improve mental health treatment in Maine.

We have models to guide us and dedicated medical professionals willing to commit to the process. Yes, budget cuts will be painful, but it should be possible to do better even under reduced circumstances. We just need the political will to make it happen.

Janis B. Petzel is an adult and geriatric psychiatrist in private practice in Hallowell. She is the president-elect of the Maine Association of Psychiatric Physicians (www.mainepsych.org).