Covering Mental Illness
Schizophrenia, yes, caffeine intoxication, no.
By Timothy A. Kelly
Sunday, May 5, 2002; Page B07
Sens. Pete Domenici (R-N.M.) and Paul Wellstone (D-Minn.) have sponsored "mental health parity" legislation requiring employers to offer the same coverage for mental illness that they do for physical illness. President Bush has signaled his support for the concept, greatly boosting its chances of becoming law.
This constitutes a long overdue recognition of the fact that people suffering from mental illness deserve as much help as those suffering from physical ailments. It could also herald the beginning of much-needed reforms in a mental health service system that too often fails those who need help.
But unfortunately the Domenici-Wellstone bill includes a poison pill --parity coverage for every mental disorder listed in the 941-page manual called the Diagnostic and Statistical Manual of Mental Disorders (DSM), which identifies more than 200 psychiatric diagnoses. This would have the unintended effect of shifting attention and care away from those who need it most by equating serious disorders such as schizophrenia with mild disorders such as caffeine intoxication.
What is the difference between schizophrenia and caffeine intoxication? According to the DSM, both are simply classifications of mental disorders appearing among the 200-plus diagnoses. Yet to equate them for coverage is roughly akin to equating cancer with a mild cold.
Schizophrenia is a debilitating mental illness usually involving hallucinations and/or delusions, as recently portrayed in the movie "A Beautiful Mind." Caffeine intoxication occurs regularly on most college campuses around exam time.
Schizophrenia should clearly be covered with parity insurance. Caffeine intoxication need not --current levels of coverage are fine for the latter.
The solution to the poison pill is to modify the bill to offer coverage for "serious mental illness," as opposed to all DSM disorders. Serious mental illnesses ought to include: schizophrenia, major depression, bipolar disorder, panic attacks, obsessive-compulsive disorder, post-traumatic stress disorder, severe attention deficit disorder and anorexia nervosa. Others have identified slightly different lists of serious mental illness over the years, but the point is the same: Health care coverage should be offered to those with the most severe and debilitating mental illnesses on a priority basis, rather than treating all mental disorders alike simply because they appear in the DSM.
1
Establishing parity coverage for persons with a serious mental illness will be a great step forward, but it needs to be accompanied by another much-needed reform --the institution of clinical outcome measures. Currently, most mental health providers gather little or no information on the effectiveness of treatment. In other words, there are no outcome data to speak of.
This means that instead of being results-oriented, the mental health system simply focuses on how many units of service are delivered, as if all services were equally effective. They are not, and it is time to improve the quality of mental health care by transforming it into an evidence-based practice focused on results rather than on units of service delivered.
The result of effective care should be that a person with serious mental illness is able to live successfully in his or her home community --with a real job, a real home and real relationships. Tragically, many today are receiving ineffective care that leaves them cycling in and out of treatment and, too often, on and off the streets.
The administration recently launched the New Freedom Commission on Mental Health Care, adding momentum to a growing impetus for mental health reforms. The commission's task is, among other things, to improve the quality of care by selecting and promoting appropriate clinical outcome measures. This should be done at the same time that parity coverage for serious mental illness is implemented, thus providing not only the means for access to care but also the assurance of quality care.
The result? Americans with serious mental illness will be provided the effective services they need. With that, they will be able to live rich, full lives in their home communities. There is no need to mandate parity coverage for caffeine intoxication. But there is every reason to offer that and more to persons who suffer from serious mental illness. The writer is a former mental health commissioner for Virginia. He is currently a visiting research fellow at the George Mason University School of Public Policy and a practicing clinical psychologist.
© 2002 The Washington Post Company
2