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Mental Health Insurance Parity Is an Empty Notion

July 08, 2002|DAVID COHEN and KEITH HOELLER | David Cohen is a professor of social welfare at Florida International University, Miami. Keith Hoeller is editor of the Review of Existential Psychology & Psychiatry in Seattle.

The symptoms of the nation's ailing health-care system are easy to recite. But making an accurate diagnosis and prescribing the proper treatment are difficult. Even with the best of intentions, we might misdiagnose the problem, prescribe the wrong treatment and kill the patient.

This might happen if Congress follows President Bush's lead and passes legislation mandating mental health insurance parity.

The basic idea behind parity legislation is to cover mental illness on the same basis as physical illness. Arguments offered by proponents of parity are well-known: Although one in five Americans suffers from a mental illness, few seek treatment because of the stigma; mental illness is just like physical illness; and new drugs help millions recover quickly.

Each of these claims is misleading, false and dangerous. The stigma associated with mental health treatment has nothing to do with the extent of insurance coverage. This stigma has more to do with the messages that people know come with a psychiatric diagnosis: that they are damaged, that no treatment can cure their illness and that prescribed treatment--usually drugs and more drugs--would be needed indefinitely.

In 1996, outpatient psychiatric drugs accounted for 9% of the nation's direct spending on mental health. This figure has increased dramatically since, with the drug companies' successful marketing. Sales of antidepressants--drugs repeatedly found to be no more effective than placebos--reached $10.4 billion in 2000, and $6.5 billion more was spent on antipsychotics and anti-anxiety drugs.

The mantra of the mental health movement--whose major lay and professional branches, such as the National Alliance for the Mentally Ill and the American Psychiatric Assn., have deep financial roots in the drug companies--has been that mental illnesses are just like physical illnesses and therefore should be covered by insurance. But mental illnesses are precisely not like physical illnesses in at least two fundamental ways: Their diagnosis bears no resemblance to diagnosis in any other branch of medicine, and mental patients routinely get treated against their will.

Before 1980 and the third edition of the American Psychiatric Assn.'s then virtually unknown Diagnostic and Statistical Manual of Mental Disorders, most mental health practitioners did not even make official mental health diagnoses. With insurers wanting standardization to pay mental health claims, however, the American Psychiatric Assn. redesigned the manual to become the standard for insurance payment. No diagnosis, no payment. As a result, the number of mental illnesses has increased, along with new drugs to treat them.

Clinical psychologists initially balked when the revised manual was set to declare that all these new diagnoses were medical "diseases." But when that word was replaced by "disorder," they eagerly began diagnosing and collecting money from insurers.

Most diagnosing in mental health is based on observation. No physical test detects or confirms the presence of any mental illness. Mental health professionals can create new illnesses without any laboratory data to back them up. Nonmedical personnel can diagnose these illnesses simply by looking them up in the manual.

When about 40 million Americans still lack medical insurance and millions more have minimal coverage, and when private coverage of nursing-home expenses is nil, why should mental illnesses be covered by health insurance?

There is another way in which mental illnesses are not like physical illnesses. Psychiatrists and other mental health professionals routinely force their treatments on people who explicitly refuse them and they then get paid by insurers for these "treatments."

That millions more Americans are using a dozen new psychiatric drugs does not mean we are reducing the burden of suffering. The scientific evidence does not show that the incidence or prevalence of any major mental disorder has been reduced over the last 50 years, or even that long-term outcomes have improved.

Clearly, mental health parity would increase coverage for specialty and general medical services such as hospitalization and drugs. However, there is no evidence that parity would encourage the development of a diversified human service sector or that consumers would benefit from easier access to a free marketplace of mental health services.

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