OPINIONS

A Golden Age of Mental Health

In the past six years, more has been done to rectify the mental health situation in American healthcare than in the past six decades. Contrary to popular belief, the historical tragedies of mental health treatment in America—which include forced lobotomies, long-term confinement in prison-like state hospitals and a plethora of quack remedies—resulted only partly from stigma, fear and misunderstanding. The other key causal factor was money: specifically, the collective unwillingness of society to fund addiction and mental illness treatment at the same level as other parts of the health care system.

For most of U.S. history, employers did not provide adequate mental health benefits in the insurance packages they assembled for employees. This wasn’t a controversial policy: most labor unions were quite happy to trade “mental for dental” when they negotiated fringe benefits. But over time, more and more families who were being destroyed by a loved one’s schizophrenia or alcoholism or manic depression went through a second round of suffering when they discovered that their employer-based insurance wouldn’t pay for care.

These families made common cause with other advocates to mount a 12-year push for equal treatment, which culminated in the 2008 Wellstone-Domenici Mental Health Parity and Addiction Act. As a result of this law, the more than 100 million Americans who receive insurance through large employers are now guaranteed that their mental health-related benefits will be comparable to those for the treatment of other disorders.

Also in 2008, a major effort to reform Medicare passed, one that critically included a little-noticed mental health provision that just came into full effect this year. Since its creation, Medicare had covered 80% of all outpatient care except for mental health and addiction treatment, only 50% of which was covered. This extremely high co-payment effectively prevented many Medicare recipients from receiving mental health care. Today, however, the 50 million senior citizens and disabled persons who rely on Medicare enjoy the same level of coverage for outpatient psychiatric care as they do for all other types of medical treatment.

The 2010 Affordable Care Act is even more transformative. The law allows a parent to keep their children on family health insurance until the age of 26, thereby fully covering the age range in which almost all serious mental illnesses and addictions begin. Furthermore, the law defines insurance coverage for mental illness and addiction care as “essential health benefits.” As a result, both the Medicaid expansion and the private plans sold on health exchanges all cover care for psychiatric disorders at the same level as other diseases. The Department of Health and Human Services estimates that over 60 million Americans will receive improved mental health insurance coverage because of the provisions of the ACA.

The public policy revolution constituted by these three laws will literally be lifesaving for many American families. They also reflect a welcome cultural shift: mental health care has gone mainstream. Presidents George W. Bush and Barack Obama, despite their markedly different political views, nonetheless both supported expanded access to mental health care. Even during the bitter, hyper-partisan fight over the Affordable Care Act, its mental health-related provisions were largely uncontroversial in both major political parties.

Virtually everyone in this country, Republican or Democrat, Texan or Oregonian, young or old, rich or poor knows a family that has grappled with addiction or mental illness. This common knowledge has produced a rare moment of national agreement to respond to these disorders with the same seriousness and compassion as we do to cancer and heart disease.

The challenges of mental health care remain significant—most particularly, the need to expand the pool of trained providers to respond to the needs of the many individuals who, now that they can afford to do so, will be seeking help this year for the first time. But the most fundamental victory—persuading American society that mental health problems are legitimate disorders worthy of effective treatment—has already been won, setting the stage for what should be a golden age of mental health.

Keith Humphreys, Ph.D.

Professor and Director of Mental Health Policy, Department of Psychiatry and Behavioral Sciences, Stanford University

Contact Professor Humphreys at knh@stanford.edu.

  • alum

    Funny the author doesn’t mention the most important thing that happened in 2013 in the field of so called, “mental health”, namely, that both the NIMH and the APA agree that none of the DSM labels have been shown to have scientific validity and that most of the so called “mental health interventions” are about as valid as astrology or witchcraft,

    http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

    “In a few weeks, the American Psychiatric Association will
    release its new edition of the Diagnostic and Statistical Manual of
    Mental Disorders (DSM-5). This volume will tweak several current
    diagnostic categories, from autism spectrum disorders to mood disorders.
    While many of these changes have been contentious, the final product
    involves mostly modest alterations of the previous edition, based on new
    insights emerging from research since 1990 when DSM-IV was published.
    Sometimes this research recommended new categories (e.g., mood
    dysregulation disorder) or that previous categories could be dropped
    (e.g., Asperger’s syndrome).1

    The goal of this new manual, as with all previous editions, is
    to provide a common language for describing psychopathology. While DSM
    has been described as a “Bible” for the field, it is, at best, a
    dictionary, creating a set of labels and defining each. The strength of
    each of the editions of DSM has been “reliability” – each edition has
    ensured that clinicians use the same terms in the same ways. The
    weakness is its lack of validity. Unlike our definitions of ischemic
    heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a
    consensus about clusters of clinical symptoms, not any objective
    laboratory measure. In the rest of medicine, this would be equivalent to
    creating diagnostic systems based on the nature of chest pain or the
    quality of fever. Indeed, symptom-based diagnosis, once common in other
    areas of medicine, has been largely replaced in the past half century as
    we have understood that symptoms alone rarely indicate the best choice
    of treatment.”

    The chairman of the DSM-5, David Kupfer, went on to say in his response,

    http://www.psych.org/File%20Library/Advocacy%20and%20Newsroom/Press%20Releases/2013%20Releases/13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf

    “The promise of the science of mental disorders is great. In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant. We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting. In the absence of such major discoveries, it is clinical experience and evidence, as well as growing empirical research, that have advanced our understanding of disorders such as autism spectrum disorder, bipolar disorder, and schizophrenia.”

    Which in lay terms means, psychiatry and psychology amount to little more than witchcraft. The above, of course, begs the question of whether the Wellstone-Domenici Mental Health Parity and Addiction Act violates the establishment clause of the first amendment.

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