When the Cure Is Not Worth the Cost
ON its face, providing equal coverage for mental and physical illnesses sounds like a good idea, something only a managed-care bean counter could oppose. To that end, Representatives Jim Ramstad, Republican of Minnesota, and Patrick Kennedy, Democrat of Rhode Island, have introduced the Paul Wellstone Mental Health and Addiction Equity Act.
Named for the senator who was long an advocate for mental health “parity,” it would require that private insurers pay for as much treatment for mental illnesses and addiction as they do for physical illnesses.
Senators Ted Kennedy, Democrat of Massachusetts, and Pete Domenici, Republican of New Mexico, have introduced a similar bill in the Senate. President Bush has said he will sign the legislation if it passes.
Unfortunately, this change would not be as benign as it appears. Unless mental health parity is tied to evidence-based treatment and positive outcomes, generous benefits may become a profit bonanza for providers that does little to help patients.
Thanks to research by the National Institutes of Health and academic scientists during the last three decades, we now have proven treatments for depression, addiction and other mental disorders. But all too often clinicians do not use them.
Without financial incentives to provide treatments that are known to work, many mental health professionals stick with what they know, or pick up on the latest fad, or even introduce their own untested innovations — which in turn are spread by testimonials and credulous news media coverage.
Take the well-known approach featured on the cable TV reality show “Intervention” aimed at getting addicts and alcoholics into treatment. Here, the family and sometimes the employer gather with a counselor, confront the addict and threaten to shun him or fire him if he doesn’t enter a rehabilitation center. A 1999 study compared this style of intervention — which can backfire and lead to broken families — to a less confrontational approach known as “community reinforcement and family training,” which is aimed at helping the family nurture the addict’s own motivation.
More than twice as many families succeeded in getting their loved ones into treatment (64 percent) with the gentler approach than with standard intervention (30 percent). But no reality shows push the less dramatic method, and it is difficult to find clinicians who use it.
Similarly, one of the most common approaches to alcoholism treatment involves having counselors and fellow alcoholics confront patients and force them to identify themselves as alcoholics. But research finds that the more a counselor confronts, the more a patient drinks and the more likely he is to drop out of treatment. And no association between accepting the label “alcoholic” and quitting drinking has been found. Counselor empathy — not confrontation — is connected with recovery.
According to a review by the Institute of Medicine in 2006, only 10.5 percent of alcoholics received “care consistent with scientific knowledge” of the disorder; similarly, 43 percent of children in psychiatric hospitals are given antipsychotic medication despite not suffering from psychosis. Tough boot camps for troubled teenagers — which have been proven to be ineffective and potentially harmful — thrive, while “multisystemic family therapy,” which effectively treats teenagers at home, is available only through the juvenile justice system.
Even in general medicine, research is sometimes slow to be translated into practice — but mental health care is often entirely disconnected from evidence. Some therapists argue that the human mind is too complex and variable to allow for standardized treatments. But shouldn’t they at least start with approaches known to work for the largest number of patients?
If we want to provide genuine help for the 33 million Americans with mental health and drug problems, giving more no-strings-attached money to providers via insurance mandates is not the answer. It is dangerous to blindly bolster useless and even harmful treatments while failing to support proven therapies. Coverage must be tied to outcomes and evidence. And payment should be dependent, at least in part, on health improvements, not just services received. We need parity in evidence-based treatment, not just in coverage.
Maia Szalavitz, the co-author of “The Boy Who Was Raised as a Dog: And Other Stories From a Child Psychiatrist’s Notebook,” is a senior fellow at Stats, a media watchdog group.