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A New Deal for the Mentally Ill (6 Letters)

A New Deal for the Mentally Ill (6 Letters)

To the Editor:

In “When the Cure Is Not Worth the Cost” (Op-Ed, April 11), Maia Szalavitz says “providing equal coverage for mental and physical illnesses sounds like a good idea,” but only if “mental health parity is tied to evidence-based treatment.”

I applaud her wish that all patients with psychiatric illness get the best care possible. But as a psychiatrist, psychoanalyst and psychopharmacologist, I know that I need the flexibility to fit the treatment to the individual’s needs.

Many patients have a limited response to treatments that have “gold standard” evidence of efficacy. It is not unreasonable to consider decades of clinical experience when offering other options.

I also know that evidence supporting expensive treatments — like twice-weekly psychotherapy or intensive day treatment for certain disorders — is often ignored by those who decide what is covered.

I had the privilege to work on mental health policy for Paul Wellstone, the senator from Minnesota who pushed for parity legislation before his death in 2002. Senator Wellstone was well aware that policies that attempt to block every possible abuse can end up preventing millions of people from getting the care they need. Richard Gomberg, M.D.

Waban, Mass., April 11, 2007

The writer is an instructor in psychiatry at Harvard Medical School.

To the Editor:

Maia Szalavitz makes the important point that many mental health practitioners provide treatments when research has shown that another treatment is quite effective.

But many patients receive insurance coverage for ineffective medical treatment. Why should mental health be treated differently?

Although parity for mental health would surely lead to insurance reimbursement for some ineffective treatment, it would also help to alleviate the suffering of many patients who cannot afford to pay for treatment. And research has found that psychological treatment can more than pay for itself by reducing medical costs.

A mental health parity law would do a lot more good than harm.

Milton Spett

Cranford, N.J., April 11, 2007

The writer is the co-founder and a director of the New Jersey Association of Cognitive-Behavioral Therapists.

To the Editor:

If only proven treatments are covered, then effectively there will never be any new treatments in the future.

As time goes by, ineffective treatments fall by the wayside, but not before adding to the body of medical knowledge.

Besides, how would we know that the TV-style interventions with alcoholics, which Maia Szalavitz criticizes, are less effective than “community-reinforcement and family training” if data hadn’t been collected on large numbers of people over time? Lisa Wiseman, M.D.

Austin, Tex., April 11, 2007

To the Editor:

How very honest are the comments by Maia Szalavitz about bills in Congress to ensure “parity” of mental health care with that of physical health care.

The truth is, “If we want to provide genuine help for the 33 million Americans with mental health and drug problems,” we must first ask why there are so many.

When I read about these bills, I saw huge increases in costs, with increasing numbers of people identified as having a mental illness, more prescription drugs, more unproven treatments coming out of the woodwork. As if our health costs weren’t enormous already. Mimi Barron

Fredericksburg, Va., April 11, 2007

To the Editor:

Maia Szalavitz’s plea for evidence-based mental health treatment opens a Pandora’s box of ills that will both cripple and cramp clinicians, and leave many of their clients holding a bag of bills.

Over the years, there have been a host of contradictions in what constitutes appropriate treatment. As with the breakthrough diet that may become tomorrow’s dietary disaster, today’s “cure” often turns out to be tomorrow’s quackery.

More important, while many clients do respond to specific evidence-based treatments, many others do not, forcing the clinician to try several different ones until the most effective one is found. You can bet your deductible that insurance companies will not pay a penny for any but the single prescribed treatment.

Michael M. Gindi

Deal, N.J., April 11, 2007

The writer is a psychologist.

To the Editor:

It is the quality of the therapeutic relationship that most often determines outcome, not the particular therapeutic procedures utilized.

Research clearly indicates that the personality of the patient and the ability of the therapist to establish a therapeutic alliance are what determine treatment outcomes. So much of the effort to identify evidence-based treatments is misguided because it focuses on the techniques rather than relationship.

Sidney J. Blatt

New Haven, April 11, 2007

The writer is a professor of psychiatry and psychology at Yale.

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