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-Caveat Lector-
http://www.insightmag.com/main.cfm?include=detail&storyid=254286
Money and Madness
June 3, 2002
By Kelly Patricia O'Meara
A child who doesn't like doing math homework may be diagnosed with the
mental illness developmental-arithmetic disorder (No.315.4). A child
who
argues with her parents may be diagnosed as having a mental illness
called
oppositional-defiant disorder (No.313.8). And people critical of the
legislation now snaking through Congress that purports to "end
discrimination against patients seeking treatment for mental illness"
may
find themselves labeled as being in denial and diagnosed with the
mental
illness called noncompliance-with-treatment disorder (No.15.81).
The psychiatric diagnoses suggested above are no joke. They represent
a few
of the more than 350 "mental disorders" listed in the American
Psychiatric
Association's (APA) Diagnostic and Statistical Manual of Mental
Disorders
(DSM-IV), the billing bible for mental disorders which commingles
neurological diseases with psychiatric diagnoses. (Click here to see
more
examples of the mental disorders listed in the DSM-IV.) Whether the
described diagnoses are real diseases or subjective speculation,
science is
at the heart of the debate about whether lawmakers will require
employers
and insurers to cover mental illness on the same level as physical
disease.
Advocates of the Mental Health Equitable Treatment Act of 2002 (S
543), and
its sister proposal in the House (HR 4066), are seeking to expand the
1996
"mental-health parity" legislation. It mandates employers with more
than 50
employees and that offer mental-health coverage to provide insurance
benefits equal to those of standard health care, such as surgery and
physician visits.
The pending proposals would expand the 1996 legislation to require
that
caps, or limitations on coverage, be the same for mental illnesses as
those
provided for medical illnesses, in the name of so-called mental-health
parity. When it comes to "mental illness" and "medical illness"
however,
there is no scientific parity between the two schools of thought.
That is,
only one is based in physical science.
Proponents of mental-health parity believe, and have for the most part
successfully convinced lawmakers, that the mental illnesses described
in the
DSM-IV are medical diseases. For example, obsessive-compulsive
disorder
(OCD) is considered medically equivalent to, say, measles or anemia.
But critics patiently explain that the psychiatric "mental illness" as
described in the DSM-IV is a subjective diagnosis that lies in the
eye of
the beholder rather than in proved medical science. How this issue is
decided, these critics say, likely will determine whether millions of
American families will be priced out of health insurance.
Fred Baughman, a San Diego neurologist and leading critic of the
alleged
mental illness called attention-deficit/ hyperactivity disorder
(ADHD) (see
picture profile, Feb. 18), tells Insight the question that must be
answered
before a mental illness can qualify as a disease is this: "Where is
the
macroscopic, microscopic or chemical abnormality in any living
patient or at
death/autopsy?"
Baughman explains: "No one is justified in saying anyone is medically
abnormal/diseased until such time as they can adduce some such
abnormality.
This, by the way, would apply to a person suspected of having
diabetes or
cancer."
The fact is, Baughman adds, "There is no psychiatric diagnosis for
which any
part of this question can be answered in the affirmative. In other
words: no
abnormality; no disease. There is no confirmation of abnormality in
the
brain in life or at autopsy for any of the psychiatric diagnoses. And
they
[in the psychiatric community] don't say this because it's part of the
propaganda campaign to make patients out of normal people. The
findings at
autopsy would be very specific and would reveal whether it is a
diseased
brain and, if so, which disease it is. There is no proof in life or at
autopsy of any of the alleged psychiatric mental illnesses, including
schizophrenia, psychosis, depression, OCD or ADHD."
Here is Baughman, an internationally respected neurologist, denying
there is
any such thing as an authentic diagnosis of psychiatric disease at
precisely
the same time that Congress appears to be getting ready to mandate
equal and
comparable coverage of psychiatric and medical diseases as the same
thing.
Perhaps lawmakers haven't asked for the supporting science, or
perhaps it
has just been withheld from them.
To try to find out which, Insight sent carefully prepared questions
about
mental illness to the APA and the National Institute of Mental Health
(NIMH), the two leading advocates of mental-health parity. Here are
those
questions:
How many disorders that are listed in the DSM-IV are curable?
What documentable, confirmatory, diagnostic, physical abnormality is
found
in schizophrenia, ADHD and depression?
What confirmatory, diagnostic tests are available and currently
utilized to
detect a chemical imbalance?
The APA would not respond to the questions and the NIMH, which
claimed not
to get involved in policy issues, deferred to a psychiatrist who
refused to
speak on the record. Both groups did, however, suggest reviewing the
1999
Surgeon General's Report on Mental Health, which Insight promptly
read. The
report contained the remarkable statement that, "in the United States,
mental disorders collectively account for more than 15 percent of the
overall burden of disease from all causes and slightly more than the
burden
associated with all forms of cancer."
But nowhere in the surgeon general's report was there any reference
to a
single confirmatory, diagnostic test that proves any physical
abnormality in
any psychiatric diagnosis. More importantly, several chapters into the
report the surgeon general admits what Baughman and other
neurologists have
been saying for years: "The diagnosis of mental disorders is often
believed
to be more difficult than diagnosis of somatic or general medical
disorders
since there is no definitive lesion, laboratory test or abnormality
in brain
tissue that can identify the illness" [emphasis added].
Naturally, one might assume, it would be difficult to diagnose a
mental
illness if there were no confirming physical evidence that one
exists. And
one might even ask the surgeon general how he could make the
statement that
"mental disorders collectively account for more than 15 percent of the
overall burden of disease" when he admits later in the report that
there is
no physical proof thus far of mental disease in any of the psychiatric
diagnoses.
More important, critics say, is his honest admission that there is no
proof
of any physical abnormality that causes any psychiatric mental
disorder.
This begs the question: If there is no way to prove that a single
psychiatric mental illness exists in life or death, how does one
diagnose
something that doesn't exist and then require insurance companies to
pay for
treatment?
While the observations of the nation's top medicine man seem crystal
clear -
and are, in fact, a carbon copy of what critics such as Baughman long
have
been saying about mental disorders - apparently the sponsors of the
pending
legislation missed the surgeon general's report. According to Allison
Dobson, communications director for Sen. Paul Wellstone (D-Minn.), a
cosponsor of the Senate bill, "We know that mental illness is valid
based on
the volumes of science that have been presented to the senator. The
mental
illness thing has pretty much been proved by science."
Sen. Pete Domenici (R-N.M.), the biggest cheerleader for requiring
mental-health parity, didn't respond to Insight's calls. But Michael
Zamora,
the policy adviser for Rep. Patrick Kennedy (D-R.I.), a cosponsor of
the
House parity legislation, tells Insight: "We've had a number of
specialists
from NIMH who have talked about what they're doing. While they don't
have
any diagnostic criteria developed yet, they are making advances and
starting
to document the linkages between the physical and mental. But they
haven't
necessarily been able to establish yet exactly how these are working."
Indeed, says Kennedy's spokesman, "I'm pretty confident and trusting
that
the science base of the National Institute of Health, the surgeon
general
and Nobel laureates have researched this stuff when they say there is
a
science base behind mental illness. I know that the congressman is
confident
that the surgeon general and our premier medical-research facility,
NIMH, is
not full of quacks."
But that's not the issue, critics say. It's whether as-yet medically
proved
illness ought to be paid for by insurance companies, employers and
patients
at the same levels as diseases science physically has confirmed.
Neither former surgeon general David Satcher (author of the 1999
Surgeon
General's Report on Mental Health) nor former NIMH director Steven
Hyman
would agree to an interview to discuss these matters. Given the
official
admission by former surgeon general Satcher it is tempting to
speculate why
the interviews were denied. What is unclear is why lawmakers continue
to
push for mental-health parity with medical disease when, to date,
there is
no physical proof that any of the psychiatric mental disorders can be
confirmed as abnormalities of the brain.
As recently as late May sponsors of the House parity legislation,
Marge
Roukema (R-N.J.) and Kennedy, continued the push to "end
discrimination
against patients seeking treatment for mental illness." In a "Dear
Colleague" letter to members of the House of Representatives
entitled "The
Truth About The Impact of Mental Health Parity," Roukema and Kennedy
attempted to "eliminate any confusion about the DSM." The authors
sought to
give credence to the APA's diagnostic manual, explaining that, "for 50
years, DSM has been widely recognized as the 'international standard'
system
for classifying mental disorders," and the "DSM is the state of the
art of
the knowledge base."
The "Dear Colleague" advocacy letter closed by observing: "There will
always
be those who oppose ending insurance discrimination. . While we
strongly
disagree with them, we look forward to a debate on the facts."
Perhaps so.
But nowhere did the letter so much as mention that none of the
psychiatric
diagnoses in the DSM are based in physical science such as
abnormalities of
the brain found in life or death.
Meanwhile, independent groups representing businesses and other
insurers say
they are alarmed about the financial burden the proposed legislation
is
certain to produce. It is widely estimated that nearly 45 million
Americans
already are without health insurance and there is little doubt that
mandating expanded coverage of undefined "mental disease" will run up
costs
and premiums still further. No one knows how much, but consider these
guesstimates:
In 2001 the Business Journal estimated the likely increase in costs
would be
as high as 40 percent; the National Association of Health Underwriters
suggests insurance premiums likely would increase by 11.4 percent.
The National Federation of Independent Businesses (NFIB) conducted a
study
among its 600,000 members that indicates even existing state benefit
mandates could increase premiums by as much as 30 percent.
An April 2002 PricewaterhouseCoopers report estimates that government
mandates and regulations, which increased 25-fold from 1970 to1996,
will add
$10 billion to the overall increase in health premiums.
Charles N. Kahn III, president of the Health Insurance Association of
America (HIAA), testified before Congress in 1999 that coverage for
psychiatric hospital stays alone already had increased premiums by 12
percent.
In Maryland, a 1992 Blue Cross/Blue Shield Association study
documented "the
most expensive individual benefits were estimated to be substance-
abuse and
mental-health-care services." Outpatient mental-health-care visits
increased
more than 78 percent once mandates were expanded - from 448,000 in
1983 to
800,000 in 1986.
The NFIB, the National Association of Manufacturers, the U.S. Chamber
of
Commerce and the HIAA are among the many organizations opposed to the
parity
legislation. According to Randy Clerihue, a spokesman for HIAA, "We
don't
like this bill because it's going to raise the cost of health care.
It's not
that we don't think mental-health services aren't important, but we
don't
think government should be mandating the kind of insurance employers
purchase on behalf of their employees. The problem comes when you
have a
mandate that forces everyone to pay for something whether they want
it or
not. We're headed in the direction of mandating everyone out of health
insurance."
Each of the many business and insurance groups with which Insight
spoke
expressed similar sentiments and each was aware of a little-discussed
fact:
While lawmakers seem prepared to force private insurers to pay for the
increase in insurance premiums for mental disorders, which then will
be
passed along to employees in the form of higher costs and lost take-
home
pay, the federal government itself is not included - neither Medicare
nor
Medicaid are included in the mandate. Imagine the uproar if payments
for
these had to be increased 40 percent or so!
Bruce Wiseman, U.S. national president of the Citizens Commission on
Human
Rights, a nonprofit organization committed to ending abuses in
psychiatry,
tells Insight: "The government won't include Medicare and Medicaid in
parity
legislation because they know the taxpayers couldn't afford it - it
would
break the bank. And even excluding those programs it will break the
bank
because mental illness is subjective."
According to Wiseman, "Numerous studies show psychiatrists tend
strongly to
use health-insurance benefits up to the point that they are
exhausted, at
which point the patient is declared cured. For instance, a person is
found
to have anxiety disorder up to the insurance cap, whereupon the
psychiatrist
tells them they no longer have it. This kind of diagnosing would milk
the
system dry. In this legislation, the government is saying that if
there's a
million-dollar cap on treating a patient's cancer then there has to
be a
million-dollar cap on treating shyness when it is called social-
anxiety
disorder. So once the person gets 'treated,' the bill reaches the cap
and
they're pronounced cured. Such diagnoses will run insurance costs
into the
stratosphere. Parity legislation is ripe for abuse if for no other
reason
than bogus diagnosis."
The former surgeon general, however, might put an end to the debate
if he
were to testify before Congress about what he wrote in the 1999
report -
that there is no known abnormality in the brain as a marker for any
of the
psychiatric diagnoses. Meanwhile, the critics say, they will continue
to
insist that until a physical cause of mental disorder is identified
it is
not comparable to medical disease and there should be no government
mandate
that insurance companies treat them the same.
Kelly Patricia O'Meara is an investigative reporter for Insight
magazine.
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