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June 3, 2002
Money and Madness
By Kelly Patricia O'Meara
Insight on the News-National Issue
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:
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:
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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