BY: FR. MICHAEL D. PLACE, STD
Even more than other areas of health and medicine, the mental health field is plagued by disparities in the availability of and access to its services . . . . A key disparity often hinges on a person's financial status.
—U.S. Surgeon General David Satcher
Perhaps the greatest single event in the history of humanity's long, generally bleak attempt to deal effectively with severe mental illness came in 1952 when a French physician named Henri-Marie Laborit discovered that a chemical he used to relieve surgical shock also calmed people caught in the grip of psychosis.
Laborit's drug—called Thorazine in this country—helped end the practice of locking up disturbed people for life in warehouse-like mental hospitals. Beginning in the 1960s, doctors were able to discharge such patients to live more or less normal lives with the help of Thorazine or some similar chemical agent. Most of the old hospitals—long known as "snake pits"—were closed.
Another signal event in this history occurred late last year when the U.S. surgeon general's office issued its first-ever report on mental illness in the United States. In a preface to the report, Surgeon General David Satcher, MD, PhD, said that although mental and behavioral disorders affect one in every five Americans in any given year, we have traditionally been reluctant to discuss them with the same openness we grant other diseases. "Fortunately, leaders in the mental health field . . . have been insistent that mental health flow in the mainstream of health," Satcher wrote.1 "I agree and issue this report in that spirit."
Positive Trends in Mental Health Care
The surgeon general's report noted six positive trends in contemporary mental health care.2
Increased Awareness of the Biological Roots of Mental Illness Before Laborit, psychiatrists tended to seek the causes of severe mental illness outside the body. Treatment was essentially limited to confinement, psychotherapy, and such radical measures as electroshock and brain surgery. Laborit's discovery was important not just because it produced an effective psychiatric medication but also because it suggested that mental disturbances have organic roots.
Expanded Scientific Research on the Brain and Human Behavior Since the 1970s, medical science has developed an increasingly sophisticated range of drugs, both for severe mental distress and for milder problems, such as anxiety and depression. These drugs have been accompanied by a variety of new psychotherapies.
The Move from Long-Term Institutional Care to Community-Based Care As mentioned, the new therapies have made it possible to treat many patients in their own communities. In one approach (the "assertive community treatment"), multidisciplinary teams of professionals provide treatment and psychosocial services on a community basis.
The Rise of a Consumer Movement Recent decades have seen the growth of a movement dedicated to the protection of patient rights and to improvement in the planning, delivery, and evaluation of mental health services. To receive federal block grant funds, for example, states must establish mental health planning councils on which sit consumer and family representatives.
Changes in the Organization and Financing of Mental Health Services Since the closing of the old state hospitals, mental health care has been dramatically reorganized. Today's system spans both the public and private sectors, including mental health providers and social service, housing, criminal justice, and educational agencies. Medicaid, funded by matching federal and state grants, provides a safety net for severely ill people in need of catastrophic and specialized services. These services are increasingly operated under managed care arrangements.
The Growth of Private-Sector Coverage The private sector, working primarily through employer-based insurance, offers services to people with less serious mental and behavioral problems.
Problems in Mental Health Care
Although the past half-century has seen dramatic progress in mental health, a number of problems remain. One is that, despite all the scientific revelations, the origins of mental illness are still mysterious. Some varieties, like those treated with Laborit's drug, appear biological in nature. Others seem to be the result of environmental factors (family dynamics, for example). In still others, organic and environmental factors are intertwined. It will obviously be some time before these mysteries are cleared up.
In the meantime, society—rather than science—will eventually have to tackle certain other grave dilemmas.
Fraying Medicaid Coverage Medicaid provides most of the money the states use in their public mental health care systems. To conserve this money, the majority of state systems have adopted managed care programs. But for a number of reasons (failure to provide care to certain populations, for example), some of these states have dropped their managed care contracts. At the same time, many commercial programs have left the Medicaid market, usually because of what they see as inadequate state funding.
Missing Medicare Coverage for Medication Medicare provides older people with coverage for mental health services, including inpatient care, outpatient care, partial hospitalization, and medical management. Unfortunately, Medicare does not cover the costs of medication, despite the key role—which I've emphasized here—that medication plays in modern mental health therapy. This is one reason Medicare's exclusion of coverage for pharmaceutical costs is shaping up as a hot topic in the current presidential campaign.
Retrenchment in the Private Sector Most employers are doing with their workers what public health systems have done with clients: moving them into managed care plans. Unfortunately, these private plans tend to limit the mental health services provided. In many cases, the plans provide narrower coverage for mental health problems than they do for other health concerns. The passage of the Mental Health Parity Act of 1996 represents a federal attempt to establish parity between mental health coverage and coverage for other illnesses; in addition, 32 states have passed some sort of parity legislation. Nevertheless, private coverage for mental and behavioral illness continues to lag behind that for other illnesses.
Demolishing Ancient Barriers
On one hand, as the surgeon general makes clear in his report, neuropsychiatric science has in the past few decades made strides that would have been unimaginable for our grandparents. Because of them, the shame and secrecy that used to surround mental illness are at last beginning to go away.
Yet at the same time, as Satcher notes, "formidable financial barriers block off needed mental health care from too many people." These barriers—ranging from insurance with inadequate mental health benefits to no insurance at all—were built in the days when mental distress was seen as a curse rather than as an illness, Satcher argues. "We have allowed stigma and a now unwarranted sense of hopelessness about the opportunities for recovery from mental illness to erect these barriers," he says. "It is time to take them down."
The Catholic Health Association, a leader in the effort for affordable and accessible health care for all, joins the surgeon general in calling for the demolition of these ancient barriers. Mental health care, an integral part of health care, should be available to everyone who needs it.
For more information, contact the Alliance for Health Reform, 1900 L Street N.W., Suite 512, Washington, DC, 20036; phone: 202-466-5626; www.allhealth.org
Fr. Place is president and chief executive officer, Catholic Health Association, St. Louis.
NOTES
1. Mental Health: A Report of the Surgeon General, U.S. Public Health Service, Washington, DC, 1999.
2. Mental Health 2000: A New Century, A New Era, Alliance for Health Reform, Washington, DC, 2000. Much of the information in the paragraphs that follow is taken from this publication.