Insuring the 'Mentally Ill'

RICHARD E. VATZ and LEE S. WEINBERG

January 11, 1992|By RICHARD E. VATZ and LEE S. WEINBERG

Psychiatry continues to try to medicalize the unavoidable problems of life in a modern, complex society. William Styron's and Mike Wallace's erstwhile depressions receive the profession's imprimatur as ''illness,'' though Mr. Styron wrote of how he willed himself out of his, and Mr. Wallace linked his to a potentially career-threatening lawsuit and other situational problems.

The year just past also saw the discovery of still new ''mental illnesses.'' Typical was the tremendous publicity given to ''body dysmorphic disorder,'' an alleged ''mental illness'' whose major feature, according to psychiatry's diagnostic manual, is ''a preoccupation with some imagined defect in appearance in a normal-appearing person,'' or ''excessive concern'' over ''slight'' physical defects. The manual does not inform us how psychiatrists ascertain whether a person is normal-appearing, or when concern is ''excessive.''

Thomas Szasz, psychiatry's foremost critic, has argued for over 30 years that most of what is incorrectly called ''mental illness'' simply constitutes problems in living, or freely chosen deviant behavior. Illness, Dr. Szasz argues, is exclusively ''a condition of the body . . . a structural or functional abnormality of cells, tissues, organs or bodies.''

For a very few of the so-called ''mental illnesses,'' such as schizophrenia, Dr. Szasz concedes, biological psychiatrists have begun to establish some biological causes. But schizophrenia, he maintains, is diagnosed too frequently. As one neurologist put it, ''schizophrenia is a disease, but many people labeled as 'schizophrenic' do not have schizophrenia.'' And for most other ''mental illnesses,'' no biological basis has yet been shown.

Moreover, ''mental illness'' is so vaguely defined that psychiatry claims that about 20 percent of all Americans suffer from it in any six-month period. A Yale psychiatry professor, Jay Katz, conceded several years ago, ''If you look at [the diagnostic manual], you can classify all of us under one rubric or another of mental disorder.''

But skepticism is increasing, both within and outside the domain of psychiatry, about the medical model for many of the so-called ''mental illnesses.'' Much of the driving force behind the criticism is the exploding cost of all medical treatments, including psychiatric treatments, and the resulting effect on the insurance industry. And insurance coverage is the mother's milk of clinical psychiatry.

Restrictions on mental-health coverage in employers' health plans and through managed care have sown near-panic among mental-health practitioners, judging by articles in the American Psychiatric Association's newsletter, Psychiatric News, and other articles and speeches by leading psychiatrists.

While health costs are rising generally, the Employee Benefit Research Institute reports that the rise in mental-health costs is more than 40 percent higher than the general rise in health costs. The best estimates are that psychiatric coverage constitutes about one-fifth of employers' health-care costs.

Within the psychiatric profession the insurance reimbursement issue has become linked to the issue of whether some ''mental illnesses'' are real illnesses. In a recent Journal of Abnormal Psychology members of the American Psychiatric Association's task force on the revision of the diagnostic manual admit that ''unfortunately, in most instances, biological tests cannot be used even as diagnostic indicators,'' since such tests are not specific to particular ''mental disorders.'' The task force added that '' . . . there are those who want some or all mental disorders designated as diseases in order to protect reimbursement and research funding.''

Those concerned with rising costs of health care and health-care insurance will look critically at whether treatment for ''mental illnesses'' (other than schizophrenia and possibly ''bipolar disorders'' such as manic-depression) should be considered as medical problems. According to the December issue of Psychiatric News, the APA worries that legislators may force it to change its policy ''insist[ing] on parity in coverage for all mental illnesses'' to accept ''insurance parity for a portion of psychiatric disorders.'' The economics of ''mental illness'' may force a closer examination of the way we interpret many problems in living.

Richard E. Vatz teaches rhetoric at Towson State University. Lee S. Weinberg teaches at the Graduate School of Public and International Affairs at the University of Pittsburgh. They are writing an essay on Thomas Szasz for a book on the history of psychiatry.

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