Sunday, December 9, 2001

Pending passage by the House, a bill “outlawing disparities in coverage between mental and physical illness,” approved by the Senate in November, will become law.

“All too often,” complained Sen. Pete V. Domenici, New Mexico Republican, “insurance discriminates against illnesses of the brain.”

That statement and the argument for so-called parity for mental illness it supports is simply not true. Neurologists and neurosurgeons do not lobby for parity insurance for their patients because insurance companies have no special exclusions for patients with neurological diseases. Only psychiatrists lobby for such “parity.”

Advocating “parity for mental illness” is a hoax. The supporters of “mental health parity” do not want parity for mental patients: They do not seek equal “legal treatment” by legislators and courts for mental patients and medical patients. What they want is parity for psychiatrists: They seek equal “monetary treatment” by health insurance companies for psychiatrists and other physicians.

The claim that mental illnesses are brain diseases is as old as psychiatry itself. Since mental patients are no longer exiled to asylums, most people have suspended their critical faculties regarding the assertion that “mental illness is like any other illness,” until they themselves become the unwilling beneficiaries of a serious psychiatric diagnosis.

The logo of the National Alliance for the Mentally Ill (NAMI), the most influential mental health lobby in the nation, proclaims: “Mental diseases are brain disorders.”

A 1999 White House Fact Sheet on Myths and Facts about Mental Illness stated: “Research in the last decade proves that mental illnesses are diagnosable disorders of the brain.” Tipper Gore, then President Clinton’s mental health adviser, added: “One of the most widely believed and most damaging myths is that mental illness is not a physical disease. Nothing could be further from the truth.” “Mental illness is as physical as any disease that is now covered by our insurance system,” declared Sen. Debbie Stabenow, Michigan Democrat, a few weeks ago.

The phenomena we label as mental illnesses are not brain diseases, and everyone knows it. That is why psychiatrists protest that mental illnesses are bodily diseases, and why politicians proclaim the disease status of mental illness.

Politicians say that mental diseases are brain diseases, but don’t mean it. Lawmakers regard mental diseases as quasi-crimes: They pass laws that authorize psychiatrists and judges to deprive innocent persons of liberty by confining them in mental hospitals. There are commitment laws for persons diagnosed with mental diseases; there are no such laws for persons diagnosed with brain, lung, or liver diseases. Mental patients are often treated against their will and they can plead mental illness (insanity) as an excuse for murder; medical patients cannot be treated against their will and cannot plead bodily illness (brain disease) as an excuse for murder. So much for parity for patients.

Most people who now hear the term “mental illness” act as if they were unaware of the distinction between the literal and metaphorical uses of medical words. Typhoid fever is a disease, spring fever is not. Pneumonia is a literal disease, pyromania is a metaphorical disease. As presently framed, the debate about parity for mental health care is thoroughly misleading. The self-declared supporters of “parity” oppose parity in the legal statuses of medical and mental patients.

It is obvious that true parity for “mental illness” would bankrupt the payers: Loose and subjective criteria for diagnosing mental illness make everyone, at all times, a potential sufferer from such an illness. (Virtually every American could now credibly claim to be suffering from post-traumatic stress disorder.) Open-ended “treatment” plans for mental illness, with no cure in sight, make a mockery of the notion of cost-effectiveness. (To be sure, this could be avoided by defining “treatment” as writing prescriptions for mind-altering drugs.) Added to these staggering expenses would be the limitless costs of disability claims filed by patients with diagnosed but uncured and incurable mental illnesses.

Sooner or later, we shall have to confront the nature of “mental illness” and the differences between the legal statuses of mental patients and medical patients. The longer we postpone this confrontation, the greater will be the injury inflicted on our health care system and on the moral fabric of our society.

Thomas Szasz is professor of psychiatry emeritus at the State University of New York, Upstate Medical University, in Syracuse. His most recent book is “Pharmacracy: Medicine and Politics in America” (2001).

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