Sort Out Mentally Ill From ‘Worried Well’ : Health plan: Limit care to true psychiatric disorders; many cases in therapy are simply manageable ‘problems in living.’


A friend of ours started seeing his wife’s psychologist after being told that the wife’s depression could be dealt with only by including him in the therapy. The therapist asked if he wished to be diagnosed with a mental disorder so that his medical insurance would cover the treatment. This true but not unusual story illustrates just one way in which mental-health coverage in the Clinton Administration’s proposed basic health-care package is both fiscally irresponsible and medically illogical.

The outline of the Clinton plan coverage expands mental-health coverage at a time in which the trend of commercial and private insurance coverage has been toward more restriction. The Administration plan allows, for example, 30 outpatient psychotherapy sessions until the year 2001, when treatment would be unlimited. Psychotherapy would be subsidized by the plan if the patient were diagnosed as suffering from one of the hundreds of mental disorders in the diagnostic manual of the American Psychiatric Assn.

The fiscal implications are dramatic, once it is recognized that official psychiatric estimates of the number of Americans suffering from such “mental illnesses” have been expanding exponentially over the last several decades. We used to hear that 10% of all Americans were mentally ill. Then in 1984, after an extensive survey by “lay interviewers,” the National Institute of Mental Health announced that in fact 18% to 23% of all Americans suffered from a psychiatric disorder in any six-month period. More recently, NIMH and the American Psychiatric Assn. have maintained that the figure for any year is more than one-fourth of all Americans. NIMH’s Division of Epidemiology and Services Research claims that 52 million American adults have a diagnosable mental illness. If all 52 million took advantage of the 30 subsidized visits, it would account for more than a billion psychiatric sessions a year.

Given the nebulous behavioral criteria for psychiatric diagnosis, there is really no scientifically sound way to confirm or disconfirm a diagnosis. Nearly any patient could be diagnosed as suffering from “adjustment disorder,” for example--a catch-all mental disorder defined by psychiatry’s diagnostic manual as “a maladaptive reaction to an identifiable psychosocial stressor.” Unlike real physical illnesses, “mental illnesses” have no measurable pathology specific to their diagnoses, and for more than 95% of Americans, there is not even a serious claim of physically caused psychiatric disorder.


Beyond neglecting the issues surrounding diagnostic categories, the Clinton plan fails to limit who will have the authority to make such diagnoses. Under the plan, any health professional “who is licensed or otherwise authorized by the state to deliver health services,” such as psychologists and psychiatric social workers in many states, would be authorized to diagnose (and/or treat) “mental illness.” As for substance abuse, another alleged type of “mental illness” already extensively subsidized by state and local governments, the Clinton plan allows for unlimited counseling and treatment by a “licensed or certified substance abuse treatment professional.”

When President Clinton mentioned mental health in his health-care address, there was much applause. Mental-health expansionists have successfully managed to create an association in people’s minds between mental illness and pictures of pathetic, deranged people who speak incomprehensibly or are incapacitated. Even the American Psychiatric Assn. argues that only about 4.5% of the public is in that category. The rest of the “mentally ill” are mostly the “worried well” with problems in living, most of which are manageable without further taxing the overly taxed health care dollar.

Only “severe mental illness” (schizophrenia, bipolar disorders such as manic depression and major depression) should be covered at even near-parity with physical illness, and there should be extensive utilization review to ensure that even categories of severe mental illness are not applied simply at the whim of a single practitioner.

Mental illness, unlike physical illness, is an infinitely expandable category; we cannot afford the costs of allowing all of humankind’s problems in living to be transmogrified into “diseases.” We can provide care to the severely mentally ill, whether brain-diseased or not, without throwing the entire nation into what psychiatric critic Thomas Szasz calls the therapeutic state, wherein problems in living become medicalized at an unaffordable price tag to a nation with severe enough real medical needs.