A Poor State of Mind : Despite gains in treating mental illness, it's harder than ever for most people to get help. The stigma is strong and high costs have insurance companies backing away.

TIMES HEALTH WRITER

It has been called the Decade of the Brain. And, in terms of knowledge, that may be true.

But in terms of treatment for mental disorders, this could be "the year of the broken brain."

Just when a wealth of effective treatments and new knowledge is pouring into the field of mental illness, a person's chance of getting treatment is harder than ever, health-care providers say.

The cost of care is one problem. From nationwide health insurance reductions to local fiscal crises--such as Los Angeles County's decision to cut mental-health services from USC-County Hospital--fewer mentally ill people have the money or insurance to seek treatment.

"With the fiscal problems cities and states are having, we see the potential to lose all the gains we've made from the answers science has given us," says Rona Purdy, president of the powerful National Alliance for the Mentally Ill in Arlington, Va.

But the other half of the problem is an old one. It used to be called stigma, says Martha Sherwood, an advocate at the Mental Health Assn. of Los Angeles County, who coined the term "year of the broken brain."

"We tend to use the word discrimination now, because that is what it is. There is a longstanding, pervasive discrimination against mental illness due to fear and misunderstanding and myth. It dates back to ancient times when odd behaviors were thought to be related to religious beliefs."

However, in a battle with the state Legislature that has already spanned 10 years, mental-health advocates are trying once again to end what they say is unfair insurance practices for people with severe illnesses.

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A bill sponsored by the California Alliance for the Mentally Ill would prohibit insurance discrimination for certain illnesses, including schizophrenia, bipolar disorder, severe depression, panic disorder, obsessive-compulsive disorder, schizo-affective disorder and pervasive developmental disorder. The legislation stalled this year in committee and will be taken up again in January, says Lori Holman, a legislative representative for the alliance.

Despite the health-care crisis, Holman and others believe the time is right to fight for improved coverage for the mentally ill.

Unlike a decade ago when mental-health advocates stepped up their efforts for increased health-care coverage, recent scientific advances have provided significant evidence that several mental disorders are biologically based.

"When the brain becomes ill, it must be treated, just like other organs of the body," says Holman in a statement on behalf of the California Alliance for the Mentally Ill. "Likewise, its treatment should be covered by the same health-care plan that covers the body's other organs. To do otherwise is discriminatory."

Also at issue is whether it's good to pursue parity for the serious mental illnesses at the exclusion of all other mental disorders. Some experts argue that it is wrong to deny treatment to people with mental problems that emerge from life events, such as a divorce or death of a loved one.

"We think the situation can be compared to the rest of medicine," says Dr. Bernard Arons, of the Center for Mental Health Research in Washington, D.C. "Even if you have a cold, you may have to go to the doctor for some intervention. In the same way, if you have mild blues you may want to see a doctor so you don't develop a major depression."

Nationwide, only 21% of health-insurance policies provide coverage comparable to coverage for physical illnesses, according to the National Alliance for the Mentally Ill. And only 2% offer comparable outpatient coverage. More than 60% of HMOs and preferred-provider organizations (PPOs) specifically exclude treatment for people with serious mental illnesses.

Insurance-industry officials say they fear that adding mental-health benefits to plans would cause more employers to simply opt for no health insurance for their employees.

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While the lack of insurance coverage for mental illness has always been troubling, the disparity has become even more frustrating as diagnosis and treatment for a growing number of mental disorders improve dramatically, Purdy says. According to the National Institute of Mental Health, 95% of what is known about the brain has been learned in the past 10 years.

"We have learned so much about the brain. But we still have the stigma about treating the illness--even though the treatment success rates are better than for many physical illnesses," she says.

For example, many new medications are now available for treatment of schizophrenia, major depression, obsessive-compulsive disorder and panic disorder, expert says.

Overall, treatment for panic disorder and bipolar disorder is now effective in 80% of cases, the National Alliance says, and treatment for major depression is effective in 65% of cases. About 60% of people with schizophrenia and obsessive-compulsive disorder improve with treatment.

The real proof that mental disorders are not different than illnesses like cancer and heart disease, however, rests in brain imaging techniques that show how the brain is defective or sick. Brain scans of schizophrenics, for example, have clearly revealed areas of the brain that are dysfunctional.

Moreover, in a scientific paper published earlier this year, two Thousand Oaks psychiatrists describe a technique that, they say, shows whether certain medications are working.

Drs. Stephen C. Suffin and W. Hamlin Emory first take EEG scans (electroencephalography) of a mentally ill person to observe his or her particular brain-wave patterns, which appear different than those of healthy people. They can then prescribe for the patient a medication that has been previously shown to be successful in similar-aged patients with the same abnormal EEG pattern. "You can see the differences compared to the normal [scans] and then see them improve," Suffin says. "It gives you objective evidence that the treatment is working."

Advances such as these are critical to breaking the stigma of mental disorders, he says.

"There is a real feeling in society that it is difficult to distinguish between those who are taking a ride on the system and those who are really sick. There haven't been ways to measure brain dysfunction before using the medical model."

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Being able to actually see a sick brain--on a brain scan picture, for example--and then see it improve, will help convince both the public and health insurers that many serious mental illnesses are biologically based, Emory says.

"We now have a repertoire of medicines in numerous classes, and these medicines are very effective in some people. And, in some cases, the biochemistry of these medicines is very well understood," he says.

But Emory says that, until now, scientific proof that the medicines or therapeutic techniques actually worked has been lacking. To judge the effectiveness of a treatment, health professionals could only observe patients' behavior and ask them how they felt.

Holman says these scientific advances will weigh heavily in efforts to require equal insurance coverage for serious mental illness.

"We think we can prove now that these illnesses are medical illnesses, not psychological problems," she says. "There is tons of research that these illnesses are medical."

To clarify their position that the serious mental illnesses are brain disorders, Purdy is leading an effort to change the public lexicon regarding mental illness. She states that biologically based illnesses, such as schizophrenia, should be called "mental illness," or, better yet, "brain diseases" and kept separate from "mental health problems" that apply to relationship problems or stressful life situations.

"Mental health applies to half of America," she says. "Mental illness is a small part of America. Those people with mental illness have to separate themselves out. Not that life problems aren't real, but they are not the same as mental illness. We've clouded the issue by trying to get all forms of mental-health coverage in the same ball of wax."

It would be more appropriate, Purdy says, to compare major depression and panic disorder to Alzheimer's disease and epilepsy--known brain diseases that are routinely covered by insurance--rather than to mild depression from marriage or financial difficulties.

She says she agrees that it's important to prevent mild mental-health problems from becoming major disorders. But, she says: "The sickest must come first."

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Jerri Voss is in the latter group. The Santa Clarita woman, 30, last year was found to have bipolar disorder, in which depressive periods alternate with episodes of mania or euphoria. A former kindergarten teacher, Voss quit her job because of her illness. Her husband's employer offered no medical insurance. But because of his income, Voss did not qualify for Medi-Cal. The couple, who have three children, can't pay the bills for her four hospitalizations last year, outpatient counseling appointments and the four medications she takes daily.

Voss spent weeks on the telephone earlier this year calling insurance companies to see if the family could purchase medical coverage.

"It was impossible," she says. "Some companies didn't offer mental-health insurance at all. Others turned me down because my illness was a pre-existing condition. It's not fair that we can't get any help."

Voss says she is receiving treatment at the Santa Clarita Mental Health Center, but is unable to pay the small amount requested by the center.

A parity bill will not help people like Voss. The bill would require equal coverage of the serious disorders in all indemnity policies, HMOs and PPOs offering or providing benefits in California. It would not include self-insured plans, government employees or Medicaid coverage.

Even when opponents of parity acknowledge the scientific evidence that illnesses are biologically based, they say it will be too expensive to extend coverage to the depressed, panic-stricken and schizophrenic of the world.

"People say it will cost too much. Others tell us all this [legislation] would do is convince businesses to drop health-insurance coverage altogether," Holman says.

The bill is opposed by the California Assn. of HMOs because "it would make HMO premiums more expensive," says Tina Tinjus, a spokeswoman for the group. Many small-business owners already refuse to offer any health-care coverage to employees because of cost, she says, "so we feel this would make the goal of universal coverage harder to reach."

Six states have already adopted some form of parity for mental illness, and legislation has been introduced in at least 16 more, Purdy says.

A study in Texas, where parity is required for the serious mental disorders, showed an additional cost to insurance policies of about $30 per person, Holman says.

"The actual cost is not that great," she says. "The truth is, there are no good arguments against this. We just don't respect people who are mentally ill."

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