Mental Illness in Health-Care Reform
Goodwin, Frederick K., National Forum
The attention being paid to mental illness as the Clinton administration readies its proposal for health-care reform reflects the most promising policy-related development in the field since the Carter years, when mental health warranted a presidential commission, and possibly since the Kennedy era, when legislation for community centers of mental health was introduced as a "bold new approach" to meeting mental health-care needs.
Indeed, the current focus on mental illness is even more momentous in this administration than in those preceding it, for this administration has brought concern for the treatment of mental illness to the fore in all considerations of a national policy on health care. Over the years, "separate but equal" has proved to be no more tenable in health-care policy than in any other facet of our national life. Today, any vestiges of past rationales for separation of "mental" and "physical" disorders are disappearing before accumulating scientific information about the interplay of biology and the psychosocial environment in all aspects of health and, as well, because of the realities of contemporary patterns of servicing and financing.
The position of mental illness in the ongoing process of health-care reform has been made possible by the solid, research-based knowledge accumulated over the past twenty-five years of continuous National Institute for Mental Health (NIMH) research, extending from basic science, through rigorous clinical studies of treatment efficacy, to research in systems of service with emphasis on the effectiveness of treatments in actual community settings and the organization and financing of mental-health care. The credibility that flows from this base of knowledge has permitted us to put to rest three crippling myths about severe mental illness.
Myth 1: Mental illness is not definable.
The Facts: The reliability and precision of clinical diagnoses in the area of major mental illnesses are fully the equal of those of diagnoses in other areas of medicine. In independent assessments, multiple clinicians will agree on the diagnosis of a major mental disorder approximately 80 percent of the time.
Myth 2: Mental illnesses are not treatable, or Everything sort of works for everything."
The Facts: The outcome of rigorous research is documentary proof that treatments for major mental disorders yield success rates of 60 to 80 percent. These are fully comparable to efficacy rates of treatment in many other areas of medicine and are considerably higher than rates for some widely used and accepted treatments. When assessed by the same criteria applied to determine "successful outcome" of treatment of mental disorders, two highly utilized and well-reimbursed procedures for cardiovascular disease-atherectomy and angioplasty-show rates of successful treatment in the range of 40 to 50 percent.
Myth 3: Mental illness is so pervasive that full coverage would "break the bank."
The Facts: Twenty-two percent of the adult population meet criteria for the full spectrum of mental disorders in a given year; by comparison, 20 percent of the population meet criteria for cardiovascular disorders, and 50 percent meet those for respiratory disorders. Of greater relevance in assessing needs for service, only 7 percent of the population have persistent symptoms associated with a mental disorder, and only 9 percent report any disability or meaningful impairment in function associated with their mental illness. These 9 percent comprise 40 percent of those who meet criteria for mental disorder. Eleven percent of the population seeks services for mental health during a given year.
Research in services for mental health provides additional information that is critical to health-care planners; namely, where patients seek mental-health services. A large proportion of mental-health visits (43 percent) occur in the general sector of health, as compared with 40 percent in the specialized sector and 28 percent in the voluntary. …