Copyright 1999 Gannett Company, Inc.
USA TODAY
December 14, 1999, Tuesday, FINAL EDITION
SECTION: LIFE; Pg. 7D
LENGTH: 1494 words
HEADLINE:
Mapping the mental-illness fight Surgeon general finds many barriers to
treatment
BYLINE: Marilyn Elias
BODY:
About one out of five Americans has a mental
disorder, and most
can be successfully treated, but nearly half don't even
seek help,
says the first surgeon general's report on mental health, out
Monday.
The groundbreaking document confirms that the barriers
of stigma
and financial cost block good care for many Americans, even as
the nation is at a peak of scientific knowledge on how to cure
emotional
illness.
"A revolution in science has shown us that mental-health
problems
are also physical-health problems," Surgeon General David Satcher
says.
"Blame and stigmatization have been based on a myth that
the
mentally ill have character flaws. But we now know there are changes
in the brain associated with mental problems. These are real illnesses."
And they're expensive in the currency of productive work years
lost, the
report says. For people living in developed nations
such as the USA, mental
illness accounts for 15% of the "burden
of disease" -- that is, total years
of productive life lost to
disability or premature death. That's second only
to cardiovascular
disease, Satcher says.
"Our society no longer
can afford to view mental health as separate
and unequal to general health,"
the report concludes.
Prevention would be the ideal strategy for
battling mental disorders.
But there are multiple causes, a key reason that
prevention is
elusive.
Genes can heighten vulnerability to
illness, but they're not the
full story. Physical factors that influence
brain development
in the womb also may raise the risk. "The causes of most
mental
disorders lie in some combination of genetic and environmental
factors," the report says.
Effects of managed care
When emotional illness strikes, the ability of most people to
get effective treatment hinges on insurance coverage and personal
wealth. Among the worst-off: the 44 million Americans who lack
any
insurance, mostly the working poor.
About 84% have insurance
coverage, chiefly through their employers.
But the employed, insured middle
class is paying a hefty share
of its own mental-health bill, the report
suggests. In 1996, of
more than $ 32 billion spent on
mental-health services for those
with private insurance, $
18 billion came from insurers.
Unequal coverage for
mental and physical illness -- typically
lower benefits and less access to
specialists for mental disorders
-- is a continuing problem. In the past few
years, 27 states have
passed laws to ensure "parity" of access for physical-
and mental-health
treatment, Satcher says.
Although 53% of
Americans have some form of parity in their insurance
benefits, that's often
an empty victory, says Laurie Flynn, executive
director of the National
Alliance for the Mentally Ill (NAMI).
"The money dedicated to mental
health is declining. Yes, they
offer access, but it's access to not much or
not enough," Flynn
says. "These bachelor's (degree)-level counselors may be
fine
for minor adjustment problems, but with serious mental illness
you
need more expertise."
Recent analysis of a California insurance plan
showed it spent
$ 1 per member per year on mental health, she says.
Says Satcher, "I agree that the quality is a key issue."
The most controversial part of the report is on managed care.
The jury is out, the report says, because "research is just beginning
on
how managed-care cost-reduction techniques affect access and
quality."
Some studies find that a shift to managed plans increases the
chances of getting mental-health treatment, especially outpatient
care.
But other research suggests that when plans limit access or
encourage
non-specialists to treat mental-health problems, disability may
increase and work performance decline. It's difficult to generalize,
because managed-care plans vary widely, the report emphasizes.
Satcher puts it more bluntly: "There is no reason to think managed
care lowers the quality of mental-health care." But he concedes
that
"some may think we are giving managed care more credit than
it deserves."
One who definitely thinks so is Michael Faenza, president of the
National Mental Health Association (NMHA), an education and advocacy
group. More than 40 states have turned to some form of managed
care in
their public mental-health systems in the past three years,
Faenza says.
Several independent, scientifically sound studies show that "states
have done a terrible job of writing these contracts with for-profit
firms. There are huge holes allowing access to decline and quality
of
services to decrease. We've lost ground in many states. The
poor and most
severely ill are the big losers."
The problem is "you're only
getting competition around cost,
not quality," says Russ Newman, executive
director for professional
practice at the American Psychological
Association. "The incentives
are to save money, and there's little
accountability for bad service."
Consumers won't keep buying a
"lemon" brand of car, but many
moderate-income Americans feel they have no
leverage for quality
in managed-care plans, he says.
Little
money for prevention
The report "is fair and science-based" on
managed care, says
psychiatrist Jerry Vaccaro, spokesman for the American
Association
of Health Plans, a trade group for managed-care firms.
"There's evidence more do receive help under managed care, although
for many it will be outpatient," Vaccaro says. "Some presume
the
seriously ill need to be in hospitals. But a lot of them don't
look back to
when the mentally ill were warehoused. The 'good
old days' under
fee-for-service mental health were not good."
Primary-care doctors,
often the gatekeepers under managed care,
could detect mental disorders
early, but many aren't up to speed
on the latest science, Satcher says.
Professional groups should
issue guidelines for good practice on mental
health, and medical
schools should better educate future physicians, he
says.
Some prevention tactics have proved to lower the risk of
mental
disorders for children: high-quality preschool programs, parent
education and home visits by nurses when babies are at risk for
problems
because of poverty or having a young, single parent.
Charlotte
McCullough of the Child Welfare League of America doesn't
dispute the
report's findings. "The words are right, but show
me the dollars. We know
prevention works, yet there isn't much
money for it."
She
laments that too few kids with mental disorders are identified
before "they
fail their way into jail or a juvenile detention
system."
The
report agrees that "an alarming number of children and adults
with mental
illness are in the criminal justice system inappropriately."
Boomers
and dementia
Another flash-point problem will be upon us soon, the
report warns.
Baby boomers are surging toward the over-65 years, when the
rate
of such costly disorders as Alzheimer's disease goes straight
up.
Depression also is common, particularly in widowed men, but often
goes undiagnosed by doctors.
"Disability due to mental illness
over 65 will become a major
public health hazard in the near future due to
demographic changes,"
the report says.
Physicians often wrongly
assume dementia is normal in older people,
says T. Franklin Williams of the
University of Rochester Medical
School. That myth hinders testing for the
treatable causes of
dementia and prevents early detection of Alzheimer's,
which can
be slowed for some with medication.
Says Williams, "We
need better treatments, but we also need doctors
to have much more knowledge
about mental health in later years."
The problems depicted in the
report "should be a call to action,"
Faenza says. He hopes the document will
spur health insurance
reforms and encourage public funding of worthy
programs.
"The report can be an historic event that changes how
mental
health is addressed in this country," he says, "or not even
worth
the binding costs if elected officials pay no attention
to it."
TEXT WITHIN GRAPHIC BEGINS HERE
The toll of mental illness
Mental illness is second only to heart disease in industrialized
countries as a cause of lost years of healthy life -- that is,
years
lost to premature death or years spent suffering from severe
disability.
Global rankings
Disease% total years lost to disability
Cardiovascular conditions18.6
Mental illness (includes suicide)15.4
Malignant diseases (cancer)15.0
Respiratory conditions 4.8
Alchohol use 4.7
Infections and parasitic diseases 2.8
Drug use 1.5
Problems in the USA
53 million
Americans -- on in five -- experience some type
of mental disorder each
year; many suffer from more than one.
10 million suffer from serious
mental illness.
2.5 million suffer from schizophrenia
19
million suffer from anxiety disorders
19 million suffer from
clinical depression
GRAPHIC: GRAPHIC, B/W, Web
Bryant, USA TODAY, Sources: Global Burden of Disease study by the World Health
Organization, Harvard and the World Bank, 1990; National Mental Health
Association
LOAD-DATE: December 14, 1999
