http://www.washingtonpost.com/wp-dyn...2002Apr26.html

A 941-Page Manual Takes On More Weight
'DSM' Will Be at the Center of Debate on Bush's Proposal for Mental Health 'Parity'

By Shankar Vedantam
Washington Post Staff Writer
Saturday, April 27, 2002; Page A02


In his administration's first major initiative on mental health, President Bush is expected to announce Monday his support for "parity," legislation that would require large employers to extend the same health benefits for mental illnesses that they do for physical ailments.

As word of the initiative broke on Thursday, it appeared that mental health advocates' long fight for parity was finally nearing resolution. Though House Republicans have long opposed parity, advocates reasoned that the president's support meant victory was at hand.

But Bush's involvement may portend a sharper debate, and difficult choices ahead for patients, doctors and advocates. The issues -- how to define mental illness, how to treat it and who should pay -- have been looming for years.

In the coming debate, the battleground will shift to a 941-page book -- the American Psychiatric Association's Diagnostic and Statistical Manual, or DSM, a compendium of the diseases, disorders and distress that affect the human psyche. The primary issue is whether equal health benefits should be extended to every condition listed in the DSM or limited to the most serious disorders, such as schizophrenia, bipolar disorder and major depression.

Psychiatrists, psychologists and patient groups want better coverage for all disorders, but a fault line runs between the groups: Patients and doctors dealing with the most severe mental illnesses say that if confronted with a choice between no parity and parity for only the most serious illnesses, they would settle for the limited benefit.

The Senate passed a parity bill last year, but it died after encountering strong opposition from the House Republican leadership. The bill has been reintroduced, and would offer equal coverage to all the disorders in the manual.

Insurance companies warn that opening the door to all the disorders would drive costs up steeply, making the proposal unacceptable to employers.

"The Senate bill will require coverage of a range of conditions, including caffeine addiction, jet lag, religious problems, occupation problems," said Karen Ignagni, president of the American Association of Health Plans, which represents insurers.

"When members of Congress think about mental health, they think about schizophrenia," she continued. "I don't think they are aware of the generalities and terms used in the Senate legislation which could increase costs for conditions that are not supported by the scientific research."

The group said the cost of the measure was difficult to calculate, but it released projections and estimates from state experiments with parity that showed cost increases of up to 10 percent.

Advocates for full parity, however, cited a report by the Congressional Budget Office estimating that the Senate bill would raise costs by less than 1 percent. They have also argued that limited parity would shut out many patients with legitimate needs.

"If it only covers schizophrenia and bipolar illness, as important as that is, it would not cover many of the needs that people have as a result of trauma, terrorism and many other mental health problems," said Michael Faenza, president of the National Mental Health Association, the country's oldest mental health advocacy group.

There are some hints as to what kind of parity Bush will support: While he was governor, Texas passed parity legislation limited to a few disorders. And in a research paper published on the Web site of the conservative Heritage Foundation last month, Timothy Kelly, a clinical psychologist in Virginia, argued that the only diseases that should be given parity are schizophrenia, bipolar disorder, major depression, severe panic disorder, obsessive compulsive disorder and post traumatic stress disorder, attention deficit disorder and the eating disorder anorexia nervosa.

Fuller Torrey, a psychiatrist and longtime critic of the psychiatric establishment, said parity coverage should be limited to patients with disorders that have a biological basis, not to someone "who is being divorced by their third husband or second wife and is upset."

The American Psychiatric Association said critics were spreading misinformation about the validity of the group's manual. Jay Cutler, special counsel for the association, said that diagnosis and treatment were separate issues, and that clinicians would offer treatment only to those people whose disorders significantly interfered with their lives.

"There would have to be clinically significant impairment" in order to be eligible for treatment, he said. "If I have a cold it would be covered, but should it be treated? If you only sneeze once, you are not going to get coverage."

The Senate bill is sponsored by Pete V. Domenici (R-N.M.) and Paul D. Wellstone (D-Minn). Allison Dobson, a spokeswoman for Wellstone, said parity should cover all disorders, so as not to "start a new form of discrimination, pitting one form of mental illness against another."

While the major mental health patient and physician groups agreed with her, those dealing with the more serious illnesses said they might be willing to compromise if backed into a corner. Cutler, for example, said, "I believe it's better to begin the road to parity than never to set foot on it."

Groups like the American Psychological Association and the Bazelon Center for Mental Health Law will resist such a move.

It is unclear how many people would be affected by either proposal. Tens of millions are in such employer-covered plans, and many of those employees and their families would benefit from better mental health coverage. Employees with family members having the most serious disorders would especially benefit, but people with the most serious disorders are less likely to be employed themselves.

Chris Koyanagi, policy director at Bazelon, said 80 percent of people with schizophrenia were unemployed. "The more severe the disorder in adults, the less likely they are to be in this pool," she said.

For example, Chip Correll, 30, a Tampa man who suffers from paranoid schizophrenia, Philip Kirschner, 38, who lives in Brooklyn and suffers from bipolar disorder, and Carol Carlen of Ardmore, Pa., who suffers from a range of disorders, including dissociative identity disorder, which causes her to assume multiple personalities, all depend on Medicare.

The government insurance covers people who suffer from a serious disability. But Medicare covers only 50 percent of the costs of their doctor visits. If they had a physical ailment, it would cover 80 percent.

Carlen, 60, has been seeing psychiatrists since she was 19. She has been hospitalized 14 times, and owes her doctor $40,000.

While she, Correll and Kirschner support parity legislation covering employer insurance plans, it would not help any of them.