By Craig W. Maumus, M.D.

Psychiatrists will long remember 1996 as the year in which Congress passed the Domenici-Wellstone mental illness parity provision for group health policies. All of us can take pride in this dramatic and significant change in attitude on Capitol Hill. It certainly provided a timely topic for writers in several district branch newsletters.

"This is phenomenal!" responds Dr. O'Neil Dillon, president of the Northern California Psychiatric Society in the November/December '96 issue of Psychiatric Physician (Glen N. Peterson, M.D., editor). "The 20th century American moral equivalent, to my mind, of Philippe Pinel removing the chains from the mentally ill at the Hospital Salpetriere, of Freud discovering the unconscious mind, and of the great discoveries made in neuropsychiatry. No matter that the reality of parity will be far different from the concept (and it does nothing for the growing arm of the uninsured). It is nevertheless a big step.

"We in the mental illness disciplines. . . owe an enormous debt of gratitude to those in our own and other disciplines, to the power of the mentally ill and their families, and to the legislators with the courage to fight this unpopular battle. We all deserve credit as well, because as dues-paying members of our professional organization, we all have contributed to bringing this advancement of our civilization to fruition. Implementing and extending the statement of the law of the land will provide many an ongoing opportunity to continue our contributions."

Some caution about the results of this legislation, however, is urged by New Jersey Psychiatric Association President M. Nicolai Nielsen, M.D. Writing in the fall '96 edition of New Jersey Psychiatric News (Daniel M. Greenwald, M.D., editor), Dr. Nielsen warns us that "we must not become lax. Undoubtedly, there will be efforts to undo and sabotage this victory. And a victory I feel it is. While not parity as we know it and desire it to be, this law is a profound movement forward."

Dr. Nielsen sees this bill as a foundation on which to build. "Now is the time for progressive states like New Jersey to improve on this historic beginning. We have all become tired and frustrated by incremental efforts toward health care reform. But let us all now move forward in New Jersey to obtain parity as we know it and as our patients deserve."

An even stronger cautionary note is expressed by Dr. Loren Olson, editor of the Iowa Psychiatric Society's Iowa Psychiatrist. In his summer '96 column, Dr. Olson points out, "There is danger in a model for psychiatric illness that says all behavioral manifestations of a disease process must be described by a physicochemical process. Anything that cannot then be defined by the biomedical model is not a disease and, therefore, by definition is not medically necessary. This reductionistic thinking plays into the hands of those who control the allocation of health care resources. They will argue that the 'high cost' of parity must be met with restrictions of services for anything that is not a major brain disorder.

"To some extent this has already occurred, since psychiatrists are now being reimbursed by many insurance companies only for medication reviews. While it is disgraceful that psychiatric patients have been discriminated against in their health care benefits, my concern is that a biomedically based reimbursement system will be used as a rationale to deny benefits to a large group of deserving people.

"The biomedical model has done a great deal to advance our understanding of disease and its treatments, but there is growing uneasiness among the public that biotechnical advances are not meeting people's needs. People are flocking to alternative medicines and nontraditional practitioners. Medical students are embracing primary care because it promises the hope of focusing on the person, not just the illness. . . .

"Optimum designs for interventions must improve patients' perceptions of their health-related quality of life and to do so must move beyond the boundaries of the biomedical model. . . .

"Most who have chosen psychiatry are not only interested in medicine, but in the human condition in a broader context. We must not relinquish the fight for those with disordered emotions and behaviors whose neurophysiologic functioning presumably is intact. . . ."

Dr. Olson stresses that "the greatest contribution" to come out of the Congressional debate over insurance parity for mental illness may be the public airing by several senators of the pain they experienced when someone they loved became mentally ill.

"When our patients speak publicly about their pain without fearing consequences, and when emotional pain is seen as being as valid as physical pain, parity for all mental illness will be given."

(Psychiatric News, January 17, 1997)