Health care system leaves mentally ill children behind
British and American regulators recently warned doctors about prescribing certain antidepressants to children. Though these actions earned headlines, the publicity was misplaced.
The extra probability that some antidepressants could drive kids to suicidal behavior -- while concerning -- is only about 1 percent. And the discussion ignores a bigger problem: Our medical system is profoundly biased against young people with mental illness.
A case in point: A teenager was admitted to a community hospital with sudden chest pain. After evaluation, including stress tests and cardiac ultrasounds, his doctors were baffled. Though the tests were normal, the teenager had crushing pain. Perhaps he had some coronary abnormality, his doctors wondered. They transferred him to my hospital's cardiac unit.
The testing was repeated, but was still normal. One day, he suddenly collapsed with chest pain. Luckily, a senior cardiologist was present and rushed to his aid. He astutely noticed that the teenager was hyperventilating, which suggested something other than a heart problem. It turned out, he was having anxiety attacks.
What happened next shows how psychiatric illness gets neglected. His hospitalization had already cost thousands of dollars. If he had a coronary problem, the additional surgery could cost his insurance company up to $50,000. No claims adjuster would call us to bicker about the diagnosis. After all, he would have a serious condition requiring specialized treatment.
Instead, because he lacked a "biologically-based" illness -- more on this later -- the teenager entered a parallel medical universe with its own laws.
Today, most insurers outsource, or "carve-out," mental health services, often to for-profit companies who strictly ration inpatient and outpatient care. In some cases, outsourcing can
provide much-needed expertise, when funded well and not driven solely by profit. In North Carolina, an independent, nonprofit carve-out of mental health centers dramatically improved youth mental health services; however, costs tripled. More often, HMOs and state Medicaid programs hire for-profit firms not to expand care, but to cut costs.
According to the Hay Group, an accounting firm, spending by large corporations on mental health care dropped by 55 percent from 1988 to 1998 largely due to cuts made by carve-outs, while the companies' other health-care spending dropped only 12 percent over the same period.
Carve-outs save money in part by making it harder for children to get psychiatric care. In recent studies in Tennessee and Arizona, for example, half of all children diagnosed with mental illness received no services from for-profit carve-outs.
When I called the teenager's family three months after his discharge, they still hadn't been able to see a psychiatrist even though he was unable to attend school regularly.
Mental health providers feel the pressure. Few claim reviewers interfere with the patient care in the cardiac intensive-care unit.
Yet doctors at my hospital's psychiatric ward often get calls questioning why their patients are still in the hospital. Once the child gets discharged, their outpatient therapists are buried in arcane paperwork.
When David DeMaso, a senior psychiatrist at my hospital, made a single change on a claim form -- a patient's "global assessment of function" went from 70 to 68 out of 100 -- therapy was suddenly approved. With personalized care rationed so arbitrarily, it's no wonder many kids just get prescribed drugs like Prozac.
As outpatient care worsens, children suffer. In Worcester, for example, pediatric visits for psychiatric emergencies increased 30 percent over the course of six months in 2001.
In a 2003 study at Children's Hospital, one-third of the children with psychiatric problems were initially admitted to the general medical ward because no psychiatric beds were available. In 2000, one child in our hospital waited 51 days for a psychiatric bed where he could get more focused care. Without adequate funding of mental health, there's little incentive to improve the supply of both outpatient and inpatient care.
Unfortunately, when state legislatures tried to soften the blow of cuts, they created more confusion. They created a misleading distinction between "biologically-based" mental conditions -- which get full coverage -- and other mental disorders, which are presumably all in a person's head and get limited coverage.
But this bogus difference between "real" and "unreal" mental problems now frames public policy disputes.
In 2000, Massachusetts passed the Mental Health Parity Law, which guarantees coverage (and continues to allow carve-outs) for roughly 10 "biologically-based" mental illnesses, including schizophrenia, major depression, and obsessive-compulsive disorder. This was good for many patients who lacked any guarantees of coverage. But it excluded eating disorders, drug addiction, and others conditions determined not to be "biologically-based."
This makes little sense. First, despite pseudoscientific terms like "chemical imbalance," nobody really knows what causes mental illness. There's no blood test or brain scan for major depression. No geneticist can diagnose schizophrenia.
Second, illness severity doesn't correlate with being "biologically-based." Shockingly, one in 10 anorexics dies from the disease, but anorexics still don't get equal treatment. Finally, if you try hard enough, you can find a "biological basis" for any behavior; for example, having a Y-chromosome predicts whether a teenager likes pro wrestling.
The more one tries to understand the distinction, the more it seems designed to exclude people in need. Still, advocates work within the bounds; Boston-based Health Law Advocates is campaigning now to get eating disorders on the "biologically-based" list.
Regardless of the vocabulary applied to them, children like the teenager I treated need care and not excuses. They have conditions every bit as disabling as coronary problems -- and they deserve not to be targets of cost-cutting.
Dr. Darshak Sanghavi is a clinical fellow at
Harvard Medical School. His e-mail address is
sanghavi@post.harvard.edu. 
