THINKING HEALTHY

June 7, 1999
		At the White House conference on mental health, President Clinton announced that federal health plans must give equal coverage for treating mental illness. Health correspondent Susan Dentzer reports on the conference and current trends in research and attitudes about mental health. Then, ask two experts about health insurance for mental illness. The Health Unit is a partnership with the Henry J. Kaiser Family Foundation.

Forum: Health Insurance and Mental Illness Jan. 1999: Freud's Legacy Sept. 8, 1998: Treating Schizophrenia July 27, 1998: A schizophrenic man opens fire at the Capitol. Dec 23, 1997: Many homeless people suffer from mental illness May 9, 1996: Health insurance for mental health Complete NewsHour coverage of health   The White House Conference on Mental Health National Institute of Mental Health National Alliance for the Mentally Ill Health Insurance Association of America Cure Autism Now Foundation	SUSAN DENTZER: The stigma attached to mental illness; disparity in health insurance coverage; scientific breakthroughs that raise new hopes -- all of these came into focus at today's first-ever White House Conference on Mental Health. Joining the President were more than 300 mental-health care consumers, advocates and medical professionals. They were proxies for roughly 50 million Americans who suffer from mental illness. PRESIDENT CLINTON: Clearly people with mental illnesses have always had to struggle to be treated fairly and to get the treatment they need, and they still do. SUSAN DENTZER: No one understands that better than 38 year-old Laura Van Tosh, a professional mental health advocate from Silver Spring, Maryland. She suffers from bipolar disorder, also known as manic depressive illness. She was committed involuntarily to a hospital by her mother when she had her first breakdown at 17. There she got her first taste of the insensitivities surrounding treatment of mental illness.
	Insensitivities in treatment.
	LAURA VAN TOSH: I was put face down by a couple of orderlies, face down on a kind of examination table and tied down, both hands and feet, and then force-drugged, if you will, or force-medicated. I'm someone that now even has trouble being in an elevator as a result of being tied down to a table when I was first committed at 17, and in four-point restraints, and shot up with Thorazine. SUSAN DENTZER: Doctors eventually put Laura on the drug lithium, enabling her to pull her life back together. Stable for the next 15 years, at age 35 she suddenly began to experience toxic effects from the lithium. Her psychiatrist cut her dose -- but her symptoms of mania returned. One winter's day, Van Tosh drove to the airport in her nightgown, disrobed and ran naked into the arms of a security guard. LAURA VAN TOSH: Luckily I didn't end up in jail, and luckily I'm not dead. SUSAN DENTZER: In and out of hospitals for harrowing months afterward, she was finally stabilized again with more medication and psychotherapy. LAURA VAN TOSH: As a result of having health care in my life, and having the ability to seek services and get services, I can work now, and I'm paying taxes, and I'm voting. I mean, I think that we have to realize that if we were to bring people all of what they need, all of what they need to survive and live in this world, that all of us will bring so much to the rest of the world. SUSAN DENTZER: One person also pushing that message is Tipper Gore, wife of vice president and 2000 presidential candidate Al Gore and the chair of the White House conference. She recently revealed in an article in USA Today that she herself had experienced mental illness -- specifically, major depression, a condition that affects as many as 1 out of 10 U.S. adults in any given year. The depression struck Mrs. Gore a decade ago not long after her then 6-year-old son Albert was nearly killed in a car accident. TIPPER GORE: I was clinically depressed, which meant that I could not will my way out of it, pray my way out of it, or pull myself up by the bootstraps out of it. I really needed a medication and a form of treatment, which included therapy, and that worked for me. SUSAN DENTZER: In large part, Mrs. Gore owes the success of her treatment to recent breakthroughs in scientific research into the causes of mental illness. DR. STEVEN HYMAN: The last decade has been a time of almost unbelievable progress. SUSAN DENTZER: Dr. Steven Hyman is director of the National Institute of Mental Health. He notes that long-standing misconceptions about mental illness -- including the belief that it was caused by everything from possession by demons to bad parenting -- have persisted almost to the present day. Hyman cites the example of autism, a brain disorder that affects about two in one thousand people. It produces a wide range of symptoms including rocking and an inability to form emotional bonds. DR. STEVEN HYMAN: The mother of an autistic child was told that the reason the child was ill was because of her unconscious wishes. Now, what mother of an autistic child might not at some time in their life have the fantasy, maybe it would have been better had Johnny not been born. Well, the upshot, of course, was not of any treatment benefit, but what it did do is alienate and demoralize and blame families.
	The flowering of brain science.
	SUSAN DENTZER: All that began to change with the flowering of brain science in the 1980s. Thanks to high-tech tools like functional magnetic resonance imaging, scientists were able to see portions of the brain at work as it performed tasks like thinking or retrieving memories. That allowed them to distinguish between normal and abnormal brain functions -- and to see what went wrong in people with mental illnesses. DR. STEVEN HYMAN: Mental illnesses are diseases of a particular organ, the brain, I mean, just as coronary artery disease is a disease of another organ, the heart. Already we can see problems in information processing in people with schizophrenia. Already we can begin to see circuits involved in normal fear and how they may go wrong in anxiety disorders, and we're beginning to get the first really good research showing us the circuits that are involved in the control of moods, and possibly depression. SUSAN DENTZER: And thanks to the booming field of genetics, it's increasingly clear that many of these brain malfunctions stem at least in part from certain genes; Hyman calls them "vulnerability genes." DR. STEVEN HYMAN: This has turned out to be a very, very difficult problem because unlike some illnesses where a single gene which is readily discovered causes the illness, in mental illnesses what we have are multiple genes working together -- that is with gene-gene interactions -- and also working with the environment to produce illness. SUSAN DENTZER: In other words, a collection of "vulnerability genes" might predispose a person to a condition like schizophrenia or depression. DR. STEVEN HYMAN: Genes might set somebody up to have a risk of severe depression, for example. But it might very well be environmental events, changing brain function, that leads ultimately to the disease occurring, to the disease expressing itself. SUSAN DENTZER: And that appears to be what lay the groundwork for Mrs. Gore's depression. Her mother suffered from bouts of depression and thus may have passed on to her daughter a genetic predisposition to the illness. Among other things, Mrs. Gore says, that was propelled into depression by her son's accident. TIPPER GORE: There are many instances in life in which a person can have certain triggers and I had a number of those. SUSAN DENTZER: In any case, experts say it was an actual change in brain circuitry and chemistry that produced the feelings of sadness and despondency Mrs. Gore felt. By the same token, a combination of psychotherapy and medications apparently restored that function to normal, as it does in many who suffer from depression. For example, drugs like Prozac and Zoloft interact with molecules in the brain to increase the level of a chemical messenger, known as serotonin. What scientists don't know is precisely how that translates into a change in brain circuitry. DR. STEVEN HYMAN: We know that it takes often two or three weeks for these medications to begin to work, and what we don't know yet, and which is a very important mystery for us to solve, is how is that increase in serotonin changing brain function, almost certainly changing brain structure over the ensuing weeks so that the symptoms of depression go away.
	Health insurance and mental health.
	SUSAN DENTZER: Now that we now know a great deal about the biological roots of many mental health conditions -- and stand to know far more in the future -- advocates are pushing for health insurance to reflect the advances in science. One is Republican Senator Pete Domenici of New Mexico. A conservative who is best known as a budget hawk, he is also the father of eight children. One, a daughter, now in her 30s, was 18 when she developed symptoms of serious mental illness. Domenici claims that many private health insurance policies actually discriminate against mental illness; they do so by imposing limits on treatment that they don't impose on other medical treatments. SEN. PETE DOMENICI: To continue to act as if you are providing health care in an insurance policy and you don't cover severe, serious mental illnesses in a major way is to say we don't have health insurance. SUSAN DENTZER: A 1996 federal law that Domenici sponsored did away with some limits on mental health coverage, but others remain. For example, while many insurance policies provide almost unlimited hospital coverage for medical conditions, they routinely cover just 20 hospital days for mental illnesses. They may also limit visits to psychiatrists and other mental health providers to just 20 a year. Finally, they may also require patients to pay more for anti-psychotic medications than for other drugs. These restrictions impose a big burden on people like Laura Van Tosh, who now owes tens of thousands of dollars for hospital care that her insurance didn't cover. She has worked out a long-term payment plan with her providers. LAURA VAN TOSH: They said that from our estimate it will be at least 50 years before you have paid all of it off at the rate that you're paying now, which is not five dollars a month, by the way. I'm paying quite a bit more than that. SUSAN DENTZER: Domenici is now sponsoring a bill that would bar health plans from imposing limits on mental health care that differ from those placed on medical treatment. But some who pay the nation's health insurance bills, including many employers, are worried about the potential costs. Dr. Mary Jane England heads the Washington Business Group on Health, a group of 165 large employers. DR. MARY JANE ENGLAND: I think for small and moderate employers, they are still concerned that a very small increase of any kind in their health benefits can be -- can actually cause them to be less competitive. It can really drive them out of business. SUSAN DENTZER: But Dr. England says the concern that costs would explode is misguided. Studies of states and managed health plans that have done away with disparities in mental health coverage showed that the measures raised overall health costs by less than 1 percent. And in fact, she says, many employers have found that putting in place broad coverage for mental illnesses can even save money. That can be especially true if it fosters better treatment for depression. DR. MARY JANE ENGLAND: Actually, Digital and other companies that have, like Pitney Bowes and Bank One, that have put in place mechanisms by which we can identify depression early and really have very extensive employee assistance programs. By identifying it early, they finally have been able to reduce costs for their mental health programs. SUSAN DENTZER: To set an example for the nation's employers and insurers, President Clinton announced that insurance companies covering federal workers will have to provide full coverage of mental health and substance abuse treatment. At today's conference, he also called on Congress to hold hearings on legislation like the Domenici bill. And he unveiled a new program to improve mental health services in schools. PRESIDENT CLINTON: We have to do more to reach out to troubled young people. One out of ten children suffer from some form of mental illness, from mild depression to serious mental disease, but fewer than 20 percent receive proper treatment. SUSAN DENTZER: The National Institute of Mental Health now plans a new five-year study. It will explore the real extent of mental illness among Americans and the types of disabilities that result.