Mental toughness

Good news! Obama’s Affordable Care Act (ACA) brings hope for Americans with mental illness. I figured I’d better weigh in on this before everyone points out that I am always years behind on the news (fine, fine, it’s usually true). People with mental illness will now have close to universal health insurance for psychiatric disorders, which is major progress compared to the previously higher deductibles and lifetime caps. Under the ACA, there is no longer exclusion of people with pre-existing conditions, meaning that the Americans who have experienced psychiatric illness can’t be denied coverage.

This is a BIG DEAL given that about half of Americans experience a major psychiatric or substance disorder during their life. Sadly, the stigma surrounding mental illness and the poor access to care has prevented millions from receiving the care they needed and deserved. This is no small problem, and I am not just talking about the individuals’ suffering. People with a mood disorder cost society with their lost productivity; in fact, the World Health Organization ranks depression as the world’s leading cause of disability.

Psychiatric illness is chronic, characterized by remission and relapse even for people who respond to treatment. I spent the last year doing research on disorders including schizophrenia and bipolar depression, and I spent a fair bit of time at the psychiatric hospital. Plus, on a more personal level, multiple members of my family have dealt with mental disorders at one point or another. Anyone who has spent time with these patients and their families can tell you that relapse is common even with the best treatment. It’s completely irrational to tell someone with this condition that his lifetime mental health benefits max out after a certain number of inpatient hospital days. Psychiatric illness is treatable but rarely curable, which is why the current limits on treatment are absurd.

There are obvious public health advantages to the fact that people can remain on their parents’ insurance until they turn 26. I think this is a major step in the right direction for a whole host of reasons, but psychiatric illness provides a wonderful case in point. It turns out that 75% of serious psychiatric illness presents itself by the age of 25. Early treatment is critical in conditions such as major depression and substance abuse, so keeping young people insured through this period is clearly a good idea.

For the elderly and the poor, there are a few additional considerations. Elderly people with mental illness benefit because the law will fill the gap in Medicare drug coverage. In essence, ACA immediately requires drug companies to give a 50% discount on brand-name drugs and then subsidies will be increasingly provided until the gap closes in 2020. Unfortunately, poor people should still be worried. The new law would have expanded Medicaid, but the Court ruled that states could decline the expansion without losing the Medicaid funds. Thus, in states that opt out of the Medicaid expansion, poor people with mental illness might earn too much to qualify for Medicaid but not enough to get the federal subsidy to pay for insurance.

Back to the main point: there is recognition that psychiatric illness is on par with all other medical disorders and these problems have a real, biochemical basis. It is time that people were more open about this reality, as then people might be more willing to seek early treatment. Don’t argue and don’t stigmatize. How will you deal with this reality?