WHEN THE CURE IS NOT WORTH THE COST

ON its face, providing equal coverage for mental and physical
illnesses sounds like a good idea, something only a managed-care bean
counter could oppose. To that end, Representatives Jim Ramstad,
Republican of Minnesota, and Patrick Kennedy, Democrat of Rhode
Island, have introduced the Paul Wellstone Mental Health and
Addiction Equity Act.

Named for the senator who was long an advocate for mental health
"parity," it would require that private insurers pay for as much
treatment for mental illnesses and addiction as they do for physical illnesses.

Senators Ted Kennedy, Democrat of Massachusetts, and Pete Domenici,
Republican of New Mexico, have introduced a similar bill in the
Senate. President Bush has said he will sign the legislation if it passes.

Unfortunately, this change would not be as benign as it appears.
Unless mental health parity is tied to evidence-based treatment and
positive outcomes, generous benefits may become a profit bonanza for
providers that does little to help patients.

Thanks to research by the National Institutes of Health and academic
scientists during the last three decades, we now have proven
treatments for depression, addiction and other mental disorders. But
all too often clinicians do not use them.

Without financial incentives to provide treatments that are known to
work, many mental health professionals stick with what they know, or
pick up on the latest fad, or even introduce their own untested
innovations - which in turn are spread by testimonials and credulous
news media coverage.

Take the well-known approach featured on the cable TV reality show
"Intervention" aimed at getting addicts and alcoholics into
treatment. Here, the family and sometimes the employer gather with a
counselor, confront the addict and threaten to shun him or fire him
if he doesn't enter a rehabilitation center. A 1999 study compared
this style of intervention - which can backfire and lead to broken
families - to a less confrontational approach known as "community
reinforcement and family training," which is aimed at helping the
family nurture the addict's own motivation.

More than twice as many families succeeded in getting their loved
ones into treatment (64 percent) with the gentler approach than with
standard intervention (30 percent). But no reality shows push the
less dramatic method, and it is difficult to find clinicians who use it.

Similarly, one of the most common approaches to alcoholism treatment
involves having counselors and fellow alcoholics confront patients
and force them to identify themselves as alcoholics. But research
finds that the more a counselor confronts, the more a patient drinks
and the more likely he is to drop out of treatment. And no
association between accepting the label "alcoholic" and quitting
drinking has been found. Counselor empathy - not confrontation - is
connected with recovery.

According to a review by the Institute of Medicine in 2006, only 10.5
percent of alcoholics received "care consistent with scientific
knowledge" of the disorder; similarly, 43 percent of children in
psychiatric hospitals are given antipsychotic medication despite not
suffering from psychosis. Tough boot camps for troubled teenagers -
which have been proven to be ineffective and potentially harmful -
thrive, while "multisystemic family therapy," which effectively
treats teenagers at home, is available only through the juvenile
justice system.

Even in general medicine, research is sometimes slow to be translated
into practice - but mental health care is often entirely disconnected
from evidence. Some therapists argue that the human mind is too
complex and variable to allow for standardized treatments. But
shouldn't they at least start with approaches known to work for the
largest number of patients?

If we want to provide genuine help for the 33 million Americans with
mental health and drug problems, giving more no-strings-attached
money to providers via insurance mandates is not the answer. It is
dangerous to blindly bolster useless and even harmful treatments
while failing to support proven therapies. Coverage must be tied to
outcomes and evidence. And payment should be dependent, at least in
part, on health improvements, not just services received. We need
parity in evidence-based treatment, not just in coverage.