The New Health Dialogue

On our 7th straight snow day, we were surprised that the changes announced this week to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) did not include Blizzard-Induced Cabin Fever. We are quite sure that this is a bona fide condition requiring therapy of one form or another, but we will continue to self-diagnose and self-treat for as long as we need to (or as long as the whiskey sour mix lasts). In the meantime, it is worth examining the proposed changes to the manual that doctors, insurers and scientists use in deciding what's officially a mental disorder, what symptoms to treat. Health reform, as we'll see, will have a role in making sure Americans in need get care.

This is the first time in 10 years the APA is making significant changes to the DSM, and this is the first time that the APA is seeking feedback via the Internet from not only mental health professionals but the general public. The changes themselves are dramatic. Some diagnoses have been added (e.g., a new category of learning disabilities, binge eating is a new eating disorder). Others have been eliminated by absorbing specific diagnoses into larger categories (e.g., "autism spectrum disorders" include many conditions -- from mild social impairment to more severe autism's lack of eye contact, repetitive behavior and poor communication -- instead of differentiating between the terms autism, Asperger's or "pervasive developmental disorder").

Despite our recent experience with Blizzard-Induced Cabin Fever Syndrome, (we expect to see late night television ads soon promising a cure for BICFS) we are not mental health professionals. So we will refrain from commenting on whether these changes per se are good or bad or in between. We do know, however, that health reform will make coverage of mental health treatment much more available. In both the House and Senate bills, qualified health plans participating in the insurance exchanges must offer coverage of mental health and substance abuse disorder services, including behavioral health treatments. While this is a much-needed extension of mental health parity in our insurance coverage, we are also aware of the complaints of a shortage of mental health professionals to provide these services. In fact, many mental health disorders are currently treated by primary care physicians who may not have the training necessary to address these illnesses.

This is an excellent example of why delivery system reform must go hand in hand with insuring more Americans. Both federal bills anticipate the influx of individuals who avail themselves of newly available mental health services. One example of this is the creation of a Primary Care Extension Program to educate and provide technical assistance to primary care providers about mental health. Another is loan repayment for mental health professionals who serve in medically underserved areas. There is also a grant program for the development, expansion or enhancement of training programs in social work, graduate psychology and professional training in child and adolescent mental health. Another grant would authorize $50 million for coordinated and integrated services of primary and secondary care in community-based mental and behavioral health settings.

The changes to the DSM make these initiatives that much more important. Not only will we need to induce more individuals to seek careers as mental health professionals, we need to train existing primary care professionals on the new and existing standards of mental health treatment.