Insight Matters
Summer, 2004

The Unimpeachable Case for Parity - (It's the Brain, Stupid!)
by Henry A. Nasrallah, M.D., Editor

Of all the injustices and discriminations that mentally ill citizens and their families have to face daily, none is more egregious and irrational than the lack of parity of psychiatric disorders with other medical ailments. In a country that upholds fairness and justice for all, the parity gap between psychiatric and neurologic brain disorders defies logic and tramples on the most basic principles of common sense.

Essentially, individuals with a cerebrovascular disease manifesting as motor paralysis and aphasia are covered fully by insurance, while individuals with motor paralysis and aphasia due to catatonic schizophrenia or stuperous depression are not. This revolting and ongoing discrimination has its ugly roots in the anachronistic notions of the duality of the brain and mind, which neuroscience research has already debunked, showing that they are one and the same.

There now exists a vast neuropsychiatric literature that demonstrates the extensive similarity between neurologic and psychiatric disorders, both of which represent diseases of brain structure and function. For example, a tumor in the prefrontal lobe can manifest with a personality disorder that insurance companies would refuse to cover, until an MRI scan reveals the tumor, at which point, and abruptly, the same illness becomes fully insurable. Similarly, a patient with a left prefrontal lobe stroke frequently presents with the classic symptoms of major depression, but there is certainly no parity in the coverage of those two neuropsychiatric disorders. A complex partial seizure focus in the medial temporal lobe can manifest as psychotic behavior that is indistinguishable from schizophrenia. Interestingly, although an avalanche of neurobiological research has revealed many structural anomalies of temporal, limbic and frontal structures, the medieval dogma of not regarding psychosis as a neurological disease continues to trump scientific advances. A closed head injury with sequelae of agitation, impulsivity and violence is covered but a patient with primary psychiatric diagnosis of severe impulse control disorder is not. A person diagnosed with a cerebritis can manifest with depression can, lethargy, anxiety and cognitive dysfunction and is covered very well by insurance companies, but not so for patients with anxiety-depression syndrome displaying identical clinical features and disability.

The list of such overlap between psychiatric and neurologic disorders [two types of brain diseases] is endless, but the outrageous lack of parity for mental illness continues. The denigration of psychotherapy by insurance companies who refuse to pay for it as a legitimate medical treatment is also galling given the numerous studies of the effectiveness of psychotherapeutic interventions. And even though all serious psychiatric disorders require pharmacological therapy to improve, insurance companies still discriminate against antidepressants and antipsychotic pharmacotherapy compared to the L-DOPA pharmacotherapy of Parkinson's Disease or the triptan pharmacotherapy of migraine.

Ignorance is no longer acceptable as an excuse. The body of scientific evidence for mental illness as brain diseases that alter thoughts, mood, emotions, behavior and cognition is irrefutable and unimpeachable, and should not be subject to sociopolitical debates any more than stroke or seizures. The real debate should focus on why insurance companies and managed care organizations are allowed to persist in their blatantly arbitrary and self-serving stance of not providing identical health benefits for psychiatric brain disorders as they do for heart disease, stroke, diabetes, cancer, and other medical disorders. This is a major ethical, moral, legal, scientific and human rights issue for which the entire psychiatric community of patients, families, physicians and mental health providers should hold politicians accountable when they come asking for our votes.

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