From the Editor

The travesty of disparity and non-parity

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Senseless, unethical discrimination against mental illness goes on unabated, despite lip service by politicians and policy-makers.


Staggering disparities and lack of parity mark many aspects of mental health care, at huge cost to the 25% of Americans who suffer a mental disorder. It’s time to correct this unconscionable discrepancy.

Imagine a world in which aortic stenosis is fully covered by health insurance but coverage for atrial fibrillation is carved out and assigned partial coverage, with a high copayment, a limit on physician visits and hospital days, and a lifetime cap on coverage. If it strikes you as outrageous that disorders of the same organ could be treated so differently, with irrational discrimination, think again! Such an egregious injustice has been going on for a long time against disorders of the brain.

Care provided for stroke, brain tumor, and epilepsy is given full coverage—but not so for depression, psychosis, and panic disorder. To make the matter more bizarre, depression is a known complication of certain types of stroke; some brain tumors are associated with psychosis; and panic attacks can occur with complex partial seizures—demonstrating that the pathways of so-called “mental” illnesses are as “physical” as any neurological disorder of the brain.

Welcome to the absurd world of lack of parity for psychiatric brain disorders!

Senseless, unethical discrimination against mental illness goes on unabated, despite lip service by politicians and policy-makers. The lack of parity adds insult to injury for psychiatric patients, inflicting a financial burden atop unbearable suffering and functional disability.

How long will this injustice endure?

For a civilized society, in which discrimination based on skin color, sex, sexual orientation, and religious belief is prohibited, discrimination by medical illness seems to be tolerated with impunity. This is a blind spot of unimaginable magnitude in the conscience of society and a cancerous lesion on its ethical standards.

The lack of parity in health-care coverage for psychiatric disorders is compounded by several other disparities. Consider this array of discriminatory actions and conditions directed at psychiatrists and their patients:

• The mentally ill endure a stigma that deprives them of the compassion and sympathy that people who have other medical disorders routinely receive.

• Managed-care organizations and some health-maintenance organizations are reluctant to allow the use of newer, more tolerable, and less neurotoxic psychoactive medications by psychiatrists and nurse practitioners; instead, they impose a fail-first policy with decades-old generic drugs to save money—although newer drugs are readily available for oncologists, cardiologists, and neurologists to use.

• Behavioral health is always “carved out”—that obscene word—in insurance contracts. This is overt discrimination against the mentally ill and mental health professionals that the government should not allow, in its role as a watchdog of human rights.

• Psychiatric wards usually are the most poorly renovated and oldest section of hospitals, while obstetrics, oncology, cardiology, and orthopedics units have state-of-the-art facilities. Many inner-city community mental health centers look tad better than a war zone, with dilapidated buildings, stained and broken furniture, and peeling walls. Where are the funds that were supposed to be recovered by shuttering asylums and to flow into community care for outpatient mental health care?

• It’s the height of discrimination that the relapsed mentally ill have no place to go but jail or prison. Isn’t it the worst injustice to transform medical illness into a felony? Why are there few long-term facilities for severe mental illness any more—the equivalent of refractory patients? In a civilized nation, why is homelessness among people who have a brain disorder tolerated?

• The medical records of psychiatric patients are segregated and set aside, perpetuating the unfair shame and guilt associated with mental illness. When will a history of depression and a broken spirit be no more secretive than having a broken leg?

• The lack of regard for psychiatry as a vital medical specialty reflects medieval-like ignorance and discrimination in an age when the neurobiology of psychiatric brain disorders is unfolding with dazzling scientific elegance. When will those who treat mood, thought, behavior, and cognition receive the same respect as a surgeon who transplants a liver or a cardiologist who manages heart failure?

• The disparity in access by the seriously mentally ill to primary, secondary, and tertiary care has, literally, fatal consequences. Despite the high prevalence of serious cardio-metabolic, pulmonary, infectious, and gastrointestinal disorders among the mentally ill, a large percentage do not receive the most basic primary care to manage their ailments—let alone undergo special procedures or advanced surgical interventions. This shameful neglect and health-care disparity contribute to early mortality (by 20 to 25 years) among people who suffer a serious mental disorder. This is a deadly disparity, yet it goes unaddressed.

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