Biologically-Based Mental Illnesses

As a result of the Mental Health Parity Act, many health insurance companies are now providing the same coverage for biologically-based mental illnesses as they provide for other medical illnesses. A biologically-based conceptualization of mental illness allows advocates to frame parity legislation as antidiscrimination legislation. Using PET scans and MRI’s, researchers have testified before Congress and state legislatures that mental illness is directly linked to brain dysfunction. In light of such evidence, policy makers have been persuaded to admit that certain mental illnesses are brain disorders (Peck & Scheffler, 2002). I see this as a double-edged sword.

On the positive side, it is wonderful that individuals with certain mental illnesses are now getting the insurance coverage they so desperately need. I am a huge proponent of equitable services for all people with mental illnesses. Additionally, I am pleased to see that the tide is beginning to turn in regards to society’s attitudes about psychiatric problems. This is undoubtedly a good start. But it is only a start.

There are a number of problems with the concept of biologically-based mental illnesses as defined by insurance companies:

1.) They are creating a false dichotomy by differentiating between biologically-based and non-biologically based mental illnesses. Empirical evidence challenges the discriminant validity of the “biologically based mental illness” construct. Psychotherapy and medication yield similar changes in brain function when effective. Drug and brain imaging studies show that psychological and biochemical phenomena can be manipulated reciprocally (Seidel, 2005). The truth is, ALL mental illnesses are biologically-based because all mental functioning is biologically-based. Western society clings to the 17th century notion of Cartesian dualism; that is, the idea that mind and body are separate. But let’s take a closer look. The word “mind,” as used today, refers to intellect and consciousness, manifested as combinations of thought, perception, memory, emotion, will, and imagination, including all of the brain’s conscious and unconscious cognitive processes. And where do these cognitive processes originate? In the brain, which is part of our biology! Every thought and feeling we have, every perception and wish and behavior, has a corresponding neurobiological substrate.

2.) The insurance company’s decisions about which mental illnesses to classify as biologically-based seem rather arbitrary. Some insurance companies only classify schizophrenia, bipolar disorder, and OCD as biologically-based, while other insurance companies cover other disorders as well. For example, one major health insurance company defines biologically-based mental illness as “a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant psychological syndrome or pattern that substantially limits the functioning of the person with the illness.” This insurance company classifies the following as biologically-based mental illnesses: Schizophrenia, Schizo-affective Disorder, Major Depressive Disorder, Bipolar Disorder, Paranoia and other Psychotic Disorders, OCD, Panic Disorder, Pervasive Developmental Disorder, Autism, and Alcohol Abuse Disorders. This same insurance company defines non-biologically-based mental illness as conditions that “display symptoms that are primarily mental or nervous in nature. The primary treatment is psychotherapy or psychotropic medication.” I don’t understand this distinction at all. All of the biologically-based mental illnesses they listed are “mental or nervous in nature” and treatment for all of them includes behavior therapy, psychotherapy and / or psychotropic medication. Further, why is alcoholism considered biologically based, whereas are addictions to substances other than alcohol considered “non-biologically based?” And why is anorexia nervosa, which has numerous biological features and complications, a heritability estimate as high as that of schizophrenia and bipolar disorder, and the highest mortality rate of any psychiatric illness, considered a non-biologically based mental illness?

3.) The erroneous classification of certain mental illnesses as non-biologically based serves to increase stigma and discrimination against individuals with these illnesses. There is a subtle implication that so-called non-biologically based mental illnesses are not as serious, not as legitimate, or not as real as so-called biologically-based mental illnesses. Further, there is an even subtler implication that non-biologically-based mental illnesses are somehow the patient’s fault or the patient’s choice. It is as if they are saying: “It’s all in your head.” Well, yes, but so are Alzheimer’s Disease and brain cancer!

4.) I’m not sure why illnesses of the brain, whether they are classified as “biologically-based” or not, should be considered any different from illnesses of the heart, lungs, liver, or kidneys. Is it because environment and lifestyle, rather than biology, are presumed to be the cause? The development of heart disease, Type II diabetes, skin cancer, and AIDS are all heavily influenced by environment and lifestyle choices, and no one would argue that these diseases are not biologically-based. People with these diseases are not discriminated against in insurance coverage.