MONEY Health Care

Why Getting Mental-Health Coverage Can Be So Tough

Despite rules mandating better insurance benefits, finding care remains a challenge, a new 50-state report concludes.

Even though more Americans have access to health insurance because of the health law, getting access to mental health services can still be challenging.

A new report concludes that despite the 2008 mental health parity law, some state exchange health plans may still have a way to go to even the playing field between mental and physical benefits. The report, released by the advocacy group Mental Health America, was paid for by Takeda Pharmaceuticals U.S.A. and Lundbeck U.S.A, a pharmaceutical company that specializes in neurology and psychiatric treatments.

The report listed the states with the lowest prevalence of mental illness and the highest rates of access to care as Massachusetts, Vermont, Maine, North Dakota, and Delaware. Those with the highest prevalence of mental illness and most limited access are Arizona, Mississippi, Nevada, Washington, and Louisiana.

Among its other findings:

•42.5 million of adults in America, 18.19%, suffer from a mental health issue.

•19.7 million, or 8.46%, have a substance abuse problem.

•8.8 million, or 3.77% of Americans have reported serious thoughts of suicide.

•The highest rates of emotional, behavioral or developmental issues among young people occur just west of the Appalachian Mountains, where poverty and social inequality are pervasive.

Part of MHA’s examination focused on the exchange market and its essential health benefit requirements that guided 2014 coverage. The group found that, while information provided through plans’ “explanation of benefits” might show that there aren’t limits on mental health coverage, limitations including treatment caps and other barriers still exist.

“Parity is in its infancy. Most plans know the numerical requirements around cost-sharing, but few have taken seriously the requirements around equity—around access through networks and barriers to care through prior authorization,” said Mike Thompson, health care practice leader at PricewaterhouseCoopers. “And, in practice, we have a history of imposing much more stringent medical necessity standards on mental health care than other health care.”

However, Susan Pisano, vice president of communications for America’s Health Insurance Plans, an insurance trade group, said the report doesn’t reflect the fact that many health plans have rolling renewals. That means the plans have until Jan. 1, 2015, to fully comply with the parity law.

“Our members are committed to mental health parity, and we’re supportive of legislation, and what isn’t apparent is that benchmark plans represented a snapshot in time … so that doesn’t give us the full picture,” Pisano said. “Our plans have really been working to get in compliance.”

Chuck Ingoglia, senior vice president of public policy at the National Council for Behavioral Health, a Washington-based trade group for community mental health and substance use treatment organizations, said the report’s findings aren’t surprising — though they are troubling. Implementation of the parity law remains a work in progress, he said.

“The law is based on a sound policy premise — that addiction and mental health treatment decisions and management should be comparable to physical health conditions,” he said. “But this also creates a tremendous barrier to proving violations as it requires a consumer to obtain access to plan documents for both types of care, which is frequently handled by different plans,” Ingoglia said.

In addition, the report found that some plans didn’t set out what and how many services were covered. That means consumers would only find out a treatment wouldn’t be paid for by their insurer after they’d already received care.

Americans with mental disorders have the lowest rates of health insurance coverage, so obtaining insurance is a good first step, according to Al Guida, a Washington, D.C.-based lobbyist who works on mental health issues with Guide Consulting Services. But the only way a denial can be reversed is through an appeal, which can be a long and arduous process.

“The vast majority of insurance plans offered on Affordable Care Act federal and state exchanges have close to no transparency, which could lead to abrupt changes in both mental health providers and psychotropic drug regimens with the potential for serious clinical consequences,” Guida said.

Meanwhile, there is a shortage of mental health care professionals—nationally there is only one provider for every 790 people, according to the report.

All of these factors can cause minor mental illnesses to grow more severe, according to Mental Health America CEO Paul Gionfriddo.

He suggested that mental illness should be screened for and covered in the same way cancer, kidney disease, and other illnesses are.

“Right now we’re trapped in a stage where we wait for a crisis, when they’re in advanced stages and then we treat it, and we wonder why it’s so hard to treat it more cheaply,” Giofriddo said.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

TIME Innovation

Five Best Ideas of the Day: December 17

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

1. Independent and third party candidates could break D.C. gridlock — if they can get to Washington.

By Tom Squitieri in the Hill

2. A new software project has surgeons keeping score as a way to improve performance and save lives.

By James Somers in Medium

3. The New American Workforce: In Miami, local business are helping legal immigrants take the final steps to citizenship.

By Wendy Kallergis in Miami Herald

4. Policies exist to avoid the worst results of head injuries in sports. We must follow them to save athletes’ lives.

By Christine Baugh in the Chronicle of Higher Education

5. Sal Khan: Use portfolios instead of transcripts to reflect student achievement.

By Gregory Ferenstein at VentureBeat

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME mental health/psychiatry

Why Some Antidepressants Make You Feel Worse Before Better

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There’s a paradoxical period when a person first starts an antidepressant: they may actually begin to feel worse before feeling better. The underlying cause of this phenomenon is a bit of a mystery, but a new study from researchers at Otto-von-Guericke University in Germany explains why this might occur.

The gap between starting an antidepressant and feeling its positive effects—a time period that’s typically a couple weeks but may last up to a month—can sometimes be characterized by an increased risk for harmful behaviors. Researchers have previously speculated that when a person starts an antidepressant, they may suddenly have a surge of energy they didn’t have before. If that person is suicidal, the effect may provide enough energy to act upon their feelings.

The controversial idea caught on. A decade ago, the U.S. Food and Drug Administration (FDA) issued a “black box” warning—the most stringent of warnings—on all antidepressants warning of possible suicidal thoughts and behaviors. As TIME recently reported, many psychiatrists were (and still are) upset by the label, arguing that it’s led to a drop in antidepressant use among patients. Physicians, fearful of the risks, may also be deterred from prescribing them.

MORE: Do Depression Drugs Still Need Suicide Warnings?

In the new report, published in the journal Trends in Cognitive Sciences, the researchers reviewed several recent studies and found that the issue may stem from an effect of the most commonly prescribed antidepressants: selective serotonin reuptake inhibitors (SSRIs). SSRIs release two chemicals in the brain that kick in at different times, causing a period of negative effects on mental health, the authors report. The first chemical is serotonin, which is released very soon after an SSRI is taken but might not lessen depressive symptoms until after a couple of weeks. The second chemical is called glutamate, which can take a few days longer to be properly released. According to the new study, the serotonin neurons send off a dual signal to the two chemicals, causing the variant time frames for the chemicals, and therefore the problem period.

“There’s a lot you can do [in this period] and it’s important to let patients know that,” says Dr. Donald Malone, chair of the department of psychiatry and psychology at Cleveland Clinic. (Malone was not involved in the new study.) “It doesn’t typically last longer than the first week. But you may need to go down on the dose or switch medications. We’ve always prepared patients for how it can go, and that this was the beginning.”

Depression itself—not an antidepressant—is the greatest risk factor for suicide, and these new findings provide new insight for what patients can expect at the start of their treatment.

MONEY Health Care

5 Ways to Save on the Mental-Health Care You Need

Group therapy can be 50% less expensive than one-on-one sessions.

Get the treatment you need at a price you can handle.

Affordable mental-health care has been easier to come by in recent years. Insurance coverage, once riddled with onerous caps and restrictions, is now more widely available. “Things have gotten better for many,” says Andrew Sperling, director of federal advocacy at the National Alliance on Mental Illness.

Still, paying for care can be a challenge. The high out-of-pocket costs that you’re facing for all your health care extend to behavioral coverage too. And low reimbursement rates and billing hassles have led many therapists to not take insurance. A study published last year in the journal JAMA Psychiatry found that only 55% of psychiatrists accept private insurance; for all other medical specialties, that figure is 89%.

Here’s what you need to know about finding the best treatment at the best price.

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MONEY

Insurance Options are Better

Under a 2008 law that took effect in 2010, health plans offered by large employers that include mental-health coverage must treat it like other medical care. So a plan can’t cap annual visits or impose prior authorization rules for behavioral health if it doesn’t do the same for other illnesses, says Jennifer Mathis, director of programs at the Bazelon Center for Mental Health Law. Co-insurance rates have to be the same too. As the graphic above shows, the parity law hasn’t discouraged employers from offering coverage.

Any individual plan you buy on a state insurance exchange must include mental-health coverage; it’s one of the 10 essential benefits required by Obamacare. The provision in the law that lets children stay on a parent’s health plan until age 26 is another boon, since most major psychiatric conditions show up in late adolescence or early adulthood, notes Debbie Plotnick, senior director of state policy at the nonprofit Mental Health America.

Medicare coverage is also better. As of 2014, benefici­aries are responsible for only 20% of mental-health costs, down from 50%.

Your Employer Can Often Help

Especially if you have a high-deductible health plan, start with your company’s employee assistance program, says Kathleen Mahieu, leader of behavioral-health consulting at benefits consultancy Aon Hewitt.

About three-quarters of employers offer an EAP. These programs typically provide five or six sessions of no-cost counseling, even for family members. That’s enough for some people to resolve their issues, says Katherine Nordal, the American Psychological Association’s executive director for professional practice. An EAP can help you find a provider or connect you with other mental-health resources. “It’s a one-stop shop,” says Mahieu. And, she adds, EAPs pride themselves on confidentiality. Your boss won’t know, and you don’t even have to give your name.

Your Bill is Negotiable

When your therapist isn’t in your insurance network, you’ll have to pay upfront and submit the bills for partial payment (assuming you have out-of-network coverage) or, if you’re in an HMO, pay in full. Even if you are reimbursed, you won’t get back, say, 70% of the bill. You’ll get 70% of what the insurer considers “reasonable and customary,” leaving you on the hook for the rest.

If you can’t find an appropriate provider in your plan, ask your insurer to negotiate what’s known as a single-case agreement with someone who’s not in your network, says Barbara Griswold, a licensed marriage and family therapist in San Jose. That would let you to pay the in-network rate.

You can also ask about a reduced fee, says Griswold. “Almost every therapist has a sliding scale,” she says. Be realistic about what you’ll be able to afford and how long you’re likely to want therapy.

You Have Other Ways to Save

A university with a graduate psychology program may have a clinic, says the APA’s Nordal. Care is provided by doctoral trainees who are supervised by licensed psychologists. In an urban area, you may be able to find postgraduate training programs in psychoanalysis or cognitive behavioral therapy for experienced psychologists, says Geoffrey Steinberg, a licensed psychologist in New York City. (Google “training clinic” and the specialty you’re looking for.)

Another option: Ask your therapist if your condition might benefit from group therapy led by an experienced psychologist, which can be 50% less expensive than one-on-one sessions. Says Steinberg, “Group is so underrated and can be so valuable.”

Know Which Treatment Is Best for You

“No single therapy works for everybody,” says Renée Binder of the University of California at San Francisco’s School of Medicine. Consider these approaches for five common conditions.

1. Mild to moderate depression: Go for cognitive behavioral therapy (CBT). “A therapist works with you to break negative thought patterns by teaching specific skills,” says Binder. You might learn, for example, to ID overly critical self-talk (“Everything I do gets screwed up”) and reframe it in a positive way (“I flubbed a presentation, but I know I can rock it next time.”)

2. Severe depression: Combining antidepressants with CBT is better than meds alone, a recent Vanderbilt University study found. You need to see an MD or a psychiatric mental-health nurse practitioner for the prescription, but you can get therapy from a social worker or a psychologist.

3. Social anxiety: Your best bet is either CBT or psycho­dynamic therapy (in which you explore how your past experiences and unconscious affect you). In a study published in July in the American Journal of Psychiatry, these methods were equally effective at easing social anxiety.

4. Panic attacks: CBT is usually the treatment of choice. Some research suggests psychodynamic therapy may also work: A Weill Cornell Medical College study found that 12 weeks of biweekly sessions significantly reduced symptoms in more than 70% of patients. Medications may also be used.

5. Trauma: Look for a therapist who offers trauma-focused CBT or EMDR, which stands for eye movement desensitization and reprocessing (you’re asked to recollect the event while doing a motor task such as side-to-side eye movements). “Antidepressants and anti-anxiety meds are helpful in the short term, but therapy works to change thought patterns long term,” says Binder.

 

TIME Mental Health/Psychology

How Your Cell Phone Distracts You Even When You’re Not Using It

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Why you might want to get it out of eyesight

Even if you go all day without touching your cell phone once, just having it visible nearby may distract you from complex tasks, according to new research in the journal Social Psychology.

In the first part of the study, which looked at a group of more than 50 college students, participants were asked to complete different motor tasks with the study leader’s cell phone visible. In the second, participants completed motor tasks with their own cell phones visible. Performance on complex tasks suffered in both conditions when compared to control groups with no visible cell phone.

The sight of a cell phone reminds people of the “broader social community” they can access via texting and the internet, says study author Bill Thornton.

MORE: Why People Text And Drive Even When They Know It’s Dangerous

“With the presence of the phone, you’re wondering what those people are doing,” says Thornton, a University of Southern Maine professor. “Even if it’s just mental, your focus is not on the task at hand, whether it be trying to write an article, get this spreadsheet set up, or just socializing; your mind is elsewhere.”

While performance on complex tasks suffered, the presence of cell phones did little to keep people from successfully finishing easy tasks. Thornton says the same applies to texting while driving.

“You could probably text and drive somewhat safely if you’re on a straight road, and there’s no traffic, and you take your time,” says Thornton. Of course, those conditions rarely exist.

The study builds on previous research that suggests that having your cell phone out reduces the quality of social interaction, even if you don’t engage with your phone. Having the phone out stifled “interpersonal closeness and trust” and kept study participants from feeling empathy for one another, a 2012 study in the Journal of Social and Personal Relationships found.

“Mobile communication devices such as phones may, by their mere presence, paradoxically hold the potential to facilitate as well as to disrupt human bonding and intimacy,” it concluded.

Cell phones play a significant role in today’s social engagement, but Thornton nonetheless suggests that people just put the device away for awhile. “I’m not sure how many people’s text messages are that important,” he said. “Unless you’re an advisor to the president and we have a national emergency, you can wait an hour to get a text.”

TIME Mental Health/Psychology

Suicide Risk Drops 26% After Talk Therapy

Suicide is a problem with few concrete preventive solutions, but a new study in Lancet Psychiatry finds that intervening with talk therapy after a suicide attempt seems to have some amazing long-term effects.

Researchers from Johns Hopkins Bloomberg School of Public Health looked at data from about 65,000 people who had attempted suicide between 1992-2010 in Denmark. The country opened suicide clinics in 1992 and provided them nationwide in 2007, and some of the people had gone to one of these clinics and received 6-10 sessions of talk therapy. The rest of the people did not.

When the researchers analyzed the data after a 20-year follow-up, those who had received the talk intervention fared much better. They repeated acts of self-harm less frequently and had a lower risk of death by any cause, including death by suicide.

After five years, there were 26% fewer suicides in the group who received therapy than in the other group. About 145 suicide attempts and 30 suicides were prevented in the talk therapy group, the researchers estimated.

“People who present with deliberate self-harm constitute a high-risk group for later suicidal behavior and fatal outcomes, so preventive efforts are important; yet, implemented specialized support after self-harm is rare,” the researchers wrote in the study.

Though the study had a long follow-up period and population size, it was not a randomized controlled trial, but such an intervention would be ethically impossible, the study authors write. “These findings might be the best evidence available and provide a sound basis for policy makers who wish to limit suicidal behavior and fatal events in an accessible high-risk group, which, in many countries, receives little support.”

 

TIME mental health

Women in Positions of Power Show More Signs of Depression Than Men

A study found that women in the workplace experience more symptoms as they gain job authority, while the opposite is true for men

Symptoms of depression become more prevalent for women as they obtain job authority but less prevalent for men, a new study from the University of Texas at Austin suggests.

Researchers looked at 1,300 middle-aged men and 1,500 middle-aged women for the study, “Gender, Job Authority and Depression,” which appears in the December issue of the Journal of Health and Social Behavior. Women with the ability to affect pay and fire and hire others had more symptoms of depression than women without such authority. Men with similar authority at work had fewer symptoms of depression than those without, the study reports.

“What’s striking is that women with job authority in our study are advantaged in terms of most characteristics that are strong predictors of positive mental health,” said sociologist Tetyana Pudrovska. “These women have more education, higher incomes, more prestigious occupations, and higher levels of job satisfaction and autonomy than women without job authority. Yet, they have worse mental health than lower-status women.”

One explanation is that women face more stressors at work when in positions of power because they are faced with overcoming more stereotypes and resistance to their leadership. Men, on the other hand, don’t appear to face such obstacles.

“Men in positions of authority are consistent with the expected status beliefs, and male leadership is accepted as normative and legitimate,” Pudrovska said. “This increases men’s power and effectiveness as leaders and diminishes interpersonal conflict.”

TIME Crime

Report Identifies Missed Chances to Treat Newtown Shooter

This undated file photo circulated by law enforcement and provided by NBC News, shows Adam Lanza, the Sandy Hook Elementary School shooter.
This undated file photo circulated by law enforcement and provided by NBC News, shows Adam Lanza, the Sandy Hook Elementary School shooter. NBC News/AP

Connecticut's Office of the Child Advocate has released a report on Adam Lanza, who carried out the massacre at Sandy Hook Elementary School in 2012

The school system unwittingly enabled Adam Lanza’s mother in her preference to “accommodate and appease” him as he became more withdrawn socially, according to a state report issued Friday on the man who carried out the 2012 massacre at Sandy Hook Elementary School.

The Office of the Child Advocate identified missed opportunities to provide more appropriate treatment for Lanza, whose social isolation and obsession with mass killings have been detailed by police reports that found the motive for the shootings may never be known.

The advocate’s office investigates all child deaths in the state for lessons on prevention. The authors of the Newtown report said it aims to reinforce the importance of effective mental health treatment and communication among professionals charged with the care for children.

The report, which refers to Lanza only as “AL,” noted that recommendations by specialists for extensive special education support and expert consultations largely went unheeded.

“Records indicate that the school system cared about AL’s success but also unwittingly enabled Mrs. Lanza’s preference to accommodate and appease AL through the educational plan’s lack of attention to social-emotional support, failure to provide related services, and agreement to AL’s plan of independent study and early graduation at age 17,” the authors wrote.

The authors of the 114-page report said they could not say whether more effective treatment could have prevented the tragedy.

“This report raises, but cannot definitively answer, the question as to whether better access to effective mental health and educational services would have prevented the tragic events at Sandy Hook,” they wrote.

Lanza killed his mother, Nancy Lanza, then shot his way into the Newtown school on Dec. 14, 2012, and gunned down 20 children and six educators before committing suicide.

The police investigation into the massacre concluded more than a year ago with prosecutors saying in a summary report that a motive might never be known. It said Lanza was afflicted with mental health problems, but despite his dark interests, he did not display aggressive or threatening tendencies.

Documents released by police in December 2013 included descriptions of sporadic treatment for his mental health troubles. At one point, experts at the Yale Child Studies Center prescribed antidepressant/anti-anxiety medication, but his mother, Nancy Lanza, discontinued the treatment after her son was unable to raise his arm after taking the medicine and never scheduled follow-up visits, police reports said.

A Connecticut judge last year ordered Newtown school officials to give Lanza’s records the Office of Child Advocate for its investigation. The governor’s Sandy Hook Advisory Commission has been waiting for the office’s report before releasing its recommendations on what the state can do to prevent and respond to future mass killings.

Child Advocate Sarah H. Eagan already has met with the families of the victims and Newtown school officials to discuss the findings.

TIME Research

Having A Sense of Purpose Helps You Live Longer

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A meaningful life is a longer life

People who think their life has meaning and purpose die later than people with a lower sense of personal wellbeing, according to a new study.

About 9,000 people over age 65 were followed for eight and half years as part of a study published in the Lancet. Researchers measured their wellbeing by giving them a questionnaire that gauged how much control they felt they had over their own life, and how much they thought what they did was worthwhile. The participants were then split into four groups, ranging from the highest to lowest levels of wellbeing.

Happier people tended to outlive their less fulfilled peers. Over the eight years, just 9% of people in the highest wellbeing category died, compared to 29% in the lowest category. Previous research has linked happiness to a longer life, and this new finding adds to the theory.

MORE: Here’s Where People Are Happiest Growing Old

“There is quite good evidence from studies of people in nursing homes showing that those who have something to do and look forward to tend to be in a much better state,” says study author Andrew Steptoe, director of the University College London Institute of Epidemiology and Health Care. “I think one of the fundamental ideas is that of autonomy and sense control of their life. People can feel life is just rushing by, or once they quit working their purpose can narrow to some extent.”

Steptoe says it’s possible to engineer environments that encourage greater wellbeing, like bringing pets into nursing homes or having residents partake in gardening. Increasing meaning during the day might just increase lifespan, too.

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