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Apparently, mental illness gets you all interested in commenting and writing. 

I wrote that post a little hastily at the end of a very long week, so let me try to clarify a little.  Here's what I wrote to a therapist who asked me whether the problem of moral hazard from the "worried well" should really outweigh the potential benefits:


I think we're talking about two different things.  Should we upgrade the (IMHO) terrible "safety net" for the severely mental ill which has such enormous holes, and makes it so hard to coordinate care?  Absolutely!

Should we force insurers to provide talk therapy and drugs for people who--at least as far as I have been able to understand--will probably show, on average, little-to-no clinical improvement as a result?  As a way to get treatment for the mentally ill?  I'm skeptical.

And should we force insurance to do this because if we had to make the costs explicit by paying for it out of tax dollars, we'd never pass such a bill?  I'm against it.

Being against mental health parity is not being against help for people who are in desperate need of it.  It's against this particular thing.  You know better than I, but as far as I can tell, the benefits of talk therapy *or* drugs for mildly depressed people are underwhelming, and more than occasionally a way to avoid facing the underlying issue. 

These things show benefit in the severely impaired, and to me that means that those are the people to whom we should be trying to provide them.  I feel like a group of people who are in desperate need are being used to sell something that they largely won't benefit from--instead of upgrading the care they do use.

As the therapist agreed, the most severely ill people usually aren't able to work, so private insurance is not their major concern, but rather the uneven patchwork of state and federal programs.  If you are worried about people with severe disease that could really benefit from treatment, it is not Mental Health Parity you should target, but upgrading Medicare, Medicaid, and so forth.  If you're worried about high functioning people with severe mental illness (they exist), or the huge "marginal tax" implicit in getting off state assistance and going back to work--and I am worried about these things--we should invest in that.  By which I mean, spend actual taxpayer dollars on a government program, not pass a feel-good measure at someone else's expense that mostly provides benefits to those who are not in dire need of them.

Now, maybe I'm wrong, and someone has awesome evidence on the many benefits of antidepressants and talk therapy for the mildly depressed that I have not seen.  But so far no one has sent that along (CBT excepted, which does work, but my understanding is that the mildly depressed usually find it too tedious for the small benefit they'd derive). 

People have sent a lot of evidence that the severely depressed need help, which they do.  But Mental Health Parity is almost absurdly poorly targeted to give it to them.  To the extent that it is a substitute for improving government assistance, it is probably actually harming them.

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Megan McArdle is a columnist at Bloomberg View and a former senior editor at The Atlantic. Her new book is The Up Side of Down.

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