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On May 9, the Labor Department also issued a series of frequently asked questions (FAQ) regarding the implementation of the Mental Health Parity and Addiction Equity Act of 2008. While these FAQs do not apply directly to the Affordable Care Act, they are likely to be used to interpret the mental health parity provisions of the ACA. The FAQs clarify that if a plan provides mental health and substance abuse benefits, it may not limit those benefits to inpatient services only. Plans may carve out mental health services and handle them through managed behavioral health organizations as long as standards applied are comparable to and not more stringent than those applied to other services. Indeed, this is the standard that plans must follow generally in applying non-quantitative treatment limitations to mental health and substance abuse services.

For example, many health insurance plans still refuse to cover lifesaving treatment for eating disorders. Others create discriminatory barriers to care, such as imposing stricter prior-authorization requirements for mental health and addiction treatment than for medical benefits. Sadly, as underscored in a recent report by the assistant secretary for planning and evaluation at the U.S. Department of Health and Human Services, levels of care for evidence-based behavioral treatments, such as residential psychiatric services for children, are being eliminated because of uncertainty about what is required.

The most recent National Survey on Drug Use and Health, published last year, found that fewer than half of the 45.9 million adults with a mental illness receive treatment or counseling and that only 10 percent of the more than 23 million people who need help for a substance-use problem received any specialized treatment in 2010. Even more troubling is the fact that people with either disease have shorter life expectancies than most Americans; a 2006 study put the difference at 25 years.

More than 23.2 million people 12 and older needed treatment for an illicit drug- or alcohol-use problem in 2007, according to the National Institute on Drug Abuse, or NIDA. Only 3.9 million received treatment at a substance-abuse facility. Lack of insurance and insufficient coverage were cited in the 2009 report as two principal causes for this disparity.
Between 40 percent and 60 percent of those who seek treatment relapse, the same report found.
Robin Barnett said recent legislation to promote parity between medical and mental-health coverage has largely been circumvented or ignored by insurers. As co-owner of [a treatment facility], she said keeping patients in treatment after detox is a constant, often futile battle.
“Insurance (companies) are the gatekeepers to the amount of treatment somebody is able to obtain"....
NIDA guidelines recommend 90 days or more of primary treatment...but most insurance companies cut off patients at two weeks. Because of the tremendous costs associated with that level of treatment, she said, there’s no incentive to see patients through.
Congress passed the Mental Health Parity and Addiction Equity Act in 2008, and there was hope of improved access to treatment...Insurers, however, quickly found new loopholes.
Barnett said coverage is often dropped as soon as the physical symptoms disappear, even though the psychological addiction remains.
“Someone can come in in acute distress and withdrawal, with sweating, shaking, exhaustion and body aches...As soon as those symptoms go away, and if there’s no major damage to the liver or other organs, or high blood pressure or physiological issues, they’ll say (the treatments) don’t meet medical necessity.”

During the decade from 1998 to 2007, the percentage of the general population who used psychotherapy remained stable. Over the same period, however, psychotherapy assumed a less prominent role in outpatient mental health care as a large and increasing proportion of mental health outpatients received psychotropic medication without psychotherapy.

Psychotherapy has traditionally been regarded as a central feature of mental health service in the United States. It is widely viewed as a core clinical activity of psychiatrists, psychologists, social workers, and other mental health care professionals (1). Some evidence suggests that the role of psychotherapy in community treatment has diminished in recent years. According to the National Ambulatory Medical Care Survey, visits to office-based psychiatrists that include psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005 (2). Although the survey includes clinical diagnoses reported by the treating physicians, it offers no information about psychotherapy delivered by other mental health specialists and no person-level data on psychotherapy use. As measured by the Medical Expenditure Panel Survey (MEPS), the percentage of Americans treated with antidepressants who also received psychotherapy decreased from 31.5% in 1996 to 19.9% in 2005 (3). There has also been a decrease in employer-sponsored health plans that cover outpatient psychotherapy (4). Over this period, however, Americans have become more comfortable talking with health care professionals about personal problems (5), and concerns about antidepressant-associated suicidality may have led more depressed adults to pursue psychotherapy (6).

There is a paucity of information about recent national trends in use of psychotherapy in the United States. The most recent national profile of psychotherapy use indicated that in 1997 approximately 3.6% of Americans received at least one psychotherapy visit and most of those who received psychotherapy (61%) were also treated with a psychotropic medication (7). The scarcity of data on basic patterns in psychotherapy use contrasts with a relative abundance of information on patterns of psychotropic medication use (8, 9).

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