The US House of Representatives recently passed a bill that would require health insurance companies to cover mental illness.  Apparently, health insurance companies are none too pleased about the prospect of having to provide this coverage (for example, see NYT coverage).

This type of controversy really gets my blood boiling.  Consider the following questions raised:

“Is an ailment a legitimate disease if you can’t test for it? A culture tells the doctor the patient has strep throat. But if a patient says, ‘‘Doctor, I feel hopeless,’’ is that enough to justify a diagnosis of depression and health benefits to pay for treatment? How many therapy sessions are enough? If mental illness never ends, which is typically the case, how do you set a standard for coverage equal to that for physical ailments, many of which do end?”

First of all, many “physical” illnesses also lack a hard and fast test– there is no test to tell the doctor if you have a cold, or in many cases why some people have lower back pain, but in those cases, we expect treatment.  Second, psychiatric diagnosis does not stem from one complaint alone (e.g. “I feel hopeless”), but rather requires a systematic review of patient history, current symptoms, and other factors, just like going to the doctor for physical illness.  Third, while many mental illnesses are chronic, so are cardiovascular disease and cancer, but few people would suggest that just because a disease is chronic, insurance should not be required to cover it. Furthermore, treatment can vastly improve the lives of patients, and make them more functional and productive members of society.

Mental health and physical health are linked, and many so-called mental illnesses have distinct biological bases (genetic, neural).   If anything, I would argue that the fact that we do not understand the biological bases of mental illness provides justification to invest more in research and give more attention to treatment.  Furthermore, I would venture to guess that if we provided adequate mental health services to those in need, we might actually reduce the overall burden of healthcare costs (countries that provide universal health coverage to their citizens often cover mental health as well, because it is the smart thing to do).  As noted by the NYT: “a 2006 study in The New England Journal of Medicine, examining the costs associated with a parity program put into place by President Bill Clinton for all federal employees, found that it actually didn’t increase the use or the cost of mental health services.” 

In the long run, the United States needs to think about prioritizing the health of the population.  This means covering those who need coverage, and it means considering the person as a whole. 

Three separate teams of researchers have discovered the same set of genes that increase risk of addiction and lung cancer in smokers.  This is an exciting discovery.  When explained at the New York Times, the conclusion was:

“The genetic variations, which encode nicotine receptors on cells, could eventually help explain some of the mysteries of chain smoking, nicotine addiction and lung cancer that cannot be chalked up to environmental factors, brain biology and statistics, experts said. ”

Similarly, one researcher commenting on the finding suggested: “This is really telling us that the vulnerability to smoking and how much you smoke is clearly biologically based” (psychiatry professor Dr. Laura Bierut of Washington University in St. Louis, a genetics and smoking expert who did not take part in the studies).

However, what both of these sources do not comment on is the fact that more and more evidence suggests that biology AND the environment interact to create health, disease, dispositions.  Certain genetic variations may lead to riskier profiles, given a stressful environment, but in some cases, the same genes that are riskiest under threatening conditions can also be most protective under nurturing conditions.   Following this type of exciting discovery, in my view, what will be even more exciting is to understand the way(s) that the genes identified interact with both the physical and social environment to allow some people with those genes to avoid smoking all together, some to become addicted immediately, and some to fall in between.  To say that genes will explain the “mysteries of chain smoking, nicotine addiction and lung cancer that cannot be chalked up to environmental factors, brain biology and statistics” is to miss the most exciting part of the story– the interactions between all of these factors.