mental illness stigma

Equality in name only? How Vanderbilt promotes a discriminatory insurance policy (Vanderbilt Hustler Re-post)

While a student, I wrote several articles for Vanderbilt’s campus newspaper, but all of these were lost from the Vanderbilt Hustler website (along with all historic website content) sometime in the summer of 2016. I’m going to try to upload these articles here while I can still find scanned PDFs of the print issues that existed at the time. Unfortunately, the articles’ original links to sources are lost. 

This article did end up prompting a conversation about the tuition insurance policy. Vanderbilt Student Government passed a resolution encouraging a policy change. The Bursar (who was very genial when I met with him about this with the Student Body President) negotiated a new tuition insurance policy that reimburses mental and physical illness equitably, which took effect the following year (2015-2016).

Equality in name only? How Vanderbilt promotes a discriminatory insurance policy

(Published August 27, 2014)

Like many universities, Vanderbilt aspires to promote diversity and inclusion. The university requires its first-year students to discuss racism and the importance of pluralism, and its official policies include a promise to not discriminate in university programs. There is even an Equal Opportunity, Affirmative Action, and Disability Services Department whose “core values include equity, diversity, inclusiveness, accessibility and accommodation.” In light of the university’s seeming commitment to equality, I found it particularly vexing to receive a letter from Vanderbilt, accompanied by a signed note from the bursar, promoting a policy that is patently discriminatory.

Vanderbilt offers a “tuition-insurance” plan issued by A.W.G. Dewar, Inc., which provides reimbursement of education fees should a student withdraw from the university for medical reasons. The plan explicitly specifies that withdrawals caused by “mental health conditions” are given a 60 percent refund while a 100-percent refund is given for “injury and sickness.” The plan also indicates that withdrawals precipitated by addiction or substance abuse receive zero compensation.

On the face of it, the plan suggests either that mental illness is equivalent to three-fifths of a physical illness or that 40 percent of doctor-certified mental illnesses are feigned. Neither of these claims is borne out by any evidence. Rather than aiding a vulnerable student, the plan adds another layer of financial stress to a person likely facing a cascade of problems, possibly impeding his or her return to Vanderbilt.

This practice makes for an incoherent insurance policy, since it provides significantly less coverage for the illnesses most likely to warrant withdrawal. A 2009 study at 10 universities found that having clinical depression was the strongest predictor of withdrawing from college. So giving less coverage for mental illness is rather like having car insurance that provides 40 percent less coverage when your accident involves another car.

Moreover, distinguishing between mental and physical illness to provide unequal service perpetuates stigma against psychiatry and psychiatric illness — the idea that mental illness is “less real” than physical illness, or worse still, that someone is more blameworthy for having a mental illness than a physical one.

The practical implications of this policy are jarring to the point of ineffability. Why should a student suffering from depression because a person raped her receive a 40-percent-reduced reimbursement compared to a per-son struck by the “kissing disease”? Is post-traumatic stress caused by being robbed at gunpoint a less valid reason for withdrawing from college than a football injury?

The policy also violates the spirit, if not the letter, of federal law. In 2008, Congress passed the Mental Health Parity and Addiction Equity Act, which requires equal coverage for mental illness, including substance abuse, in health insurance plans. Hence, as The New York Times writes: “This would probably be illegal if tuition refund policies were deemed health insurance, instead of insurance that just happens to be based solely on your health.”

Since 2010, Vermont has required that colleges in the state provide equal coverage for withdrawal due to mental illness. Prompting the change was a complaint by a University of Vermont student named Sherry Williamson, a registered nurse who suffered from depression. “I couldn’t believe that UVM, which tries to promote diversity and be all-encompassing, would take on a policy that was clearly discriminatory,” Williamson said in an interview.

By choosing to contract with A.W.G. Dewar, Inc. under these terms, Vanderbilt University is complicit in unambiguous discrimination against people with mental illness. This is unacceptable for an institution that claims to be forward-looking and antithetical to the welfare of its students. Renegotiating a nondiscriminatory plan is essential if the university’s commitment to equality is more than skin-deep.

Why do so few medical students become Psychiatrists?

Today one of my coworkers and I got in an interesting discussion (or maybe an argument) about why relatively few medical students become psychiatrists. She just finished her first year at a pretty prestigious medical school.

I claimed that it boiled down to stigma against mental illness, while she argued that the difference is explained by other fields of medicine being “cooler,” “more interesting at least to some people,” and “more hands-on” (which I pointed out does not at all contradict the stigma explanation).

 I (like most people I imagine) am not very good at faithfully and fairly recounting how arguments played out, especially when they get a bit heated. So I’ll from here on try to make this objective (by which I mean independent of my conversation with my co-worker) and just flesh out a few interesting points that came up.

Psychiatrists are paid less and research is funded less than for other specialties

As New York Times writes, “Psychiatrists rarely earn enough to compensate for their additional training. Most would have been better off financially choosing other medical specialties.” Psychiatry is among the least paid medical specialties, though it looks like the pay is increasing faster than in most other areas. Interestingly, HIV/Aids specialists receive the lowest salary of all, and they also treat a stigmatized population.

Psychiatrists are least likely to accept insurance plans, possibly because they are systematically under-reimbursed, even for the same procedures  (that article also says that half of counties lack a regular psychiatrist!). Research on mental illness is significantly underfunded relative to the disease burden it creates.

Are other specialties more interesting, hands on?

Surely for some people and not others – like everything else. Maybe some people really like feet or skin or hearts or reading x-rays.  But for this to make sense in explaining the shortage of psychiatrists, it has to take the stronger form that psychiatry is systematically less interesting than other forms of medicine. And that sounds a little difficult to believe to me. (I am also inclined to think that if the average psychiatrist made $340,000 a year like the average orthopedic surgeon, interest wouldn’t matter much).

 The brain is an incredibly complex organ. Mental pathologies are extremely powerful and disruptive forces – they ruin lives and cause all kinds of bizarre behaviors. Additionally, considering that the lifetime prevalence of mental illness is one in two, and depression and substance abuse are higher among medical students than the general population (discussed later), it is fairly likely that a medical student has personally experienced a mental illness or observed its effects. It seems to me that, all else equal, you would be more likely to go into a field of medicine which has affected you or someone you know than not.

Anyhow, psychiatry sounds a lot more interesting to me than Orthopedics, for example (the highest paid specialty by far) or Plastic Surgery (another high payer). Surgery is a lot sexier than psychiatry (in addition to being much better paid) and I think this is a product of the stigma.

Are future doctors too sophisticated for stigma?

The hypothesis for this line of thinking is pretty intuitive: stigma comes from misunderstanding and misperception of mental illness. Medical students and doctors, who know a lot about mental illness, don’t make these mistakes, so they are less likely to stigmatize mental illness.

Unfortunately, it’s not true. Not at all.

According to an Journal of the American Medical Association study (specifically of med students at UMichigan), mental illness stigma may actually be higher among medical students, who, in addition to being more likely to be depressed than average, are more likely to attribute depression to “weak coping skills” and more ashamed about revealing their negative emotions. This sort of makes sense to me, as medical students strike me as the kind of people who endorse a very strong “protestant work ethic”, “internal locus of control” type of outlook. One that says if you want something, work hard and you get it; if you have a problem, work hard and you’ll solve it.

The implication is, unfortunately, that if you can’t solve a problem, you aren’t working hard enough. It’s your fault, something to be ashamed of.  It’s not hard to see how this attitude, coupled with a high-stress, hypercompetitive environment, would be ripe for high levels of depression and self-stigmatization. After graduating, doctors tend to avoid seeking mental health care.

And in the population at large, while more people attribute mental illness to neurobiological factors than in the past, stigma is actually higher, according to an American Journal of Psychiatry report. Being able to attribute illness to neurobiology doesn’t make people more accepting of illness; in fact, it may make it seem intractable, a rigid characteristic about a person that will never go away.

Mental illness stigma deters people from Psychiatry

Furthermore, there are plenty of published anecdotes (eg here, here, here) of psychiatrists describing the stigma they received for choosing their profession. A Columbia Professor of Psychiatry writing for Scientific American describes this comment made by another faculty member: “Tell all students who get low scores on their board exams not to worry, they just need to change their career plans and go into psychiatry.”

Psychiatry is also, as far as I know, the only branch of medicine with a dedicated movement opposed to its existence.  Ever heard of anti-cardiology?