Third, there is no mention of the seminal work in neuroimaging, genetics, and animal models that has begun to reveal the importance of epigenesis—essentially, the influence of environmental and psychological events on the expression of the genetic code. Epigenesis has important “permissive” effects on the development of both psychiatric and medical illnesses and helps us understand why psychotherapeutic work has important neurobiological correlates and effects. None of these fundamental developments in psychiatry, or their impact on clinical practice, were evident in Harris’ article.
Finally, Harris did not go deep enough in understanding how payment schemes in the health care insurance environment do drive the provision of care. For example, we have known for decades that primary care and non-psychiatric specialty physicians provide more than 50% of all ambulatory psychiatric care. They also write 70% of the prescriptions for antidepressants. Yet, partly because of the development of “carve outs”—specialized, fourth-party mental health insurance plans—general physicians rarely code psychiatric diagnoses because payment for these illnesses is often limited if provided by these practitioners. This makes it harder to understand the scope and quality of mental health care in the general medical sector.
Similarly, if the patient already sees a nonmedical therapist, many psychiatrists will avoid using psychotherapy codes to “protect” the patient’s limited number of psychotherapy visits. Consequently, actual psychotherapy provision by psychiatrists may be underestimated in some studies.
Moreover, with rare exceptions, insurers prohibit psychiatrists from billing the standard medical evaluation and management codes used by all other physicians (the so-called 99xxx E&M codes). These codes allow for stratified medical visits by complexity and time based on patients’ needs. As a consequence, patients may be squeezed into brief medication visits that become caricatures of psychiatric practice.
Gardiner Harris and The New York Times were near these important stories and missed them. Hopefully, Harris will find a way to return to these insurance issues—and to the real growth in psychiatric neuroscience—and tell both in a more balanced and accurate fashion.