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Kevin Cullen

Parity in mental health care a must

When John Herman heard that Robin Williams had killed himself, he was incredibly sad but not especially surprised.

John Herman is a doctor, a psychiatrist at Massachusetts General Hospital, and if you ask anybody in the country who knows about this stuff, they’ll tell you he is one of the best. But even the best lose patients to suicide.

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“Sometimes,” he said, “depression is a terminal illness.”

And so it was with Williams, one of the most talented and beloved performers of his or any generation.

His illness was there for all to see. When he ran around on “The Tonight Show” set all those years ago, manically funny, it was part of the act, but it was also mania, part of his illness. The tragic contradiction is that, at one level, his art was, at least partially, a manifestation of his illness.

No one but he could imagine the pain he endured when the laughter faded. He eventually got to the point where the darkness enveloped him and he saw no way out.

It would be a fine legacy to someone who was so wildly talented and by all accounts genuinely decent and kind that Robin Williams’ death would provoke a national conversation about the way we treat people suffering from mental illness and addiction. But I’m not going to hold my breath.

Accessing mental health care is getting harder, not easier. It’s getting more expensive for families, not less.

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“This is happening every day, to families we know,” John Herman was saying the other day.

“My sense is that there is no family that goes untouched by this. I knew immediately that Robin Williams’s death was going to be a big story, that it was going to have legs. I was hoping the ongoing story would focus on depression, but it has not.

“When I heard, beyond my sadness for Williams and his family, my immediate thought was, ‘Oh, my God. His shrink must feel terrible. His shrink must be devastated.’ I’m assuming Robin Williams had access to very good people. I’d be surprised if that person wasn’t just good but very good. And I wouldn’t be surprised if that person is devastated.

“When, in my shop, there’s a suicide, everybody feels terrible. There is a universal sense of guilt. Everyone wonders if there is something we could have done or could have done better. Any physician who loses a patient wonders that.”

One of the symptoms of a sick society is the difficulty so many people face trying to access and pay for good mental health care,the same kind of care that Williams, as psychiatrist Sean Maguire, so poignantly provided to Matt Damon’s troubled character in “Good Will Hunting. Six years ago, Congress passed the Mental Health Parity and Addiction Equity Act. It is a law routinely flouted by insurance companies that don’t want to pay to treat people who are desperately mentally ill and self-medicating themselves with drugs.

A couple of years ago, Dr. Lenny Rappaport at Children’s Hospital told me about a woman who had been turned down by 66 therapists she contacted seeking help for her young son. The therapists either didn’t take her insurance or didn’t take any insurance, because the reimbursement rates were too low.

In the days after Robin Williams’s death, I checked in with a handful of therapists I know. They said the reimbursement rates have dropped even further in the last couple of years. An increasing number of therapists can financially survive by taking only out-of-pocket patients. Some are leaving the business entirely.

Accessing mental health care is getting harder, not easier. It’s getting more expensive for families, not less.

Stigma remains a huge problem. So is ignorance. Dr. Sharon Levy, director of the Adolescent Substance Abuse Program at Children’s Hospital, said researchers there did a quality analysis with a sample group of pediatricians, and found that many don’t know what to look for when it comes to substance abuse and mental illness, or they make value judgments that have nothing to do with whether their patients are sick.

“We’ve heard physicians say, ‘I have really good kids in my practice.’ As if only ‘bad’ kids abuse substances. When it comes to addiction and substance abuse, we’re still seeing judgments made about ‘good kids’ and ‘bad kids.’ We still haven’t moved to a medical model. We haven’t internalized it yet,” Levy said.

One of the most depressing aspects of Robin Williams’s suicide is that he had all the access, all the best care. Money was not an object. But even with all that, he killed himself.

“Robin Williams could pay in cash for anything he needed. Even with that, depression can be a fatal illness,” John Herman said.

“Depression attacks resiliency. Like so many other people, we don’t know the details of what was going on. Call me crazy, but I think his shrink knows. I have some faith, rather than cynicism, that he did the best he could.”

For the vast majority of people, who have neither the money nor the clout of a Hollywood star, the prospects are even more daunting in a country where insurance companies, not doctors, decide who gets taken care of and who gets substandard care and who gets financially ruined trying to keep a loved one alive.

Dr. Larry Ronan, an internist at Mass. General, was Ted Kennedy’s doctor. Ted Kennedy did as much as anyone to make mental health parity the law of the land.

Ronan reflected on the sad passing of Robin Williams as he lamented the sorry state of mental health care for those who are not rich and famous.

“Our country’s health,” Larry Ronan said, “will never be whole until we insist that mental health be seen along with physical health as fundamental to our overall well-being, and funded as such.”

Amen.

Kevin Cullen is a Globe columnist. He can be reached at cullen@globe.com. Follow him on Twitter @GlobeCullen.
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