Healthcare professionals are divided on whether psychiatric counseling should be paid by the National Health Insurance (NHI), as voices calling for expanded coverage grow louder in the wake of high-profile incidents.
The issue was recently thrust back into the spotlight, when a man with schizophrenia, who had long been known have violent episodes, on Sept. 26 attacked a convenience store clerk in Pingtung County, potentially blinding her.
While certainly an outlier, the case has again highlighted the weak spots in mental health coverage.
Photo: CNA
Under the first article of the National Health Insurance Act (全民健康保險法), benefits are to be provided in the event of “illness, injury or maternity,” which excludes non-therapeutic psychiatric counseling.
However, some inroads have been made since a proposal calling for coverage of counseling and psychotherapy was raised earlier this year on the government’s online public policy participation platform.
The petition, which gathered 5,882 signatures, resulted in a forum on Tuesday last week held by the National Health Insurance Administration for experts and the signatories to share their thoughts.
The agency also issued a response on July 13 outlining the steps it has taken since 2013 to address the “major issue” of mental health in the absence of clear legal coverage.
In addition to the 1925 suicide prevention hotline, the agency emphasized the establishment of 385 community mental health centers nationwide, which provide counseling at no or a reduced cost to more than 20,000 people annually.
However, Association of Taiwan Clinical Psychologists member Lin Tzu-yin (林姿吟) said that many psychologists do not see a single patient during their office hours at community clinics, showing that people are unaware of the service.
In 2014, the agency also revised coverage policy for “deep psychotherapy” to eliminate disease discrimination, allowing treatment to be covered regardless of a person’s condition, it said.
Despite these efforts, critics have pointed out that treatment, even when it is covered, often takes months to receive due to limited resources, while other forms of counseling are prohibitively expensive.
The woman who posted the petition, surnamed Wu (吳), referenced her mother’s experience as an example of the need for universal coverage.
Suspecting she had a hoarding disorder, Wu’s mother years ago visited a psychiatric division at a hospital where she was prescribed medication, she said.
As it seemed to have no effect, she wanted to visit a psychologist for counseling, but the NHI would not cover it, Wu said, asking why benefits seem to be available only some of the time.
A signatory surnamed Liu (劉) said he had consulted a dozen psychologists since he was diagnosed with depression more than a decade ago.
Even after finding a suitable one, Liu said that the price was hard to swallow.
Psychiatric treatment covered by the NHI is mainly performed by psychiatrists and clinical psychologists, said Li Yu-chan (李玉嬋), president of the Taiwan Mental Health Counseling and Psychological Association.
However, there are only about 1,800 clinical psychologists in Taiwan, resulting in wait times of three to six months for a consultation, she said.
On the other hand, there are nearly 3,200 counseling psychologists who are only available to those able to afford the sessions, Li added.
The nation has 1,662 clinical psychologists, 1,233 of whom are registered to work in hospitals, Ministry of Health and Welfare figures show. Of the 2,718 counseling psychologists in Taiwan, only 344 are able to work in hospitals.
Taiwan Counseling Psychology Association president Hsu Hsi-sen (徐西森) is a staunch advocate for his colleagues’ inclusion in the NHI system, considering the preventive effect of counseling.
Psychiatric issues involve not just the individual, but entire families and societies, Hsu said.
A lack of coverage harms outcomes by not only keeping patients from treatment that could prevent deterioration into a psychiatric disorder, but also by making psychiatrists less willing to write prescriptions, he added.
In practice, psychiatrists, clinical psychologists and counseling psychologists are hard to differentiate as they all utilize the same psychiatric principles, said Tsai Hsiao-wen (蔡曉雯), a representative of the Taiwan Counseling Psychologist Union.
All three can provide psychiatric counseling and treatment, distinguished only by the recipient, work setting and treatment goal, she said.
However, not everyone agrees.
Psychiatrist Kuo Hsi-ching (郭錫卿), who represents the Taiwanese Society of Psychiatry, said that psychological issues, mental illness and serious psychiatric disorders are separate issues.
Mental disorders are caused by abnormalities in neurotransmitter activity, and are treatable with medication in conjunction with psychiatric treatment, Kuo said, adding that this is already covered by the NHI.
As for mental health counseling, Kuo equated the situation to having high blood pressure, a precursor to a disease, but not yet a medical condition.
“Maybe one day you had a fight with your boss or wife that puts you in a bad mood or you have adaptive or interpersonal issues,” he said.
“These are all a part of mental health, but as it has not progressed into a disease, by definition they are not covered by the NHI,” he said, recommending that it stay that way.
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