Illusion of access: Mental health care remains elusive for many

By Editorial Board

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If you need an x-ray, chances are your doctor can find some place where you can get it. But not if you need mental health care.
About two-thirds of primary care doctors have problems finding psychiatric treatment for at least some of their patients, a new survey finds. That’s significantly higher than the number who report difficulty finding other kinds of care like x-rays or hospital admissions for their patients.
Psychiatric care for children was among the hardest to find, the survey showed.
The reasons are varied: uninsured patients, managed-care requirements that limit treatment or community shortages of psychiatrists and psychologists.
But whatever the cause, many people who need help are forced to go without. It’s estimated that fewer than half of the people with serious mental illness like depression or bipolar disorder get treatment.

The survey, published this week in the journal Health Affairs, comes as state mental health budgets — long underfunded — are further threatened. The recession has cut state revenues, forcing legislators to look for places to reduce funding.
In Missouri, the House of Representatives recently approved a mental health budget that’s about $43 million short of what’s needed to maintain the current level of services. The state Senate might use federal stimulus money to soften the impact of those cuts. But even so, the need for care would likely far exceed what’s available.
Even for people with private health insurance, the level of state funding matters. Many psychiatrists and other mental health professionals rely on Medicaid payments to stay in business. Reductions in state funding can reduce the number of available providers and make care that much harder to find.

Changing insurance rules have made primary care doctors the gatekeepers for mental health. Most people who need care visit their family doctor first, either because they don’t know where else to go or because they need a referral to see a specialist.
Pediatricians were more likely than other doctors to report problems finding specialized mental health care for their young patients. Most said the difficulty was due to a lack of child psychiatrists in their communities or to insurance company obstacles.
Shortages of child psychiatrists are well documented around the country and by parents seeking care for their kids. Sherri Cook of Festus called more than a dozen psychiatrists before finding care for her son, Chance Roth. His struggle with bipolar disorder was detailed in an editorial on April 5.
As might be expected, doctors who treat uninsured or under-insured patients are most likely to have problems finding care for their patients. More than 47 million Americans lack health insurance and another 23 million or more are thought to be under-insured.
Legislation passed by Congress last year forbids insurance companies from placing more restrictions on mental health care than they do on other illnesses. The new survey, based on data from 2004, found fewer insurance barriers to care in states that had similar laws.
But even with good insurance, patients can’t get care if there aren’t enough psychiatrists and psychologists to treat them. Addressing those shortages, perhaps with incentives for medical students to specialize in psychiatry, is crucial to ending the illusion of access.