This article was published by Prevention.com on June 1, 2023.
Maybe you can only imagine the scenario, or perhaps you’ve experienced it. At night in bed, you hope sleep will obliterate the despairing emptiness that’s been looming all day. Or that you’ll finally escape the disembodied whispers saying no one loves you and you don’t deserve to live.
In the morning, a sick swirl of anxiety descends, and your chest tightens after yet another night plagued by racing thoughts. Placing one foot on the floor seems improbable. Calling a list of therapists feels impossible.
But in the U.S.—despite pressing hopelessness, spiraling anxiety, or other tangled symptoms of a mental health crisis—you’re required to figure out how to get help. Whom do you call within a system that’s complex and scattershot, low on providers and high in cost?
This situation may be familiar to you or someone you love, because legions struggle with mental health issues, especially since COVID-19. The numbers show in stark relief how the pandemic upended America’s mental health and increased pressure on stressed systems: In 2019, fewer than one in 10 adults reported symptoms of anxiety or depressive disorders; during the pandemic, that number increased to three in 10, according to the Centers for Disease Control and Prevention.
And the situation doesn’t seem to be improving: In December 2022, a survey by the American Psychiatric Association (APA) showed that the percentage of Americans who rated their mental health as only “fair” or “poor” increased to 37% from 31% the previous year.
Navigating a path toward support and help is, at best, a challenge. “It feels like the mental health care system by design is meant to be confusing,” says Theresa Nguyen, a licensed clinical social worker for 20 years and now chief research officer at Mental Health America (MHA).
The biggest issue in the U.S. may not even be the system but a lack of one, according to Jennifer Snow, national director of Government Relations, Policy and Advocacy at the National Alliance on Mental Illness (NAMI). She points to a patchwork of individual providers, systems, and approaches that vary by state or county. “People with mental health conditions get the short end of the stick,” she says. Compared with those with physical conditions, she adds, “it takes longer to get care, and people have to pay more to get care, with fewer choices of providers. It’s a sad state of mental health care in America.”
How access to care got to be such a problem
In 2021, 35% of adults who needed and didn’t receive mental health services said it was because they didn’t know where to go, according to a large Substance Abuse and Mental Health Services Administration (SAMHSA) survey.
In 2022, a Kaiser Family Foundation survey found that 50% of women surveyed (ages 18 to 64) needed mental health services in the previous two years—but only half made an appointment. Among those who tried to get an appointment but were unable, a third said they couldn’t find a provider accepting new patients, and another third said they couldn’t afford the care.
When a person’s crisis hits a stage needing inpatient treatment, things can become more dire. There are two main ways in which most people interface with mental health treatment, says licensed psychologist Hani Talebi, chief clinical officer at the Meadows Mental Health Policy Institute: “One is through law enforcement, and the other is through a hospital’s emergency department because crisis symptoms have worsened and they have no place to go.”
A big reason: There’s an overall shortage of inpatient beds for those experiencing an acute crisis. This partially stems from a laudable mid-20th-century goal of closing harmful psychiatric institutions and instead opening more community-centered facilities. The problem is, the latter never really happened.
Those same mid-century requirements mean Medicaid coverage for low-income Americans won’t pay for psychiatric care at a facility with more than 16 beds, and Medicare limits inpatient psychiatric stays to 190 days over a person’s entire lifetime. “There’s no similar prohibition on any other type of health care facility for medically necessary care,” Snow points out. “Can you imagine something similar for cancer?”
We all pay the price at the societal level—inadequately treated or lifelong mental illness can lead to increased homelessness, incarceration, and premature death, according to a 2022 White House brief. The brief notes that nearly one-third of those who receive Social Security Disability Insurance fall within the “mental disorder” category. That’s more than the number of people who are unable to work due to injuries, cancer, and diseases of the circulatory and nervous systems combined.
The COVID pandemic was a double-edged sword: Job loss and social isolation amplified existing problems but also led to an unprecedented increase in mental health awareness campaigns, says Elizabeth Hancq, research director at the Treatment Advocacy Center.
“There has been increased funding and attention, and we have celebrities and senators being public about inpatient mental health treatment. But we still have a long way to go,” she says. And that’s particularly true regarding two key barriers people face when trying to get the mental health care they need: too few health care providers, and costs that are too high for too many people.
The provider shortage
Two-thirds of Americans feel that it’s harder to find a mental health care provider than to find a physical health care provider, according to a 2022 survey by the National Council for Mental Wellbeing (NCMW). But why?
In 2016, a NAMI survey of more than 3,000 people looked at the issue (and one can only assume the situation has since worsened, given the pandemic). Nearly a third of the survey respondents had looked for a mental health care provider in the past year, and the top barrier they reported was the fact that psychiatrists and therapists were not accepting new patients. Other difficulties were not having their insurance accepted and getting no response to their inquiries.
Mental health providers agree that this is a serious problem. The American Psychological Association surveyed psychologists in late 2022 and found that six in 10 reported they no longer had openings for new patients, almost half couldn’t meet the demand for treatment, and nearly three-quarters had longer wait lists than before the pandemic. On average, the psychologists said that more than 15 hopeful new patients contacted them each month.
There’s a universal reason for this problem: Around half of all Americans live in areas where there’s a shortage of mental health professionals, according to federal data. There just aren’t enough providers overall, but the shortage is worse in some states and regions, including in rural America. Most states have fewer than 40% of the mental health professionals needed, and more than half of U.S. counties have no practicing psychiatrists—not a single one.
Nguyen calls these areas “mental health deserts,” large parts of the country with no available mental health provider for over 50 miles. Even in urban areas, a family could find themselves on a psychiatrist’s three-month waiting list—even after a dire event such as a child’s suicide attempt. “Finding a culturally responsive provider, one who can speak a shared language or shares a common cultural or ethnic background, is even harder,” Nguyen says.
“We just haven’t trained enough doctors in the past 20 years to keep up with an aging and growing population,” says Atul Grover, M.D., Ph.D., executive director of the AAMC Research and Action Institute. About a third of specialist physicians (including psychiatrists) are over 55, he says, and there is no pipeline of replacements in the U.S. for those who retire. Burnout may also be contributing to the problem: One survey of over 2,000 psychiatrists (done before the pandemic) found that nearly 80% reported burnout, and the researchers concluded that this could lead to their retiring earlier, among other effects. The situation may well have worsened during the early time of COVID.
With the specialist supply in dire shape, it’s no wonder that many people turn to primary care providers. But when it comes to dealing with potential mental health issues in a primary care office, complex issues may be hard to spot and address, especially during a quick appointment. If you visit your PCP for sleep difficulties, for instance, your restless nights could stem from a physical problem like a thyroid issue, which the doctor can test for and treat. But they could also be a symptom of depression, and testing and monitoring for that is often more challenging.
Also, whether a particular doctor is knowledgeable about mental health issues may be hit or miss. Many physicians were trained to be medical doctors rather than holistic practitioners addressing both physical and mental health, Talebi notes. “In essence, historical med school training removed the head from the body, unless it was about the brain as an organ as in neurology,” he says. “As a result, front-line practitioners felt ill-equipped to manage mental and behavioral health disorders. PCPs were underwater before the pandemic started.” Though physicians managed successfully for years, Talebi adds, “many have finally passed a threshold where the sheer volume of patients with mental health challenges has surpassed their capacity to manage.”
Many PCPs have admirably and honorably attempted to address the mental health crisis over the past few years, but again, burnout is an issue. “And self-reporting by patients is infamously poor,” Talebi says. Someone may tell a doctor they’re OK when they’re actually struggling, so doctors may have to rely on other signs—for example, says Talebi, “chronic pain is often a red flag for us.”
Merritt Hawkins, a physician-recruitment firm, issued a white paper in 2018 about the shortage of psychiatrists, pointing out that “mental illnesses generally cannot be addressed through medical procedures, but only made manageable through long-term treatment with drugs and/or therapy. Hospitals and clinics tend to be procedure oriented…where the appropriate surgery/intervention is performed and the next patient is addressed.”
That point is important, especially given the fact that if a person in a crisis situation can’t find help, they may well go to a hospital that is ill-equipped to help them. The report continues: “Psychiatry…is not a profit center for most hospitals (psychiatric services are not covered by some insurance companies), so such services sometimes are not given a high priority….[M]ental health problems in the United States, their causes, cures, and those who suffer from them, tend to be swept under the carpet.”
The high cost of care
Overwhelmingly, the top barrier to accessing care for people experiencing any sort of mental health issue is an inability to afford that care. When SAMHSA surveyed people with mental illness across all racial/ethnic groups, respondents most frequently cited the cost of service and the lack of insurance coverage as their reasons for not using mental health services.
In the NCMW’s 2022 survey, fewer than half of those who had received mental health care over the previous year said that their insurance covered their care in full—and this is directly connected to the provider shortage. With so few mental health providers, Snow says, there’s little incentive for them to join a network. “It’s basic economics: If your services are in demand and you can fill a whole day with people who can pay cash, why would you voluntarily go into an insurance system and get paid less?” she says. “Supply and demand creates inequities in the system.”
Experts agree that insurance often doesn’t pay enough or cover enough mental health services. “We have underinvested in mental health care for a century, and insurance did
not historically cover mental health care or cover it well,” Nguyen says.
Adding to the problem is the fact that future mental health providers who study subspecialties can end up with significant student debt—as well as limited earning potential. That’s because despite their high level of training, mental and behavioral health providers are paid relatively poorly compared with other health providers, Talebi says. And this, in turn, may contribute to the scarcity of providers as well as push them to avoid accepting insurance altogether.
The classic U.S. model of health insurance carved out different coverage or policies for dental, vision, hearing, and mental health, Dr. Grover says. Federal law now requires insurers to provide mental health coverage with “parity,” or equivalence to physical health coverage—but in reality, a 2022 report to Congress found that many insurers still treated mental health conditions differently and a confusing mix of federal and state agencies were tasked with enforcing insurance parity. This has led to what Dr. Grover calls “ghost networks”: outdated lists of therapists whom people phone, only to discover that they don’t accept their insurance, are no longer in practice, or aren’t taking new patients.
Insurers can throw up questionable financial barriers by requiring a higher copay for mental health specialists than for other specialists or otherwise not covering medical and mental treatments equally. For example, one agency found two large New York plans that were covering nutritional counseling for medical conditions like diabetes, but not for mental health conditions like anorexia, bulimia, and binge eating disorder. So it’s no surprise that many patients receive a large proportion of their mental health services out of network, according to one study—that is, when they can locate a provider in their area who is accepting new patients, has expertise in their particular mental health issue, and with whom they can connect and work well.
What can be done?
The issue of mental health care in America has touched so many, and the opinion that it needs fixing is widely held: In a 2022 poll by the APA, 79% of adults said that the state of mental health in the U.S. was a public health emergency that deserved more of lawmakers’ attention. Some politicians are stepping up: The 2023 federal spending package increased funding for mental health services, including significant funding for Lifeline, the national
988 suicide and crisis hotline. Since the launch of the new 988 number in mid-July 2022, Lifeline has received more than 1.43 million calls, over 416,000 chat requests, and more than 281,000 texts. And more medical schools are heeding the call for improved mental health care training for future physicians, Talebi notes.
That offers reason for hope, but this fact remains: In essence, America’s mental health care relies on a depressed and stressed consumer to navigate disastrously complicated paperwork and policies amid a practitioner shortage—and to pay a lot for it too. Yes, it can be disheartening and overwhelming, and yet every day providers, advocates, and others wake up and attempt to address the causes and effects of a broken and sometimes nonexistent mental health care system.
“There is great honor and virtue in knowing that the work can prove impactful in micro and macro ways to positively alter the lives of compromised people,” Talebi says. “Is there anything that can bring more meaning and purpose to our lives than offering a hand to those struggling? In the end, maybe it’s what we were meant to do as a social species.”
Where to get help
The increased awareness of mental health challenges is a step in the right direction—and now what’s needed is a focus on workforce development, including training more providers and specialty clinics to provide clinically and culturally appropriate care, says Theresa Nguyen of Mental Health America. “This is where our society needs to invest and build out,” she says. “I hope there’s a will to do that, because doing so is an opportunity to create jobs and a healthier country.”
In the meantime, here are some resources that can help people learn more about specific conditions, as well as find treatment options and affordable care:
988 is the new number for the national Suicide & Crisis Lifeline, and it’s one of the fastest ways to get 24/7 help. Calls are routed to the nearest crisis call center based on the caller’s area code, and the caller is connected to local resources.
NAMI’s HelpLine (800-950-6264) is a free peer-support service available by phone, text, or chat. It’s not a crisis line: It’s available from 10 a.m. to 10 p.m.(Eastern time), and callers are given empathy, respect, and support for their concerns, with referrals to resources and local services. NAMI’s website also provides a wealth of mental health support and treatment information, including a guide on medications. And the organization has free, peer-led support groups (many of them virtual) for adults who have experienced symptoms of a mental health condition, as well as for family members.
Mental Health America offers screening tools for symptoms of a wide range of mental health conditions. This isn’t a self diagnosis, but rather a way to arm yourself with information that can help you work with a provider. The site also includes a rundown of treatment types, including medication, psychotherapy, support groups, peer support, and types of mental health professionals.
SAMHSA’s National Helpline (800-662-4357), available 24/7 all year round, is an information resource as well as a place to get referrals to treatment facilities, support groups, and community-based organizations in your area.
Open Path Psychotherapy Collective is a nonprofit offering affordable online or in-person counseling, searchable by zipcode. The healthcare providers who are part of the collective have agreed to provide $40-$70 sessions to those without health insurance or whose insurance doesn’t provide adequate mental health benefits. A student intern can provide even lower-cost care ($30/session). The cost to access sessions is a one-time $65 fee to the collective.
This story is available on Prevention’s website here.