One of the problems neither the new health care bill nor the mental health parity law that kicks into full effect in another month or so will address is a growing problem in America’s mental health system — the lack of professionals who can see you now. The problem is most seriously felt within psychiatry, where the number of medical students who choose psychiatry over a different medical specialty continues to shrink.
A friend of mine who currently sees a psychiatric nurse for her medications wanted to switch to a psychiatrist so that she can try to get off of Effexor, a commonly prescribed antidepressant than can be extremely challenging to get off. She lives north of a major metropolitan area in the U.S. and has decent health insurance.
So she started the thankless process every American faces when trying to find a new specialty provider — making endless phone calls to the list of “approved” providers from her insurance company.
(As an aside, it’s amazing to me that in the year 2010, the only way to find out if a professional has openings — and when they are — is to physically call their office. With endless talk of electronic medical records and scheduling software, there’s still no simple, central place a consumer can go to get this information quickly and easily. Talk about a business opportunity!)
Anyway, she went around and around with the phone calls, over the course of a few days. Some providers either didn’t have front office staff, or they were busy, so she needed to leave a message. Then they had to call her back to let her know their availability. If she was on the phone for her own work, she would then have to start the fun game of phone tag, which is also fairly frustrating.
Finally, it starts becoming clear when openings are available. Six months. Five months. 4 1/2 months. Finally she found a psychiatrist who could see her in about 3 months’ time. For all the talk of having long lines or “rationed” treatment in other kinds of health care systems (such as Canada’s), you don’t have to look very far to see the same thing happening here in the U.S. The long lines have long existed here; it’s just that either people aren’t familiar with them, or believe that for some reason it’s acceptable for certain types of specialties (with little reasoning or rationale).
This issue has become the focus once again as psychologists have sought to extend their prescription privileges from the current two states to a third — Oregon. Some psychiatrists, like Dr. Danny Carlat, support such an extension because he believes there is a critical shortage of psychiatric prescribers in the U.S. If properly-trained psychologists can be allowed to prescribe a small set of medications, the thinking goes, it may help alleviate some of the burden on psychiatrists. While I am against such privileges, I understand the rationale behind the push.
Nobody seems immune from this recurring problem in the U.S. health care system. It’s nearly impossible for me to get into see my dentist for a regular cleaning unless I schedule 6 months in advance. Even the world famous Mayo Clinic isn’t immune. Their Mayo Mood Clinic has a 2+ month wait list to be seen, according to a colleague.
Treatment Only Works if People Can Get It
It’s great that we keep pushing people to seek treatment for their mental health issues, but what’s the point if that treatment isn’t readily available? Trust me when I say it takes enormous courage for most people to even take the first step toward treatment by agreeing to see someone. Imagine how deflating it is when, having toiled with the idea of seeking treatment for weeks or months, you’re told you have to wait another 3 or 4 months to see someone.
I suspect a great many of those people simply say, “Thanks, but no thanks.” Making a person who is already suffering wait longer in their emotional suffering isn’t just a bad way to run a mental health care system — it’s cruel and illogical.
As a bonus, this is the way that most people get their first interaction with a mental health provider — by being told they have to wait weeks or months to see them. In a psychotherapy relationship where the therapeutic alliance is a significant component of change, you can imagine what this must do as a “first impression” in that relationship. Whether or not the fault of the provider, patients don’t care. They don’t want finger-pointing, they want it fixed.
Unfortunately, there are no simple fixes or ready solutions to this continuing problem, which seems to have only gotten worse in the past 20 years. Treatment resources will always be constrained by the availability of someone willing to pay for them. If it’s not the consumer (and the consumer in the U.S. rarely shoulders the burden of the full price of the mental health services they receive), then it’s the government or a private insurance plan. In either case, it seems pretty clear from these examples — as well as countless others I’ve heard over the years — that neither has much interest in ensuring affordable mental health care is readily accessible and available. No matter how much additional pain and suffering the waiting causes.
17 comments
Let me tell you my opinion on why it takes so long to see a psychiatrist, at least in my area of the world, the Mid Atlantic: a sizeable portion of them, I can’t give a specific percentage but I would bet it is close to 50%, don’t agree to see people with average or poor insurance in a timely manner, to instead make them look for another provider.
Try this test if you think I am wrong: call for an appointment and say you are using your insurance, and if you are not given a date within 6-8 weeks, which is unfortunately a realistic time frame these days, then call back, (and I know some will not like this next part, but realize you might be not seeing the provider if this happens) and give a different name and say you are willing to pay out of pocket. If the office agrees to see you in a shorter time frame, and I am not talking about it being 1 week earlier but possibly as soon as the following week of the call, look at this response.
I’ve had a few patients do this after I closed my private practice 7 years ago, and they found a couple of providers did this. Do 2 people make a generalization? Of course not! But if it was 2 out of 6 calls, that is 33%, and that was 7 years ago. I also worked for an acute care organization that saw patients for urgent outpatient needs until they could set up with other psychiatrists who took their insurance. Almost all who called for long term providers could not get an appointment for 3 or more months. And yet one offered to pay out of pocket up front without falsifying things, and was offered an appointment the following week. The patient was pissed.
And so was I! My colleagues don’t help the cause of trying to get the public to see us as caring invested providers with this kind of behavior, eh?
Just remember, not all of us do this. And by the way, two points:
I’ve told Dr Carlat this at his blog, and I’ll say it here again, encouraging people without a strong medical training backround to learn psychopharmacology skills as a prolonged CME course is a poor choice, and with doctors supporting it, it is professional suicide as someone so aptly wrote at a site recently (before I wrote it last night at his site).
The health care legislation as currently set to be enacted will only further decrease psychiatry as a discipline to access. As a larger population seeks out this meds first and only mentality, who do you think the government will dump this on as a responsibility? Your PCPs/family docs/nurse practitioners. And you think 15 med checks were outrageous? Wait ’til you have a 5 minute one!
Hey man, this is what is coming down the pike. Don’t believe me, I’ve just been practicing for almost 17 years now, and witnessed these changes on the front lines.
I’m sure the internet detractors will set you straight!
These lag times can have deadly consequences.
When we had to move to another state for my husband’s work, I was just beginning to recover from a severe depressive episode. As soon as we arrived and got our list of in-network providers, I made some phone calls to try to find a new psychiatrist. Due to my illness I wasn’t able to be as systematic about it as the woman you described; in fact each “rejection” (as I interpreted it, through the depressive haze) resulted in a new hour-long bout of tears. The stress of the move, the isolation due to being separated from my social circle, and the ever-increasing sense that nobody wanted to take care of me all contributed to a serious worsening of my illness, and I started to experience suicidal ideation and even some tentative planning.
Fortunately, I was able to get care before things took an even graver turn. It helped that I didn’t have the energy or motivation to put any ideas into action enough hope returned to lessen the danger. (The irony of severe depression: it can make suicidal actions less likely.)
I don’t know if there is an answer, but there is definitely a problem. I hope things get this serious for people only rarely.
You jump the queue by multiple suicide attempts. That usually gets you labeled borderline but it also gets you treatment, then you work it from there.
Life is trade offs.
Well maybe I was just lucky, but when I looked for a psychiatrist five years ago, I got three appointments within two weeks. I called about fifty people though. I was looking for therapy as well as meds. Maybe that’s why. Some psychiatrists actually like doing therapy.
Move to New York City. Mental health providers(psychologists in particular) are a dime a dozen around here. I wish other parts of the country were as fortunate as we are. When I called to make an appointment with a psychiatrist he got me in that Friday(I made the call on a Tuesday) and he DID accept my insurance. I understand that not everyone has the luxury of living in a big city. I know some small towns only have like one or two psychiatrists available to see…many have to travel to get the care they need. Its really atrocious and can have deadly consequences if a solution isn’t reached soon.
Dr Hassman, good point. I don’t see a psychiatrist, but I do see a psychotherapist.
Although I have insurance, I wasn’t comfortable with having to ask the insurance company’s permission to enter into treatment and then have them continually looking of the shoulder of my therapy, as I have experienced before. So, I chose to leave my insurance completely out of the process. I recommend this to anyone who is able to do this. It make therapy even more personal/intimate and all choices (direction, etc) are mine to make. It is freeing and it is empowering.
I do not agree with that psychologists are the professional to prescribe medication. But that probably comes from my personal opinion that medications are very over-prescribed now, my experience with a psychologist who stated in the first 15 minutes of the first ‘meet and greet’ appointment that she would ‘get me on’ Wellbutrin. I don’t use meds and she never even considered that or talked with me about the idea of medication. In my opinion, we need more talking and less medicating.
Maybe a side issue that would be interesting to explore is why psychiatrists are so busy. And another is what if a pyschiatrist declared his practice to be cash only, no insurance accepted. I suspect the fees would be something most of us could afford on our own, after being adjusted for no need for office staff to file claims, beg for authorizations, send records or other reports to document the need for continued treatment. I say this because my Internal Med doctor said that if he could do this, he could charge $50 instead of $225 dollars for an office visit.
Perhaps we not only need to reduce our dependency on oil in ths great country, but also our dependency on the powerful and meddling insurance industry that is a business and is not “health care”.
(embarassed about my typos in my above comment!!)
“The problem is most seriously felt within psychiatry, where the number of medical students who choose psychiatry over a different medical specialty continues to shrink.”
All the more reason to support prescription priviliges for psychologists…
This is just another example that poor and middle class people have a big disadvantage when it comes to Mental Health Care:
-I called up a few psychological clinics located in university that took insurance or were free/low cost. 2 Month Wait to be seen, 3 month wait to be seen. (the same with many other specialists). However, I called up a strictly, “pay for service” anxiety clinic and I could be seen the next day. When in a week, I had been assessed, met with my therapist and started therapy. It’s expensive, but I couldn’t wait 3 months!
-Fortunately, my area has enough psychiatrist it seems, but it’s so hard to get an appt and find that that’s compatible! Basically, I have to cold-call a list of psychiatrists that my insurance has. Usually there’s very little information about the psychiatrist online, so you really don’t know what you are going to get before you meet with them. (all the referrals, my therapist gave me didn’t take my insurance). And half the time, the psychiatrist don’t call you back or say they aren’t taking new patients.
Ugh. I don’t know where my comment went…
Anyway, I just wanted to point out that in my experience, “private-pay” or “fee for service” therapist and psychiatrist always seem to have openings. I called a bunch of different specialists and clinics (I live near a major city) and the ones that take insurance or were free or low cost had 2-4 month waits. However, when I called a psychological clinic that is strictly “private-pay” and they could see me the next day! Within a week, I had been assessed, met my therapist and had started therapy. It was expensive, but I was desperate.
Not another example of how poor and middle class Americans are at a major disadvantage when it comes to healthcare. Plus, my insurance plans have $30-50 copay’s for psychiatrists, but no co-pay for primary care visits. So it’s easy to see why many Americans get their mental health care from primary care physicians who really aren’t trained in that sort of thing.
John,
I know this isn’t the solution you are looking for and people like Dr. Hassman will be horrified.
But if the nurse practitioner is willing to prescribe the Effexor, tell your friend to visit http://www.paxilprogress.org and look for a poster by the name of Mixter who has been successfully tapering Effexor.
It looks like a royal pain in the neck as you have to count out pellets if you want to taper it very slowly. But he has done a you tube video that shows you how to do it.
My fear is the psychiatrist will taper her way too fast as most psychiatrists do (not all). By the way, antidepressants should be tapered at 10% of current dose every 3 to 6 weeks.
Effexor might have to be tapered more slowly because of its short half life.
Another option is to have the nurse practitioner write a prescription that your friend could take to a local compound pharmacy. You may or may not know but they will make the doses that you can’t get at your local CVS pharmacy.
The only problem is not all insurance companies will cover prescriptions written at a compound pharmacy. But if they do, in many ways, it is the easiest solution to taper slowly.
I know you’re going to think this is practicing medicine on your own and that is not a good thing. But many people have tapered successfully on their only consulting their psychiatrists to get the prescription.
I have tapered from 4 meds down to 1 using the tapering advice of the paxil progress boards and I rarely see my psychiatrist. As good a person as he is, he has nothing to offer me other than writing the prescriptions.
If your friend still thinks she needs a psychiatrist, she could keep the appointment but at least try the advice. She really has nothing to lose.
AA
Joel — Just for the record, my friend told each and every provider she called that she would also be happy to pay out of pocket if she could just be seen sooner. It didn’t change anything or get her an appointment sooner.
What *did* happen is that her current provider contacted her insurance company to twist arms and tell them she needed a new provider asap. The insurance company then found a provider for her that will see her in about a week’s time. All it took was someone to say whatever magic words that make a difference with an insurance company. (Granted, the new provider is nowhere close to my friend’s home… it’s like a 40 minute drive!)
Dr Wayne – Perhaps. But it seems an odd argument to make. If there was a shortage of psychologists to conduct psychological testing in a certain area, would we then lobby to allow master’s level psychology graduates to do psychological assessment (assuming they had similar training)?
Or would we look at what the core of the problem was — what’s causing a lack of medical students choosing this specialty? And isn’t that likely to become a problem for any other profession that chooses it too in the future, unless the core problem is addressed?
Seems like we’re suggesting a bandaid for treatment of a lung infection because the person has a cut on their finger. The bandaid will heal the cut, but the patient’s lung infection will still not get any better.
If all it takes is 2 years of training to prescribe psychiatric meds, then really, why do you need the doctorate in the first place? A doctoral degree in psychology does nothing to help prepare someone to understand the human body, neurological function, pharmacology or physiology. Most doctoral graduates have taken one, maybe two courses in such topics. That’s it.
This is not only inhumane, but unethical.
Is there not some kind of medical board ethical code that prevents doctors from just pushing aside those who might need help the most?
The same for those who do not accept medicare/medicaid patients. There should be a law against payment type discrimination.
The whole health care system is ridiculous, much of it due to factors outside of a doctor’s control. BUT doctors, like many others, do create problems for themselves in acting upon their self interests.
I think doctors need to all unite and figure out how to deal with the insurance issues. I realize insurance and government make practicing difficult for many, but physicians are not completely powerless victims of “the system”. Put your heads together and use some innovation.
I have been unable to get an RX for Lithium for 3 months. I also cannot an appt. at all for the future. I am searching for a new doctor.
It is absolutely horrible. I have bipolar and anxiety and moved from NYC to PA. When I lived in NY I was able to take my pick of psychiatrists and get appointments made for within the week and could pick any time. I was able to walk to my psychiatrist’s office and see a few before sticking with one. Now I have lived in PA a year and have yet to see a psychiatrist. I was able to get a few Rx refills by going to a psychiatrist 2 hours away in NJ. Now all of my Rxs have run out and each office I call tells me they are not accepting patients. I found one (60 miles away) that says they will give me an appointment in 3 months but I have been unemployed and unable to go to interviews, etc because of my anxiety and depression. I just don’t even know what to do anymore and have taken to staying in the house. It is too much to call 20 places and have them tell you they will see you in 3 months- I am out of medication now and depressed now. They don’t seem to care at all. I am out of options and I really don’t want to go to the mental health worker at the hospital, which also happens to be 30 miles away. It is way too embarrassing for me to walk into the hospital and say that I’m anxious and that even though I was doing fine with medication, I am forced to go to the emergency room because I can’t see a doctor. I don’t want to be hospitalized and I am scared that they would think I was suicidal if I went into the emergency room- who wouldn’t? I am in the same boat as the person above me- unable to get a lithium rx for 3 months and coming off it with no support. I don’t see any hope in the future for being able to get treatment even though I have insurance. Thank you, doctors!!!
Remypie, I also moved to a new area and couldn’t get an appointment with a psychiatrist for over 3 months. I did go to the emergency room to get a prescription for my meds. They weren’t pleased about my asking for prescriptions, but they did write the prescriptions, and didn’t try to hospitalize me. It’s really worth a try….
My current psychiatrist has appointments out 6 months and is not accepting new patients. In her clinic two psychiatrists left or retired in the last year and the others have had to split their loads. My psychiatrist does not want this to happen. They have had jobs listed for two years without a taker (nice but smaller town). When I see her she has me set up 2 to three appointments in advance. If I need an earlier appointment (and sometimes the earliest appointment I have scheduled) is with a psychiatric nurse who elicits information about what is going on and how I am doing. Then the pdoc comes in and discusses medication issues and order medication(after speaking to nurse). I’d prefer to have a longer time with her but I understand the problem.
I believe we have a shortage of psychiatrists because of two things: 1) people who become doctors are by necessity, good in sciences and are comfortable with clear outcomes and cures while psychiatry does not have scientific tests, sometimes has ambiguous diagnoses, and the majority of patients have chronic problems. 2) The reimbursement from insurance companies is lower than for other medical specialties (although this should be changing).
Not a psychiatrist
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