As long-time readers of World of Psychology know, there’s no easy fix to the convoluted, second-class mental health care system in the United States. People with mental disorders — like depression, anxiety, ADHD or bipolar disorder — are shunted away from the mainstream healthcare system into a patchwork quilt of “care” that varies greatly depending upon where you live, what kind of insurance you have (if you have any), and whether you want to pay cash for treatment instead of using your insurance.
It shouldn’t be this way. It shouldn’t be so hard to find a good treatment provider. It shouldn’t be so complicated to get integrated care from a single practice.
Why is it so hard to get good mental health treatment in the U.S.?
A lot of hype has gone around tiny wins in the past year — the gains of the Affordable Care Act, a few million thrown at states by the federal government that does little to make up for the loss of hundreds of millions over the past decade. Any chance to trumpet these tiny gains clouds the larger picture though — for most Americans, mental health treatment is still difficult to access.
And it’s no wonder. The country has suffered from too few psychiatrists for decades (going all the way back into the 1950s). The reason is twofold — psychiatry is a medical specialty (requiring nearly a decade’s worth of education), and the lowest paying one available. That hasn’t changed much in 50 years.
What has changed is the cost of medical school tuition. As education costs skyrocket, it becomes economically unviable to most to attend medical school in the U.S. and come out making a psychiatrist’s salary. The math simply doesn’t work. So until education costs come under control, we’ll continue to have too few psychiatrists in the U.S.
Unfortunately, in an article in The American Prospect, Amelia Thomson-DeVeaux points the finger at big bad pharma. She also focuses nearly solely on medication and psychiatrists — completely ignoring (except for one passing mention) of psychotherapy. You know, that same psychotherapy treatment that is often more effective than medications in the treatment of nearly any mental disorder.
Coaxing more psychiatrists out of medical schools will be no easy task. Students who want a high-paying job generally don’t turn to psychiatry; the median income for a psychiatrist is hundreds of thousands of dollars less than the salary for a surgeon or anesthesiologist.
But money isn’t the only reason why med students are turning up their nose at the specialty. Beginning with Sigmund Freud, psychiatrists used to emphasize talk therapy. The rise of big pharma changed all that. Insurance companies pay twice as much for a medication consultation than for a traditional therapy session. Now, many psychiatrists spend their days scribbling cocktails of anti-depressants and anti-anxiety medicines on prescription pads during 15-minute consultations.
What Amelia fails to mention is that medication appointments have always been shorter than psychotherapy appointments. A psychiatrist can do 2 or 3 medication appointments in one hour, whereas they can only do one psychotherapy appointment. As the New York Times noted in this 2011 article, “A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.”
Who, in their right mind, wouldn’t choose $150/hour over the $90/hour? ((This is my primary argument against extending prescription privileges to psychologists — they’ll follow in psychiatrists footsteps in forgoing psychotherapy and instead embracing the more lucrative medication-only appointments.)) Especially when you have those high medical school bills to pay back.
It doesn’t take a rocket scientist to see that prescribing medication is more lucrative than prescribing — or actually doing — psychotherapy for psychiatrists. This has less to do with “big pharma” and a lot more to do with the perverse insurance system in the U.S. that’s been designed by insurance companies to reward medication treatment over psychotherapy treatment.
Why? Probably because insurance companies are under the delusional belief that medication treatment is more cost-effective than psychotherapy treatment. I say “delusional,” because there’s a wealth of evidence in the literature to demonstrate how, for most disorders and most patients, this is actually the opposite of the truth.
Psychiatry is Not the Problem
However, I’d argue that the shortage of psychiatrists isn’t the biggest problem in getting good mental health treatment in America. It’s a symptom of the larger problem — the lack of integrated care.
Your physical and mental health are one and the same. Your body is impacted by what’s going on in your mind, and your mind (and mood) is directly impacted by what your body is doing. This isn’t new news, and it’s well accepted by the vast majority of researchers and practitioners in the field.
Separating them out into two separate treatment systems is a relic of a bygone era. It’s an arbitrary separation that no longer serves any purpose — and in fact, likely hurts people more by limiting access to care while providing uneven service.
One thing that’s needed is integrated, holistic care by a treatment team. ((It might be composed of a physician, a mental health professional (such as a psychologist or psychiatrist), and a physician’s assistant or nurse, as well as a nutritionist or dietician, social worker, and probably another specialist or two in there.)) Who all work together in the same practice and office, treating a reasonable total population that allows the entire treatment team to be aware of each patient’s circumstances and needs. This would be one huge step forward in getting better mental health care in our country.
Mental health treatment in America can be fixed. But it won’t be through the sad band-aid approach to care that passes for “treatment” today.
Read the full article: The ACA Can't Fix Our Mental Health Crisis
7 comments
A “treatment team?” You mean, a la a “medical home?” I bet my last dime that these ‘integrated’ teams, where they exist, hyperfocus on “mental illness” factors with patients. That’s juicy stuff. amd ot trumps everything.
Consider the enculturation and resultant group think that occurs in any one practice. In a building filled with both primary care physicians specialists, how often do physicians cross-consultant with other physicians in that building to provide optimal care? In my experience – never.
So, throw in psychological health, the juicy fruit scapegoat, the fact that the intraoffice discussion about a patient does not get entered into medical records – records that are now shared system-wide, and you’ve got one (explitive) patient.
I find it so incredibly odd that a country which has managed care for its military and veterans has not created something similar for all of its citizens. I am incredibly grateful, as a veteran, to have a “care team” that works together to ensure that I have the best care possible, including mental health. I was terribly resistant to psych care for many years, until my team put 2+2 together for me and was able to awaken me to my need.
I have to laugh when people say that “managed care” is socialistic or that our country is too big for that. Unfortunately, while the Affordable Care Act is one step in the right direction, generations will go by without seeing real managed care unless we are able to break through the established mentality toward social medicine.
I don’t really get this post, the problem is way beyond the access to psychiatrists, but in fact the dumbing down of making mental health problems just a biochemical imbalance, so anyone who can prescribe is now the defacto “psychiatrist” and just wants to make the interaction quick and simple.
Besides, I witness nearly every day of late in Community Mental Health Clinics these past 5 or more years at least that therapists aren’t really interested in providing psychotherapy any more. They are just a go between for maintaining the CMHC licenses with the state, and let’s have a moment of brutal candor, what can you do in providing for primary socioeconomic issues that drive at least a third of admissions to CMHCs of late?
What, a pill to get a job, get money back in the house, regain healthy and appropriate supports?
CMHCs are becoming extensions of DSS offices, and so SWs are finding out that karma is quite the payback. I’ll let readers figure out what that means in specifics without stating it directly in this comment.
Frankly, as I wrote a post about this at my blog a few days ago, I think CMHCs can save money by just cutting unessential staff. Again, I think people can figure out what that means in reading the post alone.
Sorry, honestly, but it is what it is in 2014. The biopsychosocial model is nearly dead, and that is a tragedy. Therapy is still the mainstay of good mental health care, it just requires both the patients and providers to embrace that basic premise.
Why is so hard to get even halfway-decent mental health treatment?
Because so-called “health” plans are mainly profit funnels for Big Pharma.
Because Health Insurance companies were placed above the law. They can not be sued. (It’s the only part of “HilaryCare” that passed about 20 years ago. Now, with ObamaCare, every American is FORCED to be a customer of companies that are above the law.)
Because, just like with physical health care, no one in the mental health field can be trusted. (That’s years of experience talking here.)
I’ve been looking for help for many years, and I still can’t find a therapist. My former psychiatrist just abandoned me and my daughter.
Someone with mental health problems is better off keeping it to themselves and NOT seeking any sort of treatment. When the pressure builds and one explodes, the police will come and shoot them down. THAT’S the answer America is quickly approaching.
I with I could move to a civilized country.
I have GAD. I really need cognitive therapy. But I cannot afford the $65 copay for every visit….because mental health is a “specialty “, I have to pay the higher copay.
But I can go to my regular practitioner and get a handful of pills. Great! Then what? I’m numb now but I still have the same problems.
Its a joke in the US that in this day and age you’re still crazy if you have mental health problems.
And we wonder why people go off and hurt themselves or others. Its because they can’t get any real help. Just a pill bandage.
Disgusted! I just need some therapy not a pill to numb me!
$150 for three medication despensing visits? Prior to writing this article the good doctor should have made a few visits anonymous to his fellow doctors waiting rooms,timing the amount of minutes they spend with patients. Then reconsider the copay alone is $20 to $30 dollars. That does not include the @$75 from the carrier. My math puts it at twice the doctors..and that still assumes that three person an hour that any patient will scoff at. Nothing will change in ANY important life issue, my friend, until we are ALL on board with realities….
Don’t psycologist think that if they would medicate people with depression and anxiety, ect. there might not be as many robberies,killings, break-ins… I just don’t get it you didn’t hear about ALL this violence in the past until they(dea) started taking away peoples medication.
I am one example of them taking away my medicine, the social security Doctor said I needed them now I am depressed I have anxiety atacks I’m over weight, because I sit around eating, I don’t leave my house, I have to push myself to do anything around the house.
I worry about my bills I worry about everyday things in life, I hate the way I feel, I hate the way I look, I wasn’t like this when I was on my medication. can someone refer me to a doctor PLEASE!