Five months ago, I wanted to die. It took me ten days to get help.
Sporadically over the past eight years, I’ve been treated for some type of mental-health disorder. But I’ve never really wanted to die before. I’ve also never wanted to commit suicide. So when I told my primary care physician I’d been imagining ways I could be “put out of my misery,” explaining I wouldn’t mind if a tree fell on me or a car hit me, she suggested I leave her office and go directly to the emergency room of a hospital.
But that reaction felt extreme. I didn’t want to put myself out of my misery. I wanted something or someone else to do it. I was rational enough that I knew a physician at an ER wouldn’t admit me. I was not a danger to myself because I didn’t want to commit suicide. I was not a danger to anyone else and I knew the date, the president’s name, and all other questions I’d be asked to test my lucidity.
I knew I needed something in between weekly talk therapy and round-the-clock care. Like any good student, I researched nearby facilities and started calling them. I came to learn that the spectrum of mental and behavioral health care is no match for the spectrum of illness it purports to treat. The search tools on Psychology Today’s website, are frequently recommended, as it’s one of the only mental-health databases of its kind. But in using its tools, I learned the information listed on each treatment center’s profile was outdated or incorrect. The providers who did meet my insurance and treatment needs were located more than an hour away from where I lived.
In my cold calling, intake coordinators and program administrators could not make sense of my needs based on my explanation of symptoms and what could have been defined as suicidal ideation. I also didn’t find an option to undergo an assessment to determine the appropriate level of care for my situation. It took nearly two weeks for someone in one hospital’s psychiatry department to return my call and schedule an appointment several weeks out. By then, I was desperate, overwhelmed, and exhausted; I’d already visited a $350-an-hour psychiatrist as a patch on my crisis. I was back where I started: medicated by a doctor I only see once a month.
I am one of 43.8 million adults in the U.S. who experiences mental illness in a given year. According to the National Alliance for Mental Illness and my inability to quickly find adequate care is all too common. The U.S. health care system was not built to support the one in six adults suffering from mental illness; it’s expected that both the availability and affordability of for us will continue to decline.
As the number of people needing mental health care continues to rise — including children, for whom psychiatric disorders are the most common illness — there is a dearth of mental health care providers. The National Council for Behavioral Health concluded that the shortage of mental health professionals will be between 6,100 and 15,600 in the next seven years. As Dr. Carl Clark, the president and CEO of the Mental Health Center of Denver, told me, “out of the people that need help, only two out of five people are actually accessing [it].”
Psychiatric emergencies in our state, much like the rest of the country, have been slowly escalating, and are now very rapidly escalating, over the last couple of years.
Clark clarified: “When I say mental health, people think mental illness. But for all of us, our mental health is the most important thing we have. We’re all somewhere on a continuum; some people are doing well… sometimes circumstances result in an illness, and some people even debate themselves asking ‘Am I ill enough?’”
Even if you know where to look for care or what kind of care you need, the cost, distance, or immediacy of a mental health facility or provider might be prohibitive, which is why so many people with mental illness turn to the emergency room. One in eight emergency room visits nationwide are associated with a primary complaint of behavioral health, according to Dr. Anne Zink, the emergency department medical director of Mat-Su Regional Medical Center in Palmer, Alaska. “Psychiatric emergencies in our state, much like the rest of the country, have been slowly escalating, and are now very rapidly escalating, over the last couple of years,” she said. “We have approximately 48 percent of patients presenting to the [emergency department] either have a primary or secondary behavioral health diagnosis.” Both Zink and Clark said the rise is more likely linked to increased awareness and willingness to consider mental health as a treatable illness rather than something to be overcome by sheer will, but the resources still don’t meet the needs of most patients.
One possible explanation for the lack of psychiatric resources is that the cost of providing mental health care, which includes continuing education and hours of administrative work in addition to patient contact, far exceeds the returns. Many mental health providers choose not to accept health insurance as “in-network” providers because insurers provide them scant reimbursement; providers who operate in-network are frequently refused acceptance into insurance networks because they’re not accepting new providers. Insurers are required to include a minimum number of caregivers within a geographic radius and often don’t go beyond that minimum because of the cost to the insurer.
The 2010 Patient Protection and Affordable Care Act reaffirmed and promised to expand on the Mental Health Parity Act of 1998, which states that insurers must offer mental health care comparable to medical and surgical benefits. But insurers still skirt the law or simply do not cover an adequate number of providers. Another source of distress is that many dedicated mental health facilities are closing or are understaffed because of funding issues. The facilities are beholden to state and federal funds, as well as grants from other institutions and wealthy benefactors and mental health funding is low priority for most of these agencies. There’s also the issue that patients’ concern over the cost of mental health care reaches the point in which they are inclined to wait until their situation is dire before seeking treatment.
When patients exhaust their options for affordable care within a reasonable distance, they turn to emergency departments. These, according to Zink, have become places of “overflow” for mental and behavioral health patients who cannot access care elsewhere. Unfortunately for these patients, emergency medicine physicians only receive basic psychiatric training. “Most people are worried that they can’t afford it. Some people think they can handle the problem without any treatment,” Zink said. “Most people don’t know where to actually go for services. People feel like they don’t have time for treatment. Maybe they feel like they don’t really need treatment.”
Physicians, therapists, crisis hotlines, and even family members and friends refer people to the ER too frequently without realizing most patients who visit will not be admitted on the basis of psychiatric need. And there’s limited follow-up for the patients who visit or are turned away.
With lack of access to the appropriate level of care and the exorbitant cost of it looming over an already-stigmatized community, cities and states are looking to alternative methods of care. The Mental Health Center of Denver is changing the way we provide mental-health treatment by bridging the vast gulfs between doing nothing, basic talk therapy, and emergent treatment. In addition to embedding its staff in places where people are already showing up — such as school-based health clinics, nursing homes, and community-based organizations — the center operates theDahlia Campus for Health and Well-Being. Clark described the Dahlia Campus as having a variety of activities going on, including fitness and cooking classes, “ so when people walk through the door nobody really knows why they’re going there. There’s no real stigma associated with [mental health] on that campus. I think it makes it easier for people to feel comfortable being in a place where if they also need help with an illness, they can get it.”
Zink emphasized that patients, providers, politicians, and even the press must work together to change the broken system of emergency mental health care. So in spite of purposely ambiguous ACA standards for network size and quality and wholly ignoring the Mental Health Parity and Addiction Equity Act of 2008 , cities are getting creative with policies for mental-health funding. A recently passed initiative led by Colorado state Rep. Leslie Herod will enact a 0.25 percent tax increase (so, $0.25 on $100 purchase) to fund mental-health programs throughout the city. It could raise as much as $45 million annually.
Another low-cost, high-impact change that could vastly improve mental-health care is for patients to have strong relationships with their primary health-care providers. “Data shows patients actually prefer getting behavioral health care from their primary care providers… probably because they have an ongoing relationship with that person,” Zink said.
According to a study published earlier this year in the Journal of the American Board of Family Medicine, depression screenings performed by primary-care physicians are an untapped resource in a very dry field. According to Matthew Hirschtritt, one of the study’s authors, “with a simple questionnaire, primary care doctors have a big opportunity to better spot depressive symptoms in at-risk patients and help improve their lives through treatment”; yet only 1.4 percent of all adult primary care visits involve a mental-health screening. Zink also emphasized the importance of telemedicine, through which patients, ED, and primary care physicians can consult with psychiatrists no matter how far apart they are.
The field of mental health has, unfortunately, always been bleak and the future of care, much like the mind, remains a black box. But progress is being made in spite of efforts to undermine access to health care in the U.S.
It has been five months since my doctor pointed me toward a hospital’s emergency department, and even after all of the phone calls I made and treatment plans I researched, I’m still not sure the care I’m receiving from my psychiatrist is enough. No longer am I daydreaming of accidents that would make my pain go away and I’m functioning better than I have in years. But I want more than to simply function, and for that to happen, there need to be emergency options for people like me.
