Helping People Get Proper Treatment for their Mental Health Needs

I had the pleasure of teaching a group of adult and family NP’s about depression and anxiety disorders last week. They have a large proportion of patients with mental health needs, who are unable to access specialty mental health care. Why is that? I was impressed with their questions and concerns about treatment of mental health needs in their care.

It is interesting, because others (specialists in psych) have questioned if primary care providers should be treating psychiatric patients without specialized knowledge and course work in mental health assessment, psychopharmacology, neurobiology, and treatment methods. While generally I agree that there is a great difference between a primary care provider managing psychiatric needs and a psychiatric mental health provider’s care, the reality is that they probably are not managing these needs by choice. I can see at least 4 reasons a lot of this care occurs in primary care by non-psych specialists:
1. Simple non-complex needs like depression improve with medications alone in some cases. (this of course ignores the fact that depression is a recurrent disorder that benefits from other therapies in addition to medication)
2. Psych specialty provider waiting lists are long (3-6 weeks consistently at least in Connecticut for adults, more than double this for children or adolescents). So many patients improve with meds within this time frame and lose the motivation to go for specialty care.
3. Lack of insurance coverage to cover specialty psychiatric care – this was reported by the students as being a common reason identified when they see patients… the question is why isn’t care being covered? What does this mean? Is it lack of mental health coverage (i.e. being told no, you will not be able to have that tx paid for by insurer), limits in coverage, or requirements to call in for approval ahead of time (which I don’t think should be required), or overall lack of insurance coverage (although they are at the primary care provider).
4. Stigma and stereotype of needing psychiatric care (despite the fact that probably 25% of all adults will at some point need some mental health care across their life). Unfortunately those with mental health needs remain second class citizens in health care.

So what is the real story? I thought we had legislation that changed things so that there was mental health parity? Why can’t people get their mental health care paid for? That would be a great study (there’s a good idea for your thesis!). I would love to hear from students and clinicians about the circumstances in which they see this happen every day.

Another area that came up as a concern for these primary care providers was what to do when a person is in both primary care complaining about mental health needs and in specialty care treatment for those same needs. The answer to this is simpler:
1. Have at least one psychiatric provider in their practice to manage these patients with complex needs. OR
2. Communication and collaboration between providers is essential. If someone is in specialty care and we see a problem with a physical condition then we should call the primary care provider. If the primary care provider sees unmet mental health needs they should contact the mental health provider. I realize this may mean that we have to manage the permissions to share information, but in this case it is imperative. Nearly every week my students tell me about their clients in the mental health setting that their preceptors are medicating for a variety of complex mental health problems who also receive some mental health meds from primary care. The common problematic agents are: benzodiazepines and other sedative hypnotics. This is particularly a problem in treating the dually diagnosed patient (mental health dx with substance abuse dx). Communication is very important. If the patient is in specialty care, then the primary care practitioner can’t be providing a different Rx to the patient for the needs already managed by the other provider. I am more confident that the psych specialty providers are not writing Rx’s for the medications to manage the physical care (I hope I am not wrong about this, as psych clinicians in general should not prescribe outside of their specialty area).

We are in an era where many Psych APRN’s are working 2 or more part time jobs to make a full time position. How could that be if there is a problem getting our patients into mental health care? Why are there waiting lists for people needing care? Why aren’t primary care practices hiring psychiatric providers like Psych APRN’s to help manage their patient’s mental health needs?

How could it be that the state of CT is cutting direct care psychiatric provider positions (or have a freeze on hiring clinicians) if there are waiting lists that preclude patients from getting the care they need? It isn’t just the state, other hospitals or facilities don’t seem to be hiring more psych practitioners either or making those providers full time. What is the deal?

How can these situations co-exist? How can there be a clear need for services, yet a lack of demand for full time workers in the area?

I suspect the culprit is a system forever in the mode of saving money and cutting spending, despite abundant needs in the population…

I would love to hear examples from those of you facing these problems… maybe it will help us to solve the problem! Please comment here or send me an email: joanne.iennaco@yale.edu