Combined with the capacity to reach patients and clinics around the state via telehealth care, collaborative care presents tangible hope for patients in need of better mental-health care.
In an era of extreme partisan divide, bitterness and few areas of common ground, everybody in this country agrees on one thing — we have a major mental-health crisis right now. The discourse is ubiquitous. It transcends demographics, states, regions and, yes, even political parties. The opioid epidemic has claimed tens of thousands of lives, including celebrities, friends and loved ones. Suicide rates have increased substantially, particularly among younger adults and veterans. We have mass murders occurring with dizzying frequency. This must have something to do with mental-health care, right?
As a psychiatrist working in Seattle, I am asked this important question all the time. The answer is, to say the least, complicated. Although no single factor explains our current mental-health crisis, the widespread lack of access to appropriate health-care services is certainly a primary contributor. One recent study, in fact, deemed access challenges to be the “root cause of the mental-health crisis in America.” In my clinical experience, mental-health treatments can be effective and even positively life-altering when administered properly — we just don’t get them to nearly enough people.
Mental-health conditions are rooted deep within us and are often the consequence of complex interactions between our genetics, environment and life experiences. They are conceptualized uniquely by different cultures. In the United States, mental illnesses are most commonly diagnosed using standardized manuals and are treated with psychotherapy and/or medication. Mental-health services can be rendered by many different provider types, including primary-care providers, psychiatrists, advanced-practice nurses, physician assistants, psychologists, clinical social workers and counselors. All are currently in high demand and play important roles.
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Psychiatrists, however, are in particularly short supply. As physicians, we graduate from medical school and then complete four years of residency training in mental health, honing our diagnostic skills, performing psychotherapy and learning to prescribe medications. It is perhaps for this final role that psychiatrists are best known, and not by coincidence. In a number of states, psychiatrists remain the only independent specialty mental-health providers licensed to prescribe medication. Unfortunately, with more than half of United States counties having zero psychiatrists, demand far outpaces supply. One notable study demonstrated that only one in 10 Americans living with a mental illness sees a psychiatrist in any given year. It is no surprise, therefore, that primary-care providers now manage about two thirds of patients treated for depression and prescribe more than three quarters of antidepressant medications.
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Can you imagine if these numbers were true for patients with cancer? Only one in 10 cancer patients would get to see an oncologist. We would find this totally unacceptable.
Most of our society’s mental-health treatment needs are simply not being met. Some states have tried to bend the curve. In 2017, for example, Washington passed legislation to ensure that telemental health services were reimbursed by all payers in the state. Though challenges remain, this has improved access in underserved communities without practicing psychiatrists. Additionally, 23 states (including Washington) now allow advanced-practice nurses to prescribe medications independently.
Finally, a growing number of states (also including Washington) have ensured that collaborative care, an integrated care approach pioneered at UW Medicine, is reimbursed by Medicaid. In this care model, psychiatric consultants work with a team of care providers to treat common mental-health and addiction problems directly in primary care. Combined with the capacity to reach patients and clinics around the state via telehealth care, collaborative care presents tangible hope for patients in need of better mental-health care. However, a number of private insurance plans (including many in Washington State), still do not cover collaborative care, making it less accessible to the more than 4.1 million privately insured residents of our state.
The time for action is now — tell your legislators to ensure that all private insurance plans in Washington state cover evidence-based integrated mental-health services, both in-person and through telehealth. Washingtonians cannot afford to wait any longer.