In any given year, more than a quarter
of U.S. adults have a diagnosable mental health problem
— from depression to bipolar disorder — yet fewer than half
get any kind of treatment for it. The figures are similar for children.
Many who do receive care get it through their primary-care physician rather than a mental health professional like a psychiatrist or psychologist. That's partly by choice: People prefer to talk to someone they know and trust about medical problems, and for many, there's still a stigma in seeing a "shrink."
But part of the reason people turn to their primary-care doctors or go without care is that it can be tough to get an appointment with a mental health expert. Psychiatrists, in particular, are in short supply, especially in rural areas.
A recent survey conducted for the Tennessee Psychological Association, for example, found that the average wait to see a psychiatrist for a non-emergency appointment was 54 days for patients with private health insurance and 90 days for those covered by TennCare, the state's Medicaid program, says Lance Laurence, director of professional affairs for the TPA.
"It's a huge access issue," says Katherine Nordal, executive director for professional practice at the American Psychological Association, a trade group for psychologists.
Psychologists say they have a solution to help address the access problems: Give them more authority to prescribe psychotropic medications. They can already prescribe in New Mexico and Louisiana, as well as in all branches of the military and the Indian Health Service. A half-dozen other states are considering measures that would give more psychologists prescribing authority.
Some of those states have considered and rejected such legislation before, but Nordal says her group is "cautiously optimistic" that it may succeed in a few states this year.
Psychiatrists are medical doctors with a specialty in psychiatry; psychologists have doctoral degrees, and their training includes coursework in diagnosing and managing mental illness. Any medical doctor, from dermatologist to surgeon, can prescribe psychotropic drugs; but before psychologists can prescribe drugs — in the jurisdictions that allow it — they must complete work equivalent to an additional master's degree in clinical psychopharmacology, says Nordal. With the exception of psychiatrists, she says, no medical professional is as well versed in medication for mental disorders as prescribing psychologists.
In addition, psychologists provide other types of treatment, such as talk therapy and cognitive behavioral therapy, in contrast to psychiatrists, who often only prescribe drugs. A national survey found that only 10.8 percent of psychiatrists offer talk therapy to all their patients. "We have a bigger toolkit than many others do that prescribe," Nordal says.
Health insurance generally covers prescription drugs to treat mental illness, but coverage for therapy sessions with a mental health provider is less routine. This has resulted in an over-reliance on drug therapy in recent years, all agree. Experts say this imbalance should change under the Mental Health Parity Act, which took effect last year; it requires mental health benefits, if offered, to be at least as generous as benefits for medical and surgical care. Even if the type of treatment shifts somewhat, however, many patients will still need drug therapy.
Physician groups such as the American Medical Association and some patient advocacy groups, however, are cool to the idea of letting psychologists prescribe drugs. "These are serious drugs with serious side effects," says Mike Fitzpatrick, executive director of the National Alliance on Mental Illness, a consumer advocacy organization. "We feel strongly that [prescribing] should be handled by someone with medical training."
The problem is likely to become more acute with an estimated 32 million people expected to gain health insurance under the health-care overhaul law. The Association of American Medical Collegesprojects a shortage of 45,000 primary-care physicians alone by 2020.
Experts agree that solutions lie in better integration between primary care and mental health care. This makes sense in part because for more than a third of patients with mental health problems, the only practitioner they see is a primary-care provider.
In addition, people with chronic illnesses such as diabetes, heart disease and asthma are significantly more likely to have mental health problems than those without chronic illness. People with serious mental illness, in fact, die 25 years sooner, on average, than the rest of the population.
The health-care overhaul, with its emphasis on medical homes and accountable care organizations that take responsibility for managing a patient's health rather than just providing medical services, offers promising models for integration, experts agree.
In clinical psychologist Benjamin Miller's primary care "dream world," mental health providers work alongside primary-care physicians, in the same office. Miller is an assistant professor of family medicine at the University of Colorado's school of medicine in Denver. Part of his job is to integrate mental health into the family medicine department's clinical, education and research functions.
"There's a range of mental health needs that will be seen in primary care," he says. "You can't tease it out from the other conditions that an individual is facing."