(Illustration: Walt Brandt @waltgabriel.art)

Part 1
The Lack of Psychiatrists: Just One Barrier to Treatment

When Theresa Nguyen, LCSW, worked as a clinical social worker in a hospital just outside Washington, DC, she saw the frustrating–and heartbreaking–fall-out of the nation’s psychiatrist shortage first-hand. “Here we were in one of the wealthiest areas in the country and we couldn’t find child psychiatrists for kids coming out of a hospital mental health program without waiting four months or longer,” says Nguyen, now Vice President of Policy and Programs for Mental Health America, a community-based nonprofit dedicated to mental wellness. “The need was urgent. But no one was available. The shortage is so significant it’s affecting everyone, regardless of income level.”

Consider potential outcomes: A postpartum mom with severe depression takes her life in desperation because the only psychiatrist that takes her insurance has a 3-month waiting list. A college student away from home for the first time and struggling with anxiety and depression contacts her school’s behavioral health center only to be told, sorry but they aren’t taking new patients.  A 42-year-old depressed man in rural Idaho considers turning his gun on himself when he’s told he must wait 3 weeks—and drive 4 hours—to see one of the state’s few psychiatrists.

One in five US adults and kids have a mental health or substance abuse issue according to a 2017 report from the Kaiser Family Foundation, published in the Journal of the American Medical Association.[1] It’s a bigger “disease burden” in America than cancer or heart disease, but just 40% of adults and 50% of kids get help, the group found. There are lots of reasons. Some people are too embarrassed or afraid to reach out. But other common reasons found by the Kaiser Family Foundation line up with the yawning psychiatrist gap—people who couldn’t get help didn’t know where to turn. They couldn’t afford care. Or their insurance didn’t cover it.

The Silent Shortage

There are about 30,451 practicing psychiatrists in the US, according to a 2018 report “The Silent Shortage: A White Paper Examining Supply, Demand and Recruitment Trends in Psychiatry” by Merritt Hawkins, a large physician search firm.[2] The group says that’s about 9 psychiatrists per 100,000 people, short of the nearly 15 per 100,000 that provides good mental health care. But the shortage is bigger than that in plenty of places. Sixty percent of US counties have no practicing psychiatrists—the front-line medical doctors who evaluate mental health issues and prescribe and manage medications and other treatments—according to a 2017 New American Economy report.[3] Many if not all are rural. In the rest, coverage is uneven. There are an estimated 612 psychiatrists per 100,000 people in parts of New York State but less than 1 per 100,000 in Idaho. In 185 of Texas’s 254 counties, the number is zero. In Hawaii, you might need a boat or plane to reach one. The islands of Lanai and Molokai had few or no psychiatrists in 2010 according to a 2017 University of Hawaii study.[4]

The numbers could nose-dive soon. While the number of doctors in other medical specialties is rising, the number of psychiatrists fell 0.2% between 2003 and 2013 according to a 2016 study in Health Affairs.[5] And those working with insured people or in government healthcare jobs fell 10% in that time.[6] Sixty percent of psychiatrists are over age 55, making them one of the oldest (and closest to retirement) of all medical specialties.[7] (Only pulmonology and oncology have more 55-and-over doctors.)

“The need was urgent. But no one was available,” says MHA’s Theresa Nguyen, LCSW. “The shortage is so significant it’s affecting everyone, regardless of income level.”

While the number of new psychiatrists emerging from residency programs has increased somewhat recently, we may be short by 6,090 to 15,600 psychiatrists by 2025, says a 2017 National Council for Behavioral Health report.[8]

Waiting times can be long. Benzion Blech, MD, now in the neurology department of the Mayo Clinic in Phoenix, Arizona, and two other researchers called 150 psychiatrists affiliated with three of the largest health insurance carriers in the Washington, DC, area as “mystery shopper” patients for a 2017 study. Just 15%  said they were accepting new patients with that insurance and only 7% could schedule an appointment within two weeks.[9] A similar study of 1,154 psychiatrists in a Maryland health plan found that just 14% were accepting new patients with appointments in the next 45 days. “It is definitely important to seek mental health care if needed,” Dr. Blech told Psycom. “The biggest problem that patients run into is that they have difficulty finding a psychiatrist that has open slots—never mind that actually take their insurance.”

When researchers on the West Coast called 229 psychiatrists listed in the Los Angeles County Super Pages for a similar “mystery shopper” study, they described themselves as a person with serious mental health symptoms who needed a medication evaluation. Just 28 could make an appointment. The average waiting time was more than five weeks for 80%. And the median consult fee was $450.[10]

Cost is a big concern. About 45% of psychiatrists didn’t accept private health insurance or Medicaid in a 2014 Weill Cornell Medical College study in JAMA Psychiatry that used nationwide data.[11] That’s far higher than other medical specialties and had dropped 17% since 2006. Many in solo practices don’t have the time to handle all the paperwork, the researchers note. But “these low rates of acceptance may pose a barrier to access to mental health services,” they add.

Mental Health Fall-Out

A shortage of psychiatrists isn’t the only problem faced by people with mental health conditions looking for treatment. For those with severe problems, in-patient programs are shrinking, for one thing. Health insurance may limit who you can see or the amount of help you’ll get, in inconvenient ways. That, plus the shortage, are leading to long wait times, shorter doctor visits for psychiatric issues, longer-running prescriptions for medications with less monitoring, and long wait times as more people end up in hospital emergency rooms when a mental health crisis. And it’s simply difficult getting a good diagnosis and treatment plan, especially for “vulnerable populations such as foster children and older adults,” according to the 2017 National Council for Behavioral Health report “The Psychiatric Shortage: Causes and Solutions.”[7]

Finding Help When You Can’t Find a Psychiatrist

It’s not easy, but these steps can help you or a loved one get mental-health help when you need it:

  1. Talk to your primary care provider. Your family doctor may be able to refer you to a psychiatrist with whom she has a professional relationship or who she trusts. She may also be aware of other resources, like mental health clinics, group practices that also employ advanced practice nurses or physician assistants with a psychiatry specialty or community health centers. Your primary care provider may also feel comfortable prescribing and monitoring some medications for mental health issues and be able to refer you for other services you’ll need, such as therapy.  Some doctors even participate in a new type of mental-health care called collaborative care, where they partner with a psychiatrist or a nurse practitioner or physician assistant to provide care in the family doctor’s office.“We know there’s a shortage of mental health professionals in America, so if you live in a community where there simply isn’t a psychiatrist, or you’d have to drive a great distance to see one, or there’s an incredible waitlist for the one or two that are in town, your primary care doctor is a good option,” says Christine Allen, a spokesperson for NAMI, the National Alliance on Mental Illness. “As part of their training, all doctors have to become familiar with mental health conditions. So, your family doctor will have general knowledge on mental health conditions—their knowledge likely won’t be as deep and rich as a doctor who has specialized in mental illness, but in the absence of a mental health professional, they will be a fine ally for you.
  2. Turn to your health insurer but beware of “ghost” networks. “Health insurance companies have case managers who can help you find a psychiatrist who accepts your insurance or an advanced practice nurse in psychiatry who practices alone or in a clinic or a doctor’s office,” says Gail Stern, RN, MSN, PMHCNS-BC, president of the American Psychiatric Nurses Association. However, be aware that many managed care organizations tout the availability of clinicians in their provider networks, but upon contacting the providers on the lists patients have been know to experience wrong numbers and deceased providers.  their clients seeking mental healthcare may find it difficult to obtain such care in a timely and effective manner. Inaccurate providers lists are so common-place they have a name: ghost (or phantom) networks.
  3. Ask family and friends for a referral. “I would recommend enlisting the help of others in your search for psychiatric care,” Dr. Blech says. Some people that can be the most useful would be family members and close friends. They may be aware of valuable resources that you might not be, and being open with them about your mental health issue can allow for great dialog and exchange of good information in order to get the care that you need.”
  4. Consider another type of practitioner. Advanced-practice nurses and physician assistants with a specialty in psychiatry can evaluate you, prescribe medication and follow your progress. Practice rules differ by state; in 22 states plus the District of Columbia, for instance, advanced-practice nurses in psychiatry can practice on their own; in others supervision by a doctor is required. In five states—New Mexico, Louisiana, Illinois, Iowa, and Idaho—some psychologists can also prescribe some medications for mental health conditions.[11] If you are in a hospital or receive mental health care at a university medical center, your team may also include a board-certified psychiatric pharmacist who is trained to evaluate, recommend and monitor medications.[12] [13]
  5. Try telepsychiatry. Some family doctors and community health centers offer video appointments with a psychiatrist, nurse practitioner or physician assistant. They can evaluate you, manage your medications and consult with your doctor.[14]
  6. Don’t rely on medication alone. “There are three main pillars of mental health care: therapy, medication, and self-care,” Allen says. “You cannot recover from mental illness through self-care techniques, such as exercise or healthy eating, alone. You likely cannot recover from mental illness through therapy alone. It would be very difficult to recover from mental illness through medication alone. When these three pillars are working together in unison, they create the greatest odds for mental health recovery. You’d be surprised just how significantly a person’s condition can improve when they’re engaging in the right therapy for their diagnosis, consistently taking their medication, and treating their body and mind right.”
  7. Reach out. Groups like NAMI and Mental Health America can help you find support, such as ways to connect with people who’ve experienced similar issues. Call the NAMI HelpLine at 1-800-950-NAMI (6264) or check the Mental Health America website for more information.
  8. Emergency? Head for the ER. Suicidal thoughts or actions, delusions or paranoia, violence or threats of violence are signs of a crisis that deserve fast, professional attention. Take a friend or family member (or ask someone to take you) to the nearest emergency room at a hospital.[15] You can also call 9-1-1 first or call 1-800-273-TALK (8255) to reach a 24-hour crisis center.[16]

 

Illustration of mental health treatment providers lining up to care for depressed patient

(Illustration: Walt Brandt @waltgabriel.art)

Part 2
Can’t Find a Psychiatrist? How About an Advanced Practice Nurse, Physician Assistant or Prescribing Psychologist?

Psychiatrists are medical doctors who diagnose and manage mental health conditions, prescribing and monitoring medications and other treatments. But these days, they aren’t the only mental-health practitioners performing these services. A growing number of specially-trained advanced practice nurses, physician assistants and, in some places, psychologists, are filling a looming mental health care gap as America’s need for mental health help outpaces its dwindling supply of psychiatrists.

Surprised? Right now, about 14,000 advanced practice nurses[17] and 1,500 physician assistants[18]—as well as psychologists authorized to prescribe in five states (Idaho, Illinois, Indiana, Louisiana, and New Mexico)—are evaluating and diagnosing mental health conditions, prescribing medications and monitoring the on-going mental health of children and adults in the US.  These practitioners may work in their own private practices or in doctors’ offices, hospitals, mental health clinics, community health centers, hospitals, nursing facilities, and jails.

Can They Do What Psychiatrists Can Do?

“Psychiatric-mental health advanced practice nurses (PMH-APRNs) have the medical background, the clinical experience, and the rigorous training to offer this care. And we offer something more—the whole health connection, the focus on the whole person that nurses do so well,” says Gail Stern, RN, MSN, PMHCNS-BC, president of the American Psychiatric Nurses Association. “I’m the administrative head of the department of psychiatry for a large hospital network. The psychiatric nurses here and everywhere want to build therapeutic relationships. They want to get to know people, really understand who they are, what they need, and what’s best for them as a whole person.” Stern says that PMH-APRNs (both nurse practitioners and clinical nurse specialists) see the person beyond their diagnosis, prioritizing person-centered treatment that promotes both mental and physical health. She explains that PMH-APRNs have the skills and training to assess patients’ mental health, diagnose mental health and substance use disorders, prescribe medication, and provide therapeutic treatments, such as psychotherapy. She credits the PMH-APRNs’ basis in nursing with their ability to offer holistic care and care coordination in order to ensure that their patients obtain the full range of physical and mental health care they may need.

“The biggest problem that patients run into is that they have difficulty finding a psychiatrist that has open slots—never mind that actually take their insurance,” says Benzion Belch, MD.

The scope of practice and expertise of physician assistants in psychiatry has much to offer, says Catherine Judd, MS, PA-C, CAQ, DFAAPA, chair of Continuing Education and Professional Development for the Association of Physician Assistants in Psychiatry and clinical assistant professor at the University of Texas Southwestern Medical Center in Dallas, Texas.[20] “A PA in psychiatry can do the initial assessment and evaluation at a diagnostic interview and begin medication,” Judd says. “PAs can prescribe most forms of medication and then manage and follow patients. They may also do brief psychotherapy. Thanks to our knowledge base in medicine, we are positioned well to also handle care for people with multiple chronic diseases who may be taking multiple medications with their own risks for side effects and interactions—such as someone with depression, diabetes, and high blood pressure. Our expertise is important because we can work with psychiatrists, doing more general health management of patients, and we can work with primary care doctors, offering the mental health care they may feel they do not have the time to provide the way they would want. That’s especially important because it’s becoming more difficult for primary care doctors to refer their patients to psychiatrists due to the shortage.”

In summary, here are some of the duties an advanced NP or PA could take on:

  • Create healthcare plans, based on an outpatient or home-based care for acute or chronic mental health care conditions
  • Provide consultations
  • Perform patient assessments
  • Prescribe medications per their state laws
  • Prescribe and offer various treatments, such as psychotherapy, medication therapy, cognitive behavioral therapy, etc.
  • Work alongside doctors for referrals and to provide patient care
  • Educate the patient on mental health disorders
  • Contribute to policy development, quality improvement, practice evaluation, and healthcare reform

Can these practitioners do everything a psychiatrist can? Depending on the state, pretty much, says Stern. “If you have a mental health condition that’s not responding to medications, or if your health condition is complex or you have severe mental health conditions, your PMH-APRN may need to collaborate with another provider, often a psychiatrist,” she says. Judd adds that PAs are “well-positioned to increase mental health access by patients, because of our broad-based medical training. PAs are trained to diagnose, treat and prescribe medications and make life-saving diagnostic and therapeutic decisions while working autonomously or in collaboration with other members of the healthcare team. As trusted healthcare providers, studies have shown that when PAs are able to practice to the full extent of their training and experience, patient access to care increases, hospital readmission rates and lengths of stay decrease, and infection rates go down.”

Is Care Compromised When You Don’t See a Doctor?

Research says these health practitioners provide high-quality care. In a 2018 study in the American Journal of Preventive Medicine, researchers from the University of California San Francisco School of Nursing note that “several studies found that care provided by PMHNPs [Psychiatric-Mental Health Nurse Practitioners] is similar to that of psychiatrists, is of high quality, and leads to positive behavioral health outcomes.” One study they cite even found that a nurse-led mental health clinic for homeless adults reduced the rate of psychiatric hospitalizations by more than half.[19]

Judd and Stern both say much of the general public has grown accustomed to receiving a wide range of healthcare from PAs and advanced practice nurses (NP and CNS), and are happy to work with them when it comes to mental health, too. “There’s more and more acceptance of allied health practitioners,” Judd says. “One thing I hear is that people feel the PA really listens to them and is concerned with their global health and well-being.  People feel the PA spends a lot of time with them, maybe more than the doctor would. That may not be true in minutes, but it may be the whole disposition of PAs —our holistic approach to total patient care, our way of talking with patients.”

How do doctors and mental-health experts think they stack up? The American Medical Association, American Psychiatric Association and National Alliance on Mental Illness did not provide responses requested for this article. (But the American Psychiatric Association endorses a collaborate-care approach that may include nurse practitioners working in primary-care doctor’s offices to provide mental health care, under a psychiatrist’s supervision.). But Mental Health America’s Nguyen says they could ease the shortage and provide needed care. “I think the quality of each practitioner has to be proven by your experience with them, not the letters after their name,” she says. “I’ve met many practitioners who are amazing. What they can do is driven by what is legally allowed in each state. Whether or not they’re good depends on your experience with them—do they sit and listen, treat you effectively or rush you out the door?”

Knocking Down Barriers

Advanced practice nurses (NPs and CNSs), physician assistants and prescribing psychologists may help people with mental health needs avoid some of the barriers to psychiatric care that keep adults and kids from getting the help they need. These can include:

Access: Increasing access to mental health care, especially in rural areas. One 2008 University of Pennsylvania study found that that advanced practice psychiatric nurses were more likely than psychiatrists to live in rural areas.[20] Thirteen percent of these nurses compared to 7% of psychiatrists lived rural spots in the US. Meanwhile, another group of researchers who looked at psychiatric nurses in private practice in 2017 noticed that the states with some of the lowest numbers of psychiatrists are among those who’ve legalized independent practices for nurse practitioners.[21] These included Alaska, Utah, Oregon, Montana, North Dakota, South Dakota, and Nebraska.

“Nurses have long provided community health services, often when access to any other providers is limited,” the University of Pennsylvania researchers note. “APPNs [advanced practice psychiatric nurses] may be well suited to rural realities and primary care practices. Because of their breadth of training and scope of practice, APPNs may well be the ideal rural mental health professionals.”

Cost: As stated previously about 45% of psychiatrists don’t accept private health insurance or Medicaid.[10]  That’s far higher than other medical specialties. In one study, the median fee for a first-time consult with a psychiatrist was $450. Nurse practitioners and physician assistants are more likely to take insurance, say Stern and Judd. “What happens to everybody who cannot afford high-priced mental health care?” Judd says. “Physician assistants help fill that gap.”

What Advanced Practice Nurses Can Do for You 

Who they are: Advanced practice psychiatric nurses (nurse practitioners or clinical nurse specialists) assess, diagnose, treat, and evaluate mental illness such as depression, schizophrenia, bipolar disorder, anxiety, substance use disorders, etc. They can prescribe medications, do physical exams, order and read medical tests and provide psychotherapy. All 50 states grant Advanced Practice Nurses some level of ability to prescribe medications. In 22 states plus the District of Columbia, these nurses are allowed by law to practice independently; in others, some degree of supervision from a physician is required.

They work in hospitals, mental health clinics, community health centers, medical practices, and stand-alone practices. Advanced practice nurses are also playing a growing role in telepsychiatry and in collaborative care programs where mental health services are available in the offices of primary care providers. In those programs, a psychiatrist usually oversees the care—either on-site or checking in with nurses and with primary care doctors on a regular basis, according to the American Psychiatric Association.

Training: An advanced practice registered nurse in psychiatric-mental health must have national certification from the American Nurses Credentialing Center in order to be licensed or recognized by a state-level nursing board and practice. To gain certification, nurses must have a current, active RN (registered nurse) license and complete an educational program at the master’s, post-graduate or doctoral degree level. The programs cover diagnosing and evaluating mental health conditions, patient care including therapy, education and medication, working with families, promoting mental health, understanding cultural differences and more. Education requirements include:

  • A minimum of 500 faculty-supervised clinical hours getting first-hand experience
  • Three separate courses in advanced physical/health assessment, advanced pathophysiology (the causes and development of diseases and conditions), and advanced pharmacology
  • Content in promoting health and preventing disease, diagnosis and disease management
  • Clinical training in at least two areas of mental health psychotherapy

Advanced practice psychiatric nurses are educated and trained to treat patients across the lifespan, but some may specialize in treating a specific population, such as children and adolescents or geriatric patients. There are no separate certifications for these specializations; advanced practice psychiatric nurses often seek out additional education to enhance the care they provide to a specific population.

Advanced practice nurses in psychiatry must complete a re-certification process every five years and take continuing education courses or other professional development.[22]

What Psychiatric Physician Assistants Can Do for You

Who they are: Physician assistants who specialize in psychiatric/mental health work under the supervision of a psychiatrist or other physician, such as a primary care doctor. They can provide mental health assessments, make a diagnosis and rule out underlying medical problems that could be behind symptoms, prescribe medications, order lab tests and make referrals to other medical practitioners. They can also follow and continue to care for people with mental health issues–via medication, counseling and other approaches–and work with their families, too.

Psychiatric PAs work in doctors’ practices, hospitals, behavioral health facilities, psychiatric units at hospitals, in emergency rooms, correctional facilities, private health clinics, prisons, and jails.[23]

Training: All PA’s receive academic training in a three-year graduate program plus more than 2,000 hours of clinical experience with rotations in clinical rotations in medical and surgical disciplines, including family medicine, internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry. In order to practice, a PA must pass the Physician Assistant National Certifying Examination and apply for a state license. A PA may work in mental health at that point. But some opt to receive further, specialized training via a 12-month post-graduate fellowship in psychiatry. PAs in psychiatry can also earn an additional certificate of added qualifications in psychiatry by undergoing 150 hours of additional education, getting 2,000 hours of experience in their field and taking an exam. PAs must also get 100 hours of continuing medical education every two years and pass a recertification exam in general medical knowledge every ten years.

What Prescribing Psychologists Can Do for You

Who they are: Licensed psychologists have their doctorate degree (a PhD or PsyD) and undergo extensive training before opening a practice in the US. It can take seven years to earn that degree; after that, states require 1,500 to 6,000 hours of supervised training with patients—often followed by an exam. Psychologists can diagnose mental health conditions and provide counseling. But in five states, psychologists who undergo extra training can also prescribe some medications.

Training: Rules vary in states that allow psychologists to prescribe. In Louisiana, for example, psychologists must earn a post-doctoral masters’ degree in clinical pharmacology. In New Mexico, requirements include 450 hours of instruction plus 400 hours of supervised practice. Illinois requires training in psychopharmacology plus 14 months of full-time training in a variety of mental health locations including hospitals and clinics. In addition, psychologists who want prescriptive authority must pass an exam, coordinate care with each patient’s primary care doctor. “When all the training—doctoral and post-doctoral—is completed, prescribing psychologists have more training in diagnosing, treating and prescribing for mental health disorders than primary care physicians,” according to the American Psychological Association.[11]

According to the Illinois Psychological Association, prescribing psychologists are especially aware of non-drug approaches to mental health issues and are less likely to prescribe drugs than other psychiatric healthcare practitioners. “The history of prescribing psychologists is that they prescribe 60–70% fewer medications than other health prescribers,” the group notes on its website. “Moreover, they will be more likely, than other health prescribers, to “unprescribe” medications because they are aware of behavioral therapeutic strategies that can be more effective than medications, thus reducing side effect complications.” [24]

Receiving treatment for depression via telepsychiatry

(Illustration: Walt Brandt @waltgabriel.art)

Part 3
The Psychiatrist Will See You Now—Virtually

Telepsychiatry could help solve the physician shortage. But are video mental health visits as good as in-person appointments? Does health insurance cover them? Here’s what you need to know.

A home-bound 80-year-old with schizophrenia gets her first psychiatrist check-up in 20 years. A young boy with attention deficit hyperactivity disorder visits his psychiatrist from the familiar comfort of his elementary school. Texas police deputies get real-time help for people undergoing a mental-health crisis, via iPads that connect them with mental health practitioners.

It’s all telepsychiatry—a growing trend in mental health treatment that links people via computer video-conferencing technology to psychiatrists and other mental health practitioners such as advanced-practice nurses, physician assistants, psychologists, and others. You may have your appointment from your own home, or while sitting comfortably in a private room at your family doctor’s office or in another medical setting. And you’ll interact with a practitioner who may be on the other side of your state, or even in another state.

These virtual visits could help overcome one of the nation’s biggest barriers to better mental health: A shortage of psychiatrists.[3]  Although just 40% of adults and 50% of kids get help the mental-health care they need and other mental-health specialists are playing bigger roles to help fill the gap, but problems due to shortages persist and telepsychiatry can bridge the gap.

One University of Missouri study found that video visits for kids and teens saved some families from driving hundreds of miles to get care. A West Coast study of rural military veterans with post-traumatic stress disorder—a program now being studied across the US—provided effective treatment without requiring veterans to make long trips, to0.[25] “Our researchers have worked diligently in recent years to establish the safety and efficacy of PTSD psychotherapy delivered remotely, ensuring Veterans will get the same quality of PTSD care as if they were in a doctor’s office at a VA medical center,” former Veterans Affairs Secretary David Shulkin said when the program was announced in 2018. “We are excited to see this program help greater numbers of Veterans living in rural areas and pleased that it will save them time and effort to get to a VA facility that is far from their homes.”

“Some people won’t go to a mental health clinic or a psychiatrist’s office, but getting care in front of a video monitor is fine for them. …Telepsychiatry [is also helpful in the] care of residents in nursing homes and in hospitals where there aren’t enough psychiatrists to do all the needed evaluations of people with medical issues.”—Gail Stern, RN, MSN, PMHCNS-BC.

Telepsychiatry could help you get a psychiatric evaluation and treatment plan more quickly and conveniently for a mental health issue like depression, anxiety or others. It can also erase some of the stigma that keeps people from getting help, says Gail Stern, RN, MSN, PMHCNS-BC, president of the American Psychiatric Nurses Association. “Mental health practitioners are partnering with primary-care doctors to do evaluations and monitor the mental health care of their patients using telemedicine,” she says. “Some people won’t go to a mental health clinic or walk into a psychiatrist’s office, but getting care while sitting in front of a video monitor in a private room at their family doctor’s office is fine for them. I’m also seeing telepsychiatry for the care of residents in nursing homes and in hospitals that do not have enough psychiatrists to do all the needed evaluations of people who’ve come in with medical issues.”

Does telepsychiatry work? And does insurance pay for it? Here’s what you should know:

The Health Insurance Gap

Health insurance plans don’t always cover telepsychiatry. Rules vary by insurance plan. And state and federal laws and regulations about telemedicine coverage (which includes telepsychiatry) also vary wildly. [26]  “Not all health insurers pay for it yet,” Stern says. “Regulations are not uniform in different states. Insurers and regulators have to catch up.”

Things are improving. About 40 states and the District of Columbia require private insurers to cover telepsychiatry in some way [27][28] —up from 38 in 2018. If you have Medicare because you’re age 65 or older or are disabled, telehealth—including mental health care–is typically covered only if you’re in a medical office (like your family doctor’s office, a hospital, nursing center or a clinic) for your virtual appointment and only if that office is located outside a metropolitan area.[29][30]But starting in 2019, appointments from home are covered for substance abuse. Medicaid coverage for telehealth is different in every state; some require you to have your video visit from a medical office but visits from home are covered in about 36 states. Just who can provide those visits also varies by state under Medicaid. [31]

The easiest way to find out what your health insurance covers—and how to access telepsychiatry is to call your insurance company and ask. You can also find the specifics about coverage in your state at the American Telemedicine Association’s State Policy Resource Center. It’s worth checking if you’re having difficulty making an appointment with an in-person practitioner.

“Telemedicine is all the rage these days, and telepsychiatry is no exception,” says Dr. Benzion Blech, who studied the psychiatrist shortage in the Washington, DC, area for a 2017 study. “The benefits of telepsychiatry are that psychiatrists, as well as other mental healthcare providers, can provide care to all kinds of patients, all over the country, regardless of distance. I suspect that, as telemedicine technology continues to improve, telepsychiatry encounters will become more and more common. For patients unable to travel to psychiatrist locations, or have disabilities that prevent or limit travel, this is a great option.”

How Good Is It?

Researchers are finding that telemental health care can be as good as or better than in-person care for depression, anxiety, anger management, eating disorders, alcohol abuse, post-traumatic stress disorder, and other mental health concerns, according to an August 2018 report from the National Telehealth Policy Resource Center. [32]. Psychiatrists talking with their patients via video have been able to make a mental health diagnosis as accurately as a psychiatrist in the room with the patient, according to a 2014 study from the Carillon Clinic in Roanoke, VA, of 73 people who came to a hospital emergency room with depression, substance abuse, anxiety and bipolar or psychotic disorders. [33]

Research shows that telepsychiatry benefits include:

  • Depression relief: In a 2015 study published in Psychiatric Services: A Journal of the American Psychiatric Association, of 364 adults with depression, those who got mental health care via telemedicine had more depression-free days and a higher quality of life than those who received mental health care in a practitioner’s office.[34]
  • Therapy on par with in-person care: In a 2014 University of Texas at Austin study of 158 home-bound older Texas adults with depression, those who had problem-solving therapy via Skype calls with a mental health practitioner got the same mood improvements as those whose therapy was conducted in-person. But 36 weeks later, long after the therapy ended, the telemedicine group was enjoying more depression relief than the in-person group.[35].
  • Improved mental and physical health: In a notable 2013 Dartmouth College study of 70 people who had serious mental-health disorders like bipolar disorder or depression along with chronic medical conditions, adding a telehealth intervention to their care for six months led volunteers with depression and high blood pressure to feeling in control their health. For those with diabetes and depression, some saw improvements in blood sugar control and needed fewer visits to their doctor or to an urgent-care center.[36]
  • Savings in time and money for people getting care: In two 2012 studies of veterans with post-traumatic stress syndrome, researchers from the VA San Diego Healthcare System compared video teleconferencing with in-person sessions for two types of therapy: cognitive processing, which involves becoming aware of and changing unproductive thoughts, and prolonged exposure therapy, which helps people safely face memories and situations that they fear. Veterans liked teletherapy, they found. “Our veterans have expressed satisfaction with the decreased travel time, cost savings related to purchasing less gasoline, and fewer crowds and parking problems at the remote sites. Both veterans and therapists have been patient with the technology, and several have reported enjoying (even preferring) VTC sessions,” the researchers say.[37]
  • Care in rural communities, without the long drive: In a 2016 University of Missouri study of 179 children and teens whose families made telehealth appointments through the Missouri Telehealth Network, researchers found that the program was convenient for busy families—especially in rural areas with no psychiatric services nearby. The average distance they would have had to travel to their psychiatrist was 22 miles, but for some, it was as far as 300 miles, the researchers note.[38]
  • Better mental health care in urban areas, too: A 2017 Wayne State University case study illustrates how telepsychiatry can remove other barriers to better mental health. A woman in her 80s with schizophrenia had not seen a psychiatrist in more than 20 years; she lived in a high-crime area and had a long list of other health conditions that made getting out of the house difficult—including joint problems and poor hearing and vision. A social worker brought a computer table to her home for her telemedicine virtual visits with a psychiatrist. Through the visits, the woman’s medications were adjusted and some with serious side effects were eliminated. The psychiatrist discovered that the woman had depression and set up a treatment plan.

“Telemedicine for mental health care is growing by leaps and bounds,” notes Catherine Judd, MS, PA-C, CAQ, DFAAPA. “It fills a need not just in rural areas but in any area where people are having difficulty getting the psychiatric help they need. It makes the most of a provider’s time—whether it’s a physician assistant, nurse practitioner or psychiatrist. Every hour they don’t spend on the road is another hour they can spend with patients.”

References:

  1. Kamal Al et al. JAMA. Costs and Outcomes of Mental Health and Substance Use Disorders in the US. August 1, 2017;318(5):415. Available at: doi:10.1001/jama.2017.8558. Accessed October 8, 2019.
  2. “The Silent Shortage: A White Paper Examining Supply, Demand and Recruitment Trends in Psychiatry” by Merritt Hawkins. February 22, 2018
  3. “The Silent Shortage: How Immigration Can Address the Large and Growing Psychiatrist Shortage in the United States” New American Economy, October 2017. Available at: http://www.newamericaneconomy.org/wp-content/uploads/2017/10/NAE_PsychiatristShortage_V6-1.pdf. Accessed October 8, 2019.
  4. Aaronson A, Withy K. Does Hawai’i Have Enough Psychiatrists? Assessing Mental Health Workforce Versus Demand in the Aloha State. Hawaii J Med Public Health. 2017;76(3 Suppl 1):15–17. Accessed October 8, 2019.
  5. Bishop T, Seirup J et al Population Of US Practicing Psychiatrists Declined, 2003–13, Which May Help Explain Poor Access To Mental Health Care Health Affairs. Available at: doi.org/10.1377/hlthaff.2015.1643. Accessed October 8, 2019.
  6. National Council Medical Director Institute. The Psychiatric Shortage: Causes and Solutions. National Council Medical Director Institute. March 28, 2017. Available at: https://www.thenationalcouncil.org/wp-content/uploads/2017/03/Psychiatric-Shortage_National-Council-.pdf. Accessed October 8, 2019.
  7. National Council for Behavioral Health. Press Release: Medical Directors’ Report Recommends Training More Psychiatrists and
    Expanding Telepsychiatry. Washington, DC, March 28, 2017. Available at: https://www.thenationalcouncil.org/wp-content/uploads/2016/11/Access-paper-release-final-3.28.17-final.pdf. Accessed October 8, 2019.
  8. Blech B, et al Availability of Network Psychiatrists Among the Largest Health Insurance Carriers in Washington, D.C. Psychiatric Services 68:9, September 2017.
  9. Caccavle J et al. The Impact of Psychiatric Shortage on Patient Care and Mental Health Policy: The Silent Shortage That Can No Longer Be Ignored. American Board of Behavioral Healthcare Practice. Available at: http://abbhp.org/survey.pdf. Accessed October 8, 2019
  10. Bishop TF et al. Acceptance of Insurance by Psychiatrists and the Implications for Access to Mental Health Care. 2014 Feb;71(2):176-81. Available at doi: 10.1001/jamapsychiatry.2013.2862. Accessed October 8, 2019
  11. American Psychological Association. About Prescribing Psychologists. Available at: www.apaservices.org/practice/advocacy/authority/prescribing-psychologists. Accessed October 8, 2019.
  12. Psychiatric Pharmacy. Board of Pharmacy Specialties. available at:www.bpsweb.org/bps-specialties/psychiatric-pharmacy/. Accessed October 8, 2019.
  13. American Pharmacists Association. What psychiatric pharmacy is, what we do, and how we treat patients? Pharmacist. March 2014. Available at: www.pharmacist.com/article/what-psychiatric-pharmacy-what-we-do-and-how-we-treat-patients. Accessed October 8, 2019.
  14. America Association of Medical Colleges. Addressing the escalating psychiatrist shortage. Weiner. February 13, 2018. Available at: https://news.aamc.org/patient-care/article/addressing-escalating-psychiatrist-shortage/.  Accessed October 8, 2019/
  15. National Alliance on Mental Illness. Getting Treatment During a Crisis. Available at: www.nami.org/Learn-More/Treatment/Getting-Treatment-During-a-Crisis. Accessed October 8, 2019.
  16. Mental Health America. Do you need to talk to someone? Available at: http://www.mentalhealthamerica.net/contact-us. Accessed October 8, 2019.
  17. Delaney KR 2017 Sep 1;68(9):952-954. doi: 10.1176/appi.ps.201600405. Epub 2017 May 15. Accessed October 8, 2019.
  18. Catherine Judd, MS, PA-C, CAQ, DFAAPA, Association of Physician Assistants in Psychiatry. Phone interviews March/Aptil 2019.
  19. Chapman SA et al 2018 Jun;54(6 Suppl 3):S243-S249. doi: 10.1016/j.amepre.2018.01.045. Accessed October 8, 2019
  20. Hanrahan NP, Hartley D. Employment of advanced-practice psychiatric nurses to stem rural mental health workforce shortages. Psychiatr Serv. 2008;59(1):109–111. doi:10.1176/ps.2008.59.1.109. Accessed October 8, 2019
  21. Yang BK et al 2017 Oct 1;68(10):1032-1038. doi: 10.1176/appi.ps.201600495. Epub 2017 Jun 15. Accessed October 8, 2019.
  22. American Psychiatric Nurses Association. FAQs about Advanced Practice Psychiatric Nurses. Available at: www.apna.org/m/pages.cfm?pageID=3866. Accessed October 8, 2019.
  23. Physician Assistant EDU.org How to Become a PA Specialized in Psychiatry/Mental health. Available at: www.physicianassistantedu.org/psychiatry-mental-health/. Accessed October 8, 2019.
  24. Illinois Psychological Association. Prescribing Psychologists. Available at: https://illinoispsychology.org/prescribing-psychologists/. Accessed October 8, 2019.
  25. US Department of Veteran Affairs. Press Release. VA launches a telehealth program for rural vets wit PTSD. March 6, 2018. Available at: https://www.va.gov/opa/pressrel/pressrelease.cfm?id=4018. Accessed October 8, 2019.
  26. Does Your Insurance Cover Behavioral Health Services? Available at http://insighttelepsychiatry.com/insurance-cover-behavioral-health-services/. Accessed October 8, 2019.
  27. 38 States Force Private Insurance to Reimburse for Telehealth. Available at: http://www.securetelehealth.com/private-insurance.html. Accessed October 8, 2019.
  28. Gorman Health Group. Telehealth Policy Trends in Medicaid. Gorman Health Group Blog. Available at://www.gormanhealthgroup.com/blog/telehealth-policy-trends-in-medicaid/ Accessed October 8, 2019.
  29. Amirsadri A, Burns J, Pizzuti A, Arfken CL. Home-Based Telepsychiatry in US Urban Area. Case Rep Psychiatry. 2017;2017:6296423. Available at: doi:10.1155/2017/6296423. Accessed October 8, 2019.
  30. Medicare Learning Network. Telehealth Services. Center for Medicare and Medicaid Services. January 2019. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf. Accessed October 8, 2019.
  31. Evisit. Does Medicaid Reimburse for Telehealth in My State? Available at: https://blog.evisit.com/medicaid-reimburse-telehealth-state. Accessed October 8, 2019.
  32. the National Telehealth Policy Resource Center. Center for Connected Health Policy. Available at: https://www.cchpca.org/sites/default/files/2018-09/Telemental%20Health%20Research%20Catalogue%20%28Aug%202018%29.pdf. Accessed October 8, 2019.
  33. Seidel R, Kilgus M. Agreement between telepsychiatry assessment and face-to-face assessment for Emergency Department psychiatry patients. Journal of Telemedicine and Telecare, January 10, 2014. https://doi.org/10.1177/1357633X13519902. Accessed October 8, 2019.
  34. Pyne J, Fortney J et al. Cost-Effectiveness of On-Site Versus Off-Site Collaborative Care for Depression in Rural FQHCs. 2015 May 1;66(5):491-9. doi: 10.1176/appi.ps.201400186. Epub 2015. Accessed October 8, 2019.
  35. Choi N, Marti N, et al Six-month post-intervention depression and disability outcomes of in-home telehealth problem-solving therapy for depressed, low-income homebound older adults, Depression and Anxiety 2014 Aug;31(8):653-61. doi: 10.1002/da.22242. Epub 2014 Feb 5. Available at: http://onlinelibrary.wiley.com/doi/10.1002/da.22242/abstract;jsessionid=8FB8DA31A8DD8DA38293755A175F5DDE.f02t01. Accessed October 8, 2019.
  36. Pratt S, Bartels S, et al (2013) Feasibility and Effectiveness of an automated Telehealth Intervention to Improve Illness Self-Management in People with Serious Psychiatric and Medical Disorders. American Psychological Association. 2013 Dec;36(4):297-305. doi: 10.1037/prj0000022. Accessed October 8, 2019.
  37. Thorp S, Fidler J et al (2012). Lessons Learned From Studies of Psychotherapy for Posttraumatic Stress Disorder Via Video Teleconferencing. 2012 May;9(2):197-9. doi: 10.1037/a0027057. Accessed October 8, 2019.
  38. Becevic M,Green T, et al. Are there other options?: Child and adolescent telepsychiatry services for rural population. Journal of Health Management. May 2016. Available at: https://doi.org/10.1177/0972063416637729. Accessed October 8, 2019.
Last Updated: Oct 11, 2019