The mental health care system is overloaded, and as a psychiatrist, I don't know what to do.
I recently saw this article and felt a pang of guilt (and a flood of worry) associated with the tagline, "Just Try Getting an Appointment With a Psychiatrist." The link connects to a research study in which investigators phoned psychiatrists' offices in three major cities attempting to set a new patient appointment, and they were only successful in getting an appointment about 20 percent of the time. Although I don't live in one of the cities where the study took place, the findings appear consistent with what I would expect here in San Antonio. And I'm sad to admit, I'm a member of the 80 percent of psychiatrists who cannot take on a new patient.
I assume the 20 percent of psychiatrists accepting new patients are probably newer to practice, or seeing patients for the dreaded seven-minute appointments that have become the norm in primary care. Listening and understanding requires spending more time with each patient, less time means relying on overly simplistic checklists to categorize our patients' experiences. But there is a clear downside to spending 20, 30, 45, or even 60 minutes with each person in my care: My practice remains small. The total number of patient care contacts would be much higher if each patient was seen for only a few minutes and follow-ups were months instead of weeks away.
Advocates estimate that one in four of us suffers from a mental disorder, with many of the most severely ill unable to access care. Even professionals cannot get appointments for those with the greatest need. Just this week I tried to facilitate getting an appointment with a child psychiatrist for the 8-year-old daughter of one of my adult patients. The child had been receiving treatment until her doctor retired. The clinic were she was receiving care, probably the largest children's mental health care clinic in the city, informed me that they were "unable to accommodate new patients at this time." Another family looking for a child psychiatrist was told it would be at least a six-month wait. Desperate, parents call the primary care doctor. Although it's difficult to get an appointment even with the pediatrician (two weeks is now standard for a mental health crisis situation), at least they can see a physician.
But seeing the primary care doctor for a mental health problem isn't ideal either. Primary care doctors may feel ill-equipped to handle psychiatric illnesses. Even when they can, two weeks wait in crisis is an unreasonable time frame. And then the doctor may only spend seven minutes in the room (sometimes three minutes). Or the appointment might be made with the PA instead of the physician, often a surprise to patients when they arrive expecting to see the physician. Seven minutes with the primary care doctor can only offer one kind of treatment for mental health issues: prescription medications. But some patients need treatments other than meds.
Primary care is overwhelmed, too, not just for the treatment of mental illness, but for the care of general health as well. I have patients asking me to write prescriptions for their blood pressure medicine because they cannot get them filled reliably in the overloaded primary care system. They can't get through to a person on the phone when its time for an appointment or a medication refill.
All my doctor friends look exhausted, usually sporting dark circles under tired eyes and chugging coffee to keep up. We all want to provide excellent care, but there are only 24 hours in each doctor's day. Every additional slice in the pie of time comes from somewhere -- shortening appointment times, shaving off hours of valuable sleep, cutting in to family time... The system needs more physicians, but training doctors adequately takes many years. Physician extenders like PAs and RNPs can help expand access, but have far less training and they seem to be getting thrown into the pool to function as physicians, taking on a percentage of all patients in a practice, not necessarily the most straight forward cases.
What's the solution? Many opinions are offered, but as a doctor, I don't think there's an end in sight.