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Shortage of psychiatrists, funding issues create crisis in mental health care

Shortage of psychiatrists, funding issues create crisis in mental health care

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Suzanne Falvey of north St. Louis County said it took years of red tape and frustration to find the right support for her 22-year-old son who as a teenager developed schizoaffective disorder, which can cause severe mood swings, aggressive behavior and paranoia.

Even though the Falvey family had good insurance, their initial wait to see a child psychiatrist was six months. Once they got in, the psychiatrists rotated every few months so the family had to repeat the medical history and try to re-establish a rapport each time.

“Many people who have family members with mental illness go to wherever there’s an opening or to whoever will take them,” Falvey said. “When you’re needing help and you’re reaching for someone to help you out of the water, you don’t have a lot of time to check out what the hand looks like or if they can pull you up.”

The mental health care system is strained by the number of people who need help and a shortage of psychiatrists to meet those needs. The situation has reached a crisis point, experts say, pointing to some alarming figures:

  • The federal government designates 104 out of 114 Missouri counties and most of St. Louis city as mental health shortage areas. There is no licensed psychiatrist in 72 Missouri counties.
  • A majority of psychiatrists don’t accept Medicaid, and a growing number refuse all health insurance plans.
  • The average wait to see a psychiatrist in the St. Louis area is estimated at 10 to 30 days and can reach six months for children and teens.
  • There are 1,174 psychiatric hospital beds in the state, down from 2,600 in 1990.
  • Many people with mental illness end up in county jails when they fail to find treatment elsewhere. The jails are not equipped to treat mental illness, and officers are overwhelmed by the effort to find more appropriate facilities. Recently the only deputy in Clark County, Mo., transported a mentally ill patient 325 miles to Nevada, Mo., which had the closest open bed, according to Keith Schafer, director of the Missouri Department of Mental Health.

“It’s creating huge problems for individuals, for families, for emergency rooms and certainly for law enforcement officials,” Schafer said.

After several run-ins with the police and multiple trips to area emergency rooms, the Falvey family found the right balance of inpatient and outpatient care for their son at Mercy Hospital St. Louis in Creve Coeur.

“They worked very hard with us to get the right fine-tuning to get him stable and to maintain his stability,” Falvey said. “It took years and it took a competent psychiatrist with the right kind of heart and mind.”

That Mercy Kids psychiatrist, Dr. Duru Sakhrani, said the country’s mental health care system is not adequately developed for patients who require faster and earlier attention.

“If we as a society develop mental health treatment that would be equal to the way we treat diabetes and asthma, it will serve our patients a whole lot more,” Sakhrani said.

Mercy recently opened a 13-bed psychiatric unit in its children’s hospital. It is nearly always full with children as young as 6 who stay three to five days for group and individual therapy for acute needs. But most patients don’t need that level of care, and access to community clinics can take months. To help address the shortage, Mercy offers outpatient care and is set to launch telepsychiatry services so its in-house psychiatrists can communicate electronically with rural patients.

The first symptoms of mental illness often strike young adults in their 20s and 30s, who are disproportionately uninsured and lack resources for treatment.

“As people think about tragedies like (Newtown) Connecticut and other horrible events around the nation involving young people, leaving them untreated can be horribly damaging to the young person as well as dangerous to the community,” Schafer said. “The vast majority of those individuals will never be dangerous to somebody else, but their health will deteriorate, their function will deteriorate, and if we intervened earlier we could prevent most of those problems.”

Recent budget cuts to mental health and the Legislature’s decision against expanding Medicaid funding have placed further strains on the system. CoxHealth Systems in Springfield, Mo., has abandoned plans to expand behavioral health services. BJC Behavioral Health in St. Louis has added 400 clients in the last year without increasing staff. It won’t accept new Medicaid patients until another patient is discharged from its services.

“There’s a shortage of psychiatrists, especially in rural areas,” said Kim Gladstone, vice president of BJC Behavioral Health. “(But) there is not a shortage of case managers and community support workers; there’s a shortage of money to pay for them. If you just open the doors but you don’t increase the funding for the actual care to meet that need, then you become unbalanced.”

SSM Health Care, the private hospital system with the most mental health beds in the St. Louis region, has 10 to 15 patients every day waiting for a bed. On weekends the waiting list can jump higher than 30.

“Unfortunately we have to hold people in our emergency departments,” said Dan Body, vice president of SSM Behavioral Health Services. “Absent the Medicaid expansion, we still have 25 percent of adult psychiatric patients uninsured. We’re not receiving the same amount of federal dollars, and we don’t have the funding source. It leaves us in a vulnerable spot.”

NEW COLLABORATIONS

Some new collaborations are allowing hospitals and community health centers to patch together consistent treatment programs for people with mental illness. The community centers send liaisons to hospitals to talk about follow-up care with patients when they are discharged. Since last fall, additional funding has allowed liaisons to also visit mental health patients in the state’s emergency rooms. In November, BJC started same-day access to behavioral health care in its downtown clinic. The state, BJC and SSM partnered in 2012 to open the St. Louis Regional Psychiatric Stabilization Center in the former Metropolitan Psychiatric Center on Delmar Boulevard, which closed in 2010 following state budget cuts of $7 million.

The average daily census at the stabilization center is now 20, said CEO John Eiler.

“We’re full at least a couple days out of every week, and most patients that we see come to us from other hospitals’ emergency rooms when their beds are all full,” Eiler said.

Some of Missouri’s psychiatrists are already leaving for neighboring states, including Illinois, Arkansas and Iowa that accepted federal funds to enroll more people in Medicaid. The Veterans Health Administration has also been actively recruiting psychiatrists from private practices to help treat an increase in depression and post-traumatic stress disorder among veterans, the state mental health director said. The VA offers higher salaries than the reimbursements offered through the state.

“For me it’s an opportunity to work with veterans, plus the opportunity to have more structure in my work hours,” said Dr. William Irvin Jr. who is closing his psychiatry practice based in Richmond Heights and moving to the VA.

WORSENING SHORTAGE

The national shortage of psychiatrists is only expected to get worse. More than half of psychiatrists are older than 55, unlike other higher-paying specialties like cardiology or orthopedics. In 2011, there were 16 psychiatry residency programs in the U.S. that did not fill their open spots, according to the National Institute of Mental Health.

The problem is less acute in St. Louis, where psychiatry training programs at Washington University and St. Louis University graduate 24 resident physicians every year. At BJC Behavioral Health, 17 of 20 staff psychiatrists trained at one of the local schools.

“They spend four or five years training after medical school, and they put down roots,” said Dr. Mark Johnson, medical director at BJC Behavioral Health. “We do take patients in, we do see new patients, we are treating as much as we can.”

Rochelle Brooks of St. Louis was hospitalized at Barnes-Jewish last August after a suicide attempt. Brooks, 34, had symptoms of depression since she was a teen but was reluctant to acknowledge her problems. While in the hospital, a representative from the nonprofit Independence Center visited Brooks to help her transition to outpatient support. The center offers employment, housing and treatment opportunities for people with mental illnesses.

“I’m doing wonderful now. I’m on the right combination of medicines, and they keep me busy,” said Brooks of the center she attends five days a week. “It gives you a purpose, and that’s all that some people need.”

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