It was difficult to deal with my mental health crisis. Somehow, finding the right care was even worse.
So what exactly is happening to our mental health system?
1. A shortage of psychiatrists and mental health providers
Despite increasing public demand for mental health services, there is a significant shortage of psychiatrists and mental health providers in America. Federal data shows that over 137 million Americans live in an area with a mental health workforce shortage. And according to statistics, things are getting worse.
Crawford said the shortage of psychiatrists is due to several factors, including increasing demand for mental health services, ongoing stigmatization of the profession and inadequate reimbursement from insurance companies. Low reimbursement rates can make it difficult for mental health professionals to justify the years of education and training required to enter the field, causing some professionals to leave the workforce.
According to Pallavi Yetur, a licensed therapist in California, providers are leaving the field not only because of poor reimbursement rates that are not commensurate with the time and cost of training, but also because of chronic burnout, a professional epidemic caused by patient overload, struggling to gain validation in a stigmatized field, and navigating the frustrating insurance system on the provider side.
2. Cost and insurance barriers
Experts say insurance is a big problem.
Caitlin Hochul, senior vice president of policy and government relations at Inseparable, a mental health advocacy organization, said the system was designed by insurers to put profits over people.
“We see a problem where providers are being pushed out of the system,” Hochul said. “It’s very expensive to even get the education, training and licensing to become a provider. And then once they’re licensed, in practice and in network, insurers basically make it very difficult for them to make a living. That drives a lot of providers away, which creates gaps in the care that people need.”
Snow described a similar reality. Even after decades of changes, like mental health equity laws that require health insurers to cover mental health and substance use care the same as physical medical and surgical treatments, she said people seeking mental health care “still wait longer, pay more and have less choice of providers.”
Insurance companies can also decide whether providers participate in networks at all.
Psychiatrist Rinat Tal, MD, said psychiatrists can face inadequate compensation, administrative burdens and insurance audits, which ultimately lead many psychiatrists not to participate in insurance networks at all. And because there are so few providers, psychiatrists can forego insurance and still maintain a full patient list.
The problem is that many people simply cannot afford the cost of mental health care. The result is a system in which access to specialized mental health care can become a privilege reserved for those who can afford it.
“Not everyone out there can afford hundreds of dollars a week for treatment,” Tal said. “They’re trying to put food on the table.”
And even those who are insured often find that coverage does not necessarily mean access to medical care. Hochul said insurers may deem certain treatments “not medically necessary,” refuse to cover the full scope of care someone needs, or offer networks filled with providers who are no longer available, a problem known as “ghost networks.”
“A person might look to see who is in the network, they call around and they get messages saying that provider is no longer practicing,” Hochul said. “So they’re faced with these ghost networks where they’re not able to find anyone who’s in their network. And then when they say they’ll eventually find a provider, their next appointment may not be available for months, typically. In the meantime, that person’s mental health continues to deteriorate.”
The result is a cruel paradox: You can get health insurance and still find that the provider you desperately need is virtually unavailable to you.
3. The stigma has changed, but the system has not
While the stigma surrounding mental health has decreased over the years and more people are willing to seek help, the system that is supposed to support them has not kept pace.
Crawford says part of the problem is that mental illness has historically been treated separately from physical illness, creating a divide not only in the way we think about mental health, but also in how people access and receive medical care.
“Because it is considered a separate entity, there are not as many resources put into mental health support in the community as in primary care and more physical medical issues,” she said.
Without access to adequate outpatient mental health care — and with so many barriers to finding a psychiatrist or other provider — some people don’t receive treatment until their condition worsens to the point that they end up in the emergency room.
But even then, accessing appropriate mental health care can be complicated.
“This is where the difference between mental and physical health becomes even clearer,” Crawford said. “If you come to the emergency room with an illness and need to be admitted, you just go upstairs to the hospital and look for a bed. That’s not the case with psychiatric illnesses because many psychiatric wards in many hospitals across the country have been closed. So people have to wait for a bed to become available in any hospital, sometimes hours away from their home.”
In a system without adequate outpatient care, the emergency room can become the default stop for people who needed help long before they reached an emergency.
The result is a troubling contradiction: We’ve spent years encouraging people to ask for help, but we haven’t built a system capable of helping everyone who finally does.
And while mental health stigma has improved, Crawford said it hasn’t gone away and its impact extends beyond those seeking treatment. Stigma can also discourage people from pursuing careers in mental health, adding further strain to a workforce that is already struggling to meet demand.
“Who wants to go into a stigmatized profession?” Crawford said.
In other words, stigma doesn’t just make it harder for people to ask for help. It can also result in missing the very people they should be asking.
